Lobectomy via minimally invasive video-assisted thoracic surgery (VATS) has proved to be a feasible and oncologically acceptable approach for non–small-cell lung cancer (NSCLC) and other isolated tumors and conditions. However, despite multiple studies showing clear benefits over a traditional thoracotomy approach, such as decreased length of stay, decreased short-term postoperative pain, and fewer complications,^1–3 VATS is still not accepted as the standard approach for anatomic resection, and is only slowly being implemented more widely. The explanation is likely multifactorial including (1) technical issues, such as two-dimensional imaging and limited maneuverability of instrumentation; (2) lack of adequate training; and (3) concerns about the consequences of major vascular injury with a closed chest approach.

To address the perceived technical limitations of conventional minimally invasive platforms, a master–slave robotic surgical system was developed (da Vinci Surgical System, Intuitive Surgical, Sunnyvale, California). The major advances were the three-dimensional visual system that reestablished binocular vision and wristed instrumentation capable of seven degrees of freedom enabling more natural bimanual movement for precise dissection. Initially, the system was approved by the Food and Drug Administration for cardiothoracic surgery because the original intent was to achieve true closed chest cardiac surgery. This, however, has not been fully realized. Instead, the most common applications that evolved were for pelvic procedures—prostatectomy and hysterectomy. Similarly, while use of robotics for general thoracic surgical procedures dates back to initial case reports in the early 2000s, it was not until 2004 and 2006 that actual series of robotic lobectomies were reported by Melfi et al. and Park et al., respectively.^4,5 These centers reported the initial technique and early perioperative experiences that demonstrated feasibility, safety, and concordance of outcomes with the largest series of VATS lobectomies. Subsequently, there has been a steadily increasing interest in robotic lobectomy with additional publications with greater numbers of patients and various modifications of the technique.^6–8

This chapter will focus on review of the general principles and clinical aspects of robotic lobectomy with an emphasis on patient selection, preoperative preparation, technical aspects, and perioperative outcomes.

The guiding principle that must be remembered when one is considering utilizing robotic surgical systems for any procedure is that the robot is a tool like any other in the art of surgery. It is up to the surgeon to use his or her best judgment as to whether its use is appropriate and in the best interest of the patient. Robotic procedures are simply minimally invasive procedures, that are performed with a different, perhaps more advanced technology that has unique advantages and disadvantages. In the case of pulmonary lobectomy the robotic approaches that have been described all conform to the consensus criteria of a standard VATS lobectomy put forth in the Cancer and Leukemia Group B (CALGB) prospective, multi-institutional registry study (CALGB 39802).⁹ For early stage NSCLC (node-negative, peripheral tumors ≤3 cm) this definition includes: absence of rib-spreading, minimal incision size (no greater than a 4–8 cm access incision with 0.5-cm port incisions), videoscopic guidance at all times, and traditional hilar dissection with individual ligation and division of lobar structures. Adhering to these principles the authors were able to demonstrate that VATS lobectomy is associated with acceptable morbidity and mortality. Similarly, multiple independent centers have demonstrated the feasibility and safety of robotic lobectomy^4–8 while adhering to these same universal aspects of minimally invasive thoracic surgery established for VATS lobectomy. Moreover, a recent multicenter study by Park et al.¹⁰ also demonstrated excellent long-term oncologic results of robotic lobectomy in the treatment of early NSCLC.

For anatomic lobectomy the author practices a VATS-based robotic approach with a small (3–4 cm), non–rib-spreading access incision whereas others advocate a complete portal approach.^7,8 While there are minor technical differences, the conduct of the procedure and utilization of the robotic technology for dissection are uniform. Major emphasis will be placed on the VATS-based technique.

Currently, much like with VATS lobectomy neither the American Board of Thoracic Surgery nor any governing surgical society, such as the American College of Surgeons, Society of Thoracic Surgery or American Association of Thoracic Surgery has any published guidelines for the training and accreditation of surgeons and operating room teams for the performance of robotic thoracic procedures. As a result, each hospital typically has developed its own policies. Hospitals uniformly mandate that surgeons attend an intensive, 2-day training course given by Intuitive Surgical® that is comprised of didactic instruction regarding the system components followed by simulation training for basic skills and cadaver-based training for specific procedures. It is critical for specialty-specific personnel – operating room nurses, surgical technicians, and bedside assistants – to be formally trained on the basics of system functioning, instrument changes, and position of the surgical cart. This is typically done by the robotic company representative. It is common, but not required for the prospective robotic surgeon to observe an established practitioner to become familiar with specific index procedures. This author cannot stress enough how critically important case observation is during the training and prior to implementation of robotics into treatment of patients.

Once the entire surgical team has received the appropriate training, institutions usually will allow implementation of the robotic system into procedures under the supervision and guidance of a case proctor, defined as a surgeon with documented clinical experience independently performing robotic procedures. The console surgeon is typically required to perform between three and as many as ten proctored cases before being granted independent robotic procedure privileges. Some hospitals require that eligible proctors themselves have performed a minimum number of cases, while the majority has no such requirement. In fact, most institutions do not mandate that the proctor be specialty-specific—thus, a robotic urologist may proctor a thoracic surgeon. While this may be in compliance with a specific institutional requirement, this type of implementation is ill advised. The ideal situation is for the training surgeon to observe an experienced robotic surgeon in their respective field and then enlist that individual, if possible, to serve as the case proctor. This maximizes the continuity of training and, consequently, patient safety during clinical implementation.

The theoretical benefit of utilizing robotic technology is to replicate what can be done through VATS or almost entirely what can be done through a thoracotomy. Patients eligible for robotic lobectomy include those with suspicious or biopsy-proven NSCLC or other pathologic tumors or disease processes confined to the lung and ipsilateral hemithorax. This should be verified through computed tomography (CT) of the chest and whole body positron emission tomography (PET/CT). For NSCLC, suspicious mediastinal nodal or extrathoracic disease warrants further invasive staging to identify patients with advanced disease requiring multimodality or systemic therapy only. Patients should have adequate cardiopulmonary status and performance status to tolerate lobectomy. Specifically, cardiac disease should be asymptomatic and stable on medication and preoperative pulmonary function tests should demonstrate a postoperative predicted forced expiratory volume in 1 second (FEV₁) and diffusion capacity (D_LCO) above 40% of predicted. Borderline postoperative predicted lung function should be further investigated by quantitative lung scanning and/or exercise testing. Smoking cessation for active smokers should be aggressively advocated.

As with any new surgical technique or approach, careful selection of initial cases is critical to success and progression. While scenarios such as large tumors (>5 cm), extensive hilar or mediastinal disease, postinduction therapy, chest wall invasion, extensive adhesions, and need for bronchial or vascular sleeve resection do not absolutely preclude a robotic approach, it is wise to avoid these conditions until a sufficient experience with most straightforward cases has been developed. Informed consent for the use of robotic assistance should be obtained as a distinct portion of the procedure.

Preparation of the Robot

The operating room technical staff sets up the robotic surgical system (surgical cart, surgeon’s console, vision system) in the room (Fig. 165-1). In the beginning of the case the nursing staff power up the system, run the appropriate diagnostics, and drape the robotic arms and camera. This requires two individuals and typically takes 5 to 10 minutes for staff who are trained and are familiar with the process and occurs prior to or while the patient is undergoing induction of anesthesia and positioning.