Applications of Robotic Surgery in Thoracic Diseases

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Pulmonology".

Deadline for manuscript submissions: closed (28 February 2022) | Viewed by 15109

Special Issue Editor


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Guest Editor
1. Department of Thoracic Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
2. Department of Oncology and Hemato-oncology, University of Milan, Milan, Italy
Interests: minimally invasive surgery; robotic surgery; lung cancer; mediastinal tumors; pleural tumor
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Special Issue Information

Dear Colleagues,

The minimally invasive approach in thoracic surgery has already proven advantageous in terms of reduced postoperative pain, shorter immune response, quicker resumption of daily activities, and better aesthetic and functional results. However, the minimally invasive surgery took many years to be embraced as an effective procedure for the treatment of early stage NSCLC. This slowness in the diffusion of the technique could be attributed to reasons such as the technical difficulty of the method, the long-lasting learning curve, and above all, the concerns regarding the oncological safety of the patients. The robotic approach in thoracic surgery (RATS) was developed as a technological evolution of video-assisted thoracoscopic surgery (VATS), leading to some technical advantages and to an innovative approach to lung cancer resection and staging, with a more precise dissection, and a theoretically better oncological result. Even if there are already many studies in literature about early post-operative outcomes, few studies have been published about oncological results.

Within this Special Issue in the Journal of Clinical Medicine, we want to invite you to describe the latest state-of-the-art robotic approaches in lung cancer disease and to gather large-scale studies to help diffuse the results of this innovative approach, in particular focusing attention on long-term oncological outcomes.

Dr. Monica Casiraghi
Guest Editor

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Keywords

  • robotic surgery
  • lung disease
  • minimally invasive approaches

Published Papers (8 papers)

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Editorial

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3 pages, 191 KiB  
Editorial
Applications of Robotic Surgery in Thoracic Diseases
by Monica Casiraghi, Alessio Vincenzo Mariolo and Lorenzo Spaggiari
J. Clin. Med. 2022, 11(14), 4201; https://doi.org/10.3390/jcm11144201 - 20 Jul 2022
Cited by 1 | Viewed by 1086
Abstract
With the ever-expanding implement of screening programs, as well as a raised awareness of patients about their own health, the number of cases of early-stage lung cancer is progressively increasing, leading surgeons to adapt their practice and to develop new surgical techniques that [...] Read more.
With the ever-expanding implement of screening programs, as well as a raised awareness of patients about their own health, the number of cases of early-stage lung cancer is progressively increasing, leading surgeons to adapt their practice and to develop new surgical techniques that are less and less invasive [...] Full article
(This article belongs to the Special Issue Applications of Robotic Surgery in Thoracic Diseases)

Research

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12 pages, 1085 KiB  
Article
Long-Term Outcomes of Robotic-Assisted, Video-Assisted and Open Surgery in Non-Small Cell Lung Cancer: A Matched Analysis
by Monica Casiraghi, Alessio Vincenzo Mariolo, Shehab Mohamed, Giulia Sedda, Patrick Maisonneuve, Antonio Mazzella, Giorgio Lo Iacono, Francesco Petrella and Lorenzo Spaggiari
J. Clin. Med. 2022, 11(12), 3363; https://doi.org/10.3390/jcm11123363 - 11 Jun 2022
Cited by 8 | Viewed by 1441
Abstract
Introduction: This study makes a comparison between stage I non-small cell lung cancer (NSCLC) patients subjected to either robotic-assisted thoracic surgery (RATS), video-assisted thoracic surgery (VATS) or open thoracotomy, with the aim to evaluate differences between these three approaches in terms of oncological [...] Read more.
Introduction: This study makes a comparison between stage I non-small cell lung cancer (NSCLC) patients subjected to either robotic-assisted thoracic surgery (RATS), video-assisted thoracic surgery (VATS) or open thoracotomy, with the aim to evaluate differences between these three approaches in terms of oncological outcomes. Method: We reviewed data from 1367 consecutive patients who, between 2011 and 2017, underwent lobectomy for NSCLC with either open surgery, VATS or RATS, and performed a matched case-control study based on patients’ age, gender, clinical stage (IA, IB) and ASA score. Results: 180 patients (n = 72 RATS, n = 36 VATS, n = 72 open) were analyzed. Complication rates were found to be comparable (72.2% open, 86.1% VATS, 81.9% RATS), with similar grades of severity. The median number of resected lymph nodes was higher in open surgery (n = 22) than in VATS (n = 15; p = 0.0001) and in RATS (n = 17; p = 0.004). Pathological N2 upstaging was higher in open surgery (9.7%) compared to VATS (5.6%) and RATS (5.6%). However, the recurrence rate in VATS was significantly higher than in RATS (log rank p = 0.03). No statistically significant differences were detected in 5-year OS and cancer-specific survival. Conclusions: no differences were found in OS and cancer-specific survival between VATS, RATS and open lobectomy for stage I NSCLC patients; even if in VATS, the incidence of recurrences, in particular local recurrences, was higher than in RATS and in open surgery. Full article
(This article belongs to the Special Issue Applications of Robotic Surgery in Thoracic Diseases)
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11 pages, 1644 KiB  
Article
Oncological Outcomes of Robotic Lobectomy and Radical Lymphadenectomy for Early-Stage Non-Small Cell Lung Cancer
by Filippo Tommaso Gallina, Riccardo Tajè, Daniele Forcella, Felicita Corzani, Virna Cerasoli, Paolo Visca, Cecilia Coccia, Federico Pierconti, Isabella Sperduti, Fabiana Letizia Cecere, Federico Cappuzzo, Enrico Melis and Francesco Facciolo
J. Clin. Med. 2022, 11(8), 2173; https://doi.org/10.3390/jcm11082173 - 13 Apr 2022
Cited by 12 | Viewed by 1723
Abstract
Background: While the thoracotomy approach was considered the gold standard until two decades ago, robotic surgery has increasingly strengthened its role in lung cancer treatment, improving patients’ peri-operative outcomes. In this study, we report our experience in robotic lobectomy for early-stage non-small cell [...] Read more.
Background: While the thoracotomy approach was considered the gold standard until two decades ago, robotic surgery has increasingly strengthened its role in lung cancer treatment, improving patients’ peri-operative outcomes. In this study, we report our experience in robotic lobectomy for early-stage non-small cell lung cancer, with particular attention to oncological outcomes and nodal upstaging rate. Methods: We retrospectively reviewed patients who underwent lobectomy and radical lymphadenectomy at our Institute between 2016 and 2020. We selected 299 patients who met the inclusion criteria of the study. We analyzed the demographic features of the groups as well as their nodal upstaging rate after pathological examination. Then, we analyzed disease-free and overall survival of the entire enrolled patient population and we compared the same oncological outcomes in the upstaging and the non-upstaging group. Results: A total of 299 patients who underwent robotic lobectomy were enrolled. After surgery, 55 patients reported nodal hilar or mediastinal upstaging. The 3-year overall survival of the entire population was 82.8%. The upstaging group and the non-upstaging group were homogeneous for age, gender, smoking habits, clinical stage, tumor site, tumor histology. The non-upstaging group had better OS (p = 0.004) and DFS (p < 0.0001). Conclusion: Our results show that robotic surgery is a safe and feasible approach for the treatment of early-stage NSCLC, especially for its accuracy in mediastinal lymphadenectomy. The oncological outcomes were encouraging and consistent with previous findings. Full article
(This article belongs to the Special Issue Applications of Robotic Surgery in Thoracic Diseases)
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8 pages, 227 KiB  
Article
Robotic vs. Transsternal Thymectomy: A Single Center Experience over 10 Years
by Luis Filipe Azenha, Robin Deckarm, Fabrizio Minervini, Patrick Dorn, Jon Lutz and Gregor Jan Kocher
J. Clin. Med. 2021, 10(21), 4991; https://doi.org/10.3390/jcm10214991 - 27 Oct 2021
Cited by 13 | Viewed by 1601
Abstract
Introduction: Thymomas are the most common tumors of the mediastinum. Traditionally, thymectomies have been performed through a transsternal (TS) approach. With the development of robot-assisted thoracic surgery (RATS), a promising, minimally invasive, alternative surgical technique for performing a thymectomy has been developed. In [...] Read more.
Introduction: Thymomas are the most common tumors of the mediastinum. Traditionally, thymectomies have been performed through a transsternal (TS) approach. With the development of robot-assisted thoracic surgery (RATS), a promising, minimally invasive, alternative surgical technique for performing a thymectomy has been developed. In the current paper, the oncological and surgical outcomes of the TS vs. RATS thymectomies are discussed. Methods: For the RATS thymectomy, two 8 mm working ports and one 12 mm camera port were used. In the transsternal approach, we performed a median sternotomy and resected the thymic tissue completely, in some cases en bloc with part of the lung and/or, more frequently, a partial pericardiectomy with consequent reconstruction using a bovine pericardial patch. The decisions for using the TS vs. RATS methods were mainly based on the suspected tumor invasion of the surrounding structures on the preoperative CT scan and tumor size. Results: Between January 2010 and November 2020, 149 patients were submitted for an anterior mediastinal tumor resection at our institution. A total of 104 patients met the inclusion criteria. One procedure was performed through a hemi-clamshell incision. A total of 81 (78%) patients underwent RATS procedures, and 22 (21.1%) patients were treated using a transsternal (TS) tumor resection. Thymoma was diagnosed in 53 (51%) cases. In the RATS group, the median LOS was 3.2 ± 2.8 days and the median tumor size was 4.4 ± 2.37 cm compared to the TS group, which had a median LOS of 9 ± 7.3 days and a median tumor size of 10.4 ± 5.3 cm. Both differences were statistically significant (p < 0.001). Complete resection was achieved in all patients. Conclusion: While larger and infiltrating tumors (i.e., thymic carcinomas) were usually resected via a sternotomy, the RATS procedure is a good alternative for the resection of thymomas of up to 9.5 cm, and the thymectomy is a strong approach for myasthenia gravis. The oncological outcomes and survival rates were not influenced by the chosen approach. Full article
(This article belongs to the Special Issue Applications of Robotic Surgery in Thoracic Diseases)
12 pages, 1035 KiB  
Article
Robotic Surgery for Non-Small Cell Lung Cancer Treatment in High-Risk Patients
by Carmelina Cristina Zirafa, Gaetano Romano, Elisa Sicolo, Claudia Cariello, Riccardo Morganti, Lucia Conoscenti, Teresa Hung-Key, Federico Davini and Franca Melfi
J. Clin. Med. 2021, 10(19), 4408; https://doi.org/10.3390/jcm10194408 - 26 Sep 2021
Cited by 5 | Viewed by 2013
Abstract
Robotic-assisted pulmonary resection has greatly increased over the last few years, yet data on the application of robotic surgery in high-risk patients are still lacking. The objective of this study is to evaluate the perioperative outcomes in ASA III-IV patients who underwent robotic-assisted [...] Read more.
Robotic-assisted pulmonary resection has greatly increased over the last few years, yet data on the application of robotic surgery in high-risk patients are still lacking. The objective of this study is to evaluate the perioperative outcomes in ASA III-IV patients who underwent robotic-assisted lung resection for NSCLC. Between January 2010 and December 2017, we retrospectively collected the data of 148 high-risk patients who underwent lung resection for NSCLC via a robotic approach at our institution. For this study, the prediction of operative risk was based on the ASA-PS score, considering patients in ASA III and IV classes as high-risk patients: of the 148 high-risk patients identified, 146 patients were classified as ASA III (44.8%) and two as ASA IV (0.2%). Possible prognostic factors were also analysed. The average hospital stay was 6 days (8–30). Post-operative complications were observed in 87 (58.8%) patients. Patients with moderate/severe COPD developed in 33 (80.5%) cases post-operative complications, while elderly patients in 25 (55%) cases, with a greater incidence of high-grade complications. No difference was observed when comparing the data of obese and non-obese patients. Robotic surgery appears to be associated with satisfying post-operative results in ASA III-IV patients. Both marginal respiratory function and advanced age represent negative prognostic factors. Due to its safety and efficacy, robotic surgery can be considered the treatment of choice in high-risk patients. Full article
(This article belongs to the Special Issue Applications of Robotic Surgery in Thoracic Diseases)
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8 pages, 2220 KiB  
Article
Robotic-Assisted Thoracoscopic Resection of the First Rib for Vascular Thoracic Outlet Syndrome: The New Gold Standard of Treatment?
by Adrian Zehnder, Jon Lutz, Patrick Dorn, Fabrizio Minervini, Peter Kestenholz, Hans Gelpke, Ralph A. Schmid and Gregor J. Kocher
J. Clin. Med. 2021, 10(17), 3952; https://doi.org/10.3390/jcm10173952 - 31 Aug 2021
Cited by 9 | Viewed by 2665
Abstract
In thoracic outlet syndrome (TOS) the narrowing between bony and muscular structures in the region of the thoracic outlet/inlet results in compression of the neurovascular bundle to the upper extremity. Venous compression, resulting in TOS (vTOS) is much more common than a stenosis [...] Read more.
In thoracic outlet syndrome (TOS) the narrowing between bony and muscular structures in the region of the thoracic outlet/inlet results in compression of the neurovascular bundle to the upper extremity. Venous compression, resulting in TOS (vTOS) is much more common than a stenosis of the subclavian artery (aTOS) with or without an aneurysm. Traditional open surgical approaches to remove the first rib usually lack good exposure of the entire rib and the neurovascular bundle. Between January 2015 and July 2021, 24 consecutive first rib resections for venous or arterial TOS were performed in 23 patients at our institutions. For our completely portal approach we used two 8mm working ports and one 12/8 mm camera port. Preoperatively, pressurized catheter-based thrombolysis (AngioJet®) was successfully performed in 13 patients with vTOS. Operative time ranged from 71–270 min (median 128.5 min, SD +/− 43.2 min) with no related complications. The chest tube was removed on Day 1 in all patients and the hospital stay after surgery ranged from 1 to 7 days (median 2 days, SD +/− 2.1 days). Stent grafting was performed 5–35 days (mean 14.8 days, SD +/− 11.1) postoperatively in 6 patients. The robotic approach to first rib resection described here allows perfect exposure of the entire rib as well as the neurovascular bundle and is one of the least invasive surgical approaches to date. It helps improve patient outcomes by reducing perioperative morbidity and is a procedure that can be easily adopted by trained robotic thoracic surgeons. In particular, patients with a/vTOS may benefit from careful and meticulous preparation and removal of scar tissue around the vessels. Full article
(This article belongs to the Special Issue Applications of Robotic Surgery in Thoracic Diseases)
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9 pages, 564 KiB  
Article
Preliminary Results of Robotic Lobectomy in Stage IIIA-N2 NSCLC after Induction Treatment: A Case Control Study
by Monica Casiraghi, Francesco Petrella, Giulia Sedda, Antonio Mazzella, Juliana Guarize, Patrick Maisonneuve, Filippo De Marinis and Lorenzo Spaggiari
J. Clin. Med. 2021, 10(16), 3465; https://doi.org/10.3390/jcm10163465 - 5 Aug 2021
Cited by 3 | Viewed by 1508
Abstract
Despite there already being many studies on robotic surgery as a minimally invasive approach for non-small-cell lung cancer (NSCLC) patients, the use of this technique for stage III disease is still poorly described. These are the preliminary results of our prospective study on [...] Read more.
Despite there already being many studies on robotic surgery as a minimally invasive approach for non-small-cell lung cancer (NSCLC) patients, the use of this technique for stage III disease is still poorly described. These are the preliminary results of our prospective study on the safety and effectiveness of robotic approaches in patients with locally advanced NSCLC in terms of postoperative complications and oncological outcomes. Since 2016, we prospectively investigated 19 consecutive patients with NSCLC stage IIIA-pN2 (diagnosed by EBUS-TBNA) who underwent lobectomy and radical lymph node dissection with robotic approaches after induction treatment. Furthermore, we matched a case-control study with 46 patients treated with open surgery during the same period of time, with similar age, comorbidities, clinical stage and tumor size. The individual matched population was composed of 16 robot-assisted thoracic surgeries and 16 patients who underwent open surgery. The median time range of resection was inferior in the open group compared to robotic lobectomy (243 vs. 161 min; p < 0.001). Lymph node resection and positivity were not significantly different (p = 0.96 and p = 0.57, respectively). Moreover, no difference was observed for PFS (p = 0.16) or OS (p = 0.41). In conclusion, we demonstrated that the early outcomes and oncological results of N2-patients after robotic lobectomy were similar to those who had open surgery. Considering the advantages of minimally invasive surgery, robot-assisted lobectomy appears to be a safe approach to patients with locally advanced diseases. Full article
(This article belongs to the Special Issue Applications of Robotic Surgery in Thoracic Diseases)
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Review

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8 pages, 1578 KiB  
Review
Port Placement Strategies for Robotic Pulmonary Lobectomy: A Narrative Review
by Sara Parini, Fabio Massera, Esther Papalia, Guido Baietto, Giulia Bora and Ottavio Rena
J. Clin. Med. 2022, 11(9), 2612; https://doi.org/10.3390/jcm11092612 - 6 May 2022
Cited by 4 | Viewed by 1901
Abstract
Background: Despite the use of robotics becoming increasingly popular among thoracic surgeons worldwide, there remains debate over the best robotic approach for lung resections. In this paper, we delineated the main port placement strategies and discussed their advantages and disadvantages. Methods: A PubMed [...] Read more.
Background: Despite the use of robotics becoming increasingly popular among thoracic surgeons worldwide, there remains debate over the best robotic approach for lung resections. In this paper, we delineated the main port placement strategies and discussed their advantages and disadvantages. Methods: A PubMed literature review was performed using key phrases such as “robotic lobectomy technique”, “RATS lobectomy”, and “port placement robotic lobectomy”. After the final review, 22 articles were included as references, of which 10 described common robotic port mapping techniques. Results: Several port strategies for robot-assisted pulmonary lobectomies have been proposed and described in the literature, each showing its own limitations and advantages. Conclusions: New robotic surgeons may choose their port strategy according to personal preference and previous surgical experience, especially regarding open or VATS resections. Robust data comparing different port placements in robotic surgery are lacking. Further research should be directed toward comparisons of clinical outcomes with different robotic approaches. Full article
(This article belongs to the Special Issue Applications of Robotic Surgery in Thoracic Diseases)
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