Robotic Surgery and Anatomic Segmentectomy: An Analysis of Trends, Patient Selection, and Outcomes

Trends and Disparities in Robotic Surgery Utilization for Non-Small Cell Lung Cancer

INTRODUCTION

Robotic surgery has become an increasingly utilized approach for resectable lung cancer. However, availability may be limited for certain patient populations, underscoring inequity in access to innovative surgical techniques. We hypothesize that there is an association between social determinants of health and robotic surgery utilization for resectable non-small cell lung cancer (NSCLC).

METHODS

We queried the National Cancer Database (2010-2019) for patients with clinical stage I-III NSCLC who underwent resection, stratifying the cohort based on surgical technique. Multivariable logistic regression analysis was performed to identify associations between sociodemographic and clinicopathologic factors and the robotic approach.

RESULTS

Among the 226,455 clinical stage I-III NSCLC patients identified, 34,059 (15%) received robotic resections, 78,039 (34.5%) underwent thoracoscopic resections, and 114,357 (50.5%) had open resections. Robotic surgery utilization increased from 3.1% in 2010 to 34% in 2019 (P < 0.001). Despite this, after adjusting by clinical stage, extent of resection, site of tumor, and receipt of neoadjuvant therapy, multivariable analysis revealed various sociodemographic and treatment facility factors that were associated with underutilization of this approach: lack of insurance (adjusted odds ratio [aOR] 0.83, 95% confidence interval [CI] 0.73-0.93), lower income brackets (aOR 0.93, 95% CI 0.91-0.96), provincial settings (urban aOR 0.79, 95% CI 0.76-0.82; rural aOR 0.57, 95% CI 0.51-0.64), and treatment at community centers (comprehensive community cancer programs aOR 0.73, 95% CI 0.70-0.75; community cancer programs aOR 0.51, 95% CI 0.47-0.55).

CONCLUSIONS

This study suggests that disparities in determinants of health influence accessibility to robotic surgery for resectable NSCLC. Identification of these gaps is crucial to target vulnerable sectors of the population in promoting equality and uniformity in surgical treatment.

A Comparison of Short-Term Outcomes of Robotic-Assisted Thoracic Surgery Versus Video-Assisted Thoracic Surgery Following Lung Cancer Surgery at a Tertiary Hospital in the United Kingdom: A Propensity-Matched Analysis

BACKGROUND

Robot-assisted thoracic surgery (RATS) is gaining popularity in lung resection surgeries; however, its quality outcome measures require further evaluation. This study compared the short-term perioperative outcomes of lung resection surgeries performed using RATS and video-assisted thoracic surgery (VATS) at a tertiary hospital in the UK.

METHODS

We performed a retrospective comparative analysis of 496 patients who underwent lung resection surgery at Castle Hill Hospital in the UK between January 2021 and April 2024. In the pre-matched cohort, 162 patients underwent RATS compared to 334 who underwent VATS. Using propensity matching based on the patient's forced expiratory volume in one second (FEV1) percentage of predicted age and body mass index (BMI), we included 324 patients in the analysis. Of these, 162 underwent RATS, and 162 underwent VATS, demonstrating satisfactory performance indicators.

RESULTS

The results from our analysis depicted that RATS had a significantly lower rate of prolonged air leak (≥7 minutes) than VATS (5.5% versus 7.1%, mean difference -1.32, 95% CI: -0.89-3.08, p = 0.034). RATS patients also had shorter duration of hospital stay (3.8 ± 4.1 days versus 4.7 ± 4.8, mean difference -0.901, 95% CI: -1.886-0.084; p = 0.073) and had more mediastinal lymph node dissections (39.5% versus 35.2%) than VATS. However, the proportion of patients who were upstaged after histopathological analysis of the resected lymph nodes was not different between the two groups. Furthermore, the groups had no significant differences regarding the infection rate, intermittent positive pressure ventilation (IPPV) use, and theatre return.

CONCLUSION

Robotic and video-assisted technologies produced equivalent results for the majority of the short-term outcomes evaluated. Additional research is necessary to confirm RATS's efficacy and determine its potential advantages over VATS for lung resection surgeries.

Application of uniportal video-assisted thoracoscopic surgery for segmentectomy in early-stage non-small cell lung cancer: A narrative review

Uniportal video-assisted thoracoscopic surgery (UVATS) segmentectomy has emerged as an effective approach for managing early-stage non-small-cell lung cancer (NSCLC). Compared to conventional open and thoracoscopic surgeries, this minimally invasive surgical technique offers multiple benefits, including reduced postoperative discomfort, shorter hospital stays, expedited recovery, fewer complications, and superior cosmetic outcomes. Particularly advantageous in preserving lung function, UVATS segmentectomy is a compelling option for patients with compromised lung capabilities or limited pulmonary reserve. Notably, it demonstrates promising oncological results in early-stage NSCLC, with long-term survival rates comparable to those of lobectomies. Skilled thoracic surgeons can ensure a safe and effective execution of UVATS despite the potential technical challenges posed by complex tumor locations that may hinder visibility and maneuverability within the thoracic cavity. This study provided a comprehensive review of the literature and existing studies on UVATS segmentectomies. It delves into the evolution of the technique, its current applications, and the balance between its benefits and limitations. This discussion extends the technical considerations, challenges, and prospects of UVATS segmentectomy. Furthermore, it aimed to update advancements in segmentectomy for treating early-stage NSCLC, offering in-depth insights to thoracic surgeons to inform more scientifically grounded and patient-specific surgical decisions.

A comparative study of robot-assisted thoracoscopic surgery and conventional approaches for short-term outcomes of anatomical segmentectomy

OBJECTIVES

Since anatomical segmentectomy requires meticulous dissection of the segmental pulmonary vessels and bronchus, robot-assisted thoracoscopic surgery (RATS) has been widely adopted in recent years. We investigated the usefulness of RATS segmentectomy by comparing perioperative outcomes with conventional approaches including open thoracotomy or video-assisted thoracoscopic surgery (VATS). We compared perioperative outcomes of segmentectomy between RATS and conventional approaches including open thoracotomy or video-assisted thoracoscopic surgery (VATS).

METHODS

This single-institutional retrospective study comprised 231 patients with primary lung cancer who underwent segmentectomy by RATS or conventional approaches between January 2011 and December 2022. Surgical outcomes and postoperative complications were analyzed among patients whose background factors were adjusted by propensity score matching (PSM).

RESULTS

Before PSM, there were significant differences in age, smoking status, and types of segmentectomy. After PSM, 126 patients (63 patients in each group) were included in this analysis. The RATS group had significantly shorter operative time (154 vs 210 min; p < 0.01), fewer bleeding amounts (10 vs 40 mL; p < 0.01), and shorter duration of chest drainage (2 vs 2 days; p = 0.04) than the conventional-approach group. There was no significant difference in the incidence of all complications; however, the incidence of postoperative pneumonia was significantly lower than in the conventional-approach group (p = 0.02).

CONCLUSIONS

RATS segmentectomy is proposed to be useful. It was suggested that RATS segmentectomy may be useful with better perioperative results than the conventional approach. Further studies on oncological long-term outcomes and cost-benefit comparisons are needed.

Effective division of the intersegmental plane using a robotic stapler in robotic pulmonary segmentectomy

PURPOSES

Robot-assisted thoracoscopic (RATS) segmentectomy is becoming increasingly common because of the expanded indications for segmentectomy and the widespread adoption of robotic surgery. The precise division of the intersegmental plane is necessary to ensure oncologic margins from the tumor and to preserve the lung function. In this study, we present a strategy for accurately dividing the intersegmental plane using a robotic stapler and review the surgical outcomes.

METHODS

RATS portal segmentectomy was performed using the Da Vinci Xi system and the intersegmental plane was dissected using a robotic stapler. We evaluated the perioperative outcomes in 92 patients who underwent RATS portal segmentectomy between May 2020 and January 2023. These results were compared with those of 82 patients who underwent complete video-assisted thoracoscopic surgery (CVATS) during the same period.

RESULTS

The operative and console times were 162 and 97 min, respectively. No intraoperative complications occurred, and postoperative complications were observed in four cases (4.3%). The operative time, blood loss, postoperative complications, and maximum incision size were significantly lower in the RATS group than in the CVATS group. However, RATS requires a significantly higher number of staplers than CVATS.

CONCLUSIONS

The division of the intersegmental plane using a robotic stapler in RATS portal segmentectomy was, therefore, found to be safe and effective.

Comparing Robotic, Thoracoscopic, and Open Segmentectomy: A National Cancer Database Analysis

INTRODUCTION

Minimally invasive approaches to lung resection have become widely acceptable and more recently, segmentectomy has demonstrated equivalent oncologic outcomes when compared to lobectomy for early-stage non-small cell lung cancer (NSCLC). However, studies comparing outcomes following segmentectomy by different surgical approaches are lacking. Our objective was to investigate the outcomes of patients undergoing robotic, video-assisted thoracoscopic surgery (VATS), or open segmentectomy for NSCLC using the National Cancer Database.

METHODS

NSCLC patients with clinical stage I who underwent segmentectomy from 2010 to 2016 were identified. After propensity-score matching (1:4:1), multivariate logistic regression analyses were performed to determine predictors of 30-d readmissions, 90-d mortality, and overall survival.

RESULTS

22,792 patients met study inclusion. After matching, approaches included robotic (n = 2493; 17%), VATS (n = 9972; 66%), and open (n = 2493; 17%). An open approach was associated with higher 30-d readmissions (7% open versus 5.5% VATS versus 5.6% robot, P = 0.033) and 90-d mortality (4.4% open versus 2.2% VATS versus 2.5% robot, P < 0.001). A robotic approach was associated with improved 5-y survival (50% open versus 58% VATS versus 63% robot, P < 0.001).

CONCLUSIONS

For patients with clinical stage I NSCLC undergoing segmentectomy, compared to the open approach, a VATS approach was associated with lower 30-d readmission and 90-d mortality. A robotic approach was associated with improved 5-y survival compared to open and VATS approaches when matched. Additional studies are necessary to determine if unrecognized covariates contribute to these differences.

Comparison of Short-Term Outcomes Between Robot-Assisted and Video-Assisted Segmentectomy for Small Pulmonary Nodules: A Propensity Score-Matching Study

BACKGROUND

Our study aimed to compare the short-term outcomes between robot-assisted segmentectomy (RAS) and video-assisted segmentectomy (VAS) for small pulmonary nodules.

METHODS

The study included of 299 segmentectomies (132 RAS and 167 VAS procedures) for small pulmonary nodules between June 2018 and November 2021. The patients were divided into two groups: the RAS group and the VAS group. Propensity score-matching (PSM) analysis was performed to minimize bias. A logistic regression model was performed to identify the independent risk factors associated with complications.

RESULTS

Before PSM, the following clinical variables were not balanced: age (P = 0.004), tumor size (P < 0.001), forced expiratory volume for 1 s (FEV1), and FEV1 percentage (P < 0.001). The patients with RAS had a shorter operative time (P = 0.014), less blood loss, a shorter postoperative hospital stay, less use of strong opioids, less drainage on postoperative day 1, and less postoperative total drainage, but more cost (all P < 0.001). Conversion to open surgery was performed for two patients in the VAS group but none in the RAS group. After PSM, 53 pairs were successfully matched. The data again suggested that the patients with RAS had less blood loss, a shorter postoperative hospital stay, and less use of strong opioids, but more cost (all P < 0.001). The operation time also was shorter in the RAS group, with a borderline statistically significant P value (0.053).

CONCLUSIONS

In our study, RAS had better short-term outcomes than VAS, indicating a safer and more efficient technique than VAS.

Uniportal robotic-assisted thoracoscopic surgery for early-stage lung cancer with the Da Vinci Xi: Initial experience of two cases

BACKGROUND

Minimally invasive surgery (MIS) techniques, currently considered the gold standard in the treatment of early-stage non-small cell lung cancer (NSCLC), are mainly represented by video-assisted thoracoscopic surgery (VATS), both uniportal and multiportal, and by robotic-assisted thoracoscopic surgery (RATS). While multiportal RATS has been accepted as a valid alternative to VATS, carrying the advantages of three-dimensional high-definition visualisation and improved maneuverability, very few reports exist in literature on the application of uniportal RATS (U-RATS). Therefore, we describe our initial experience with this recently developed method in the treatment of early-stage NSCLC.

MATERIALS AND METHODS

U-RATS was conducted through a single 4 cm long antero-lateral mini-thoracotomy (ALMT) in the sixth intercostal space at the mid-axillary line. Three 8 mm robotic trocars were positioned and connected, from back to front, to robotic arms as follows: 30° camera arm, robotic arm 2 (bipolar fenestrated grasper) and 1 (Maryland bipolar forceps). Assistant access was identified as the most anterior part of ALMT.

RESULTS

Case 1: an 82-year-old woman (American Society of Anaesthesiologists [ASA III]) underwent a left S6 segmentectomy for a clinical stage IA2 NSCLC, complicated by an air leak that resolved spontaneously by postoperative day three (POD 3). Case 2: a 75-year-old man (ASA III) underwent an uncomplicated right lower lobectomy for a clinical stage IA3 NSCLC. Case 1 and 2 were discharged on POD 5 and 4, respectively.

CONCLUSIONS

From what emerged in our small series, U-RATS with the Da Vinci Xi surgical system might be considered a safe, reliable, and effective alternative to other MIS techniques. Larger prospective studies are required to validate these findings.

Three-Arm Robotic Lung Resection via the Open-Thoracotomy-View Approach Using Vertical Port Placement and Confronting Monitor Setting: Focusing on Segmentectomy

To perform robotic lung resections with views similar to those in thoracotomy, we devised a vertical port placement and confronting upside-down monitor setting: the three-arm, robotic “open-thoracotomy-view approach (OTVA)”. We described the robotic OTVA experiences focusing on segmentectomy and its technical aspects. We retrospectively reviewed 114 consecutive patients who underwent robotic lung resections (76 lobectomies and 38 segmentectomies) with OTVA using the da Vinci Xi Surgical System between February 2019 and June 2022. To identify segmental boundaries, we administered indocyanine green intravenously and used the robotic fluorescence imaging system (Firefly). In all procedures, cranial-side intrathoracic structures, which are often hidden in the conventional look-up-view method, were well visualized. The mean durations of surgery and console operation were 195 and 140 min, respectively, and 225 and 173 min, for segmentectomy and lobectomy, respectively. In segmentectomy, console operation was significantly shorter (approximately 30 min, p < 0.001) and two more staplers (8.2 ± 2.3) were used compared with lobectomy (6.6 ± 2.6, p = 0.003). In both groups, median postoperative durations of chest tube placement and hospitalization were 0 and 3 days, respectively. This three-arm robotic OTVA setting offers natural thoracotomy views and can be an alternative for segmentectomy and lobectomy.

Adoption of Robotic Core Technology in Minimally Invasive Lung Segmentectomy: Review

A recent randomized trial demonstrated the survival superiority of lung segmentectomy over lobectomy in patients with early stage, small-sized lung cancer. Hence, there is a pressing need for thoracic surgeons to gain familiarity with lung segmentectomy. However, lung segmentectomy, especially via minimally invasive surgery, is a technically challenging thoracic surgical procedure. The robotic surgery platform helps surgeons to improve their operative performance based on its core technological features: improved dexterity, precision, and visualization. Herein, we have discussed the key issues related to robotic lung segmentectomy, explicitly focusing on the technical features of complex segmentectomy under difficult conditions. We have also introduced our preferred surgical strategy for robotic lung segmentectomy with specific maneuvers.

Complications of Robotic Video-Assisted Thoracoscopic Surgery Compared to Open Thoracotomy for Resectable Non-Small Cell Lung Cancer

(1) Background: Conventional open thoracotomy has been the accepted surgical treatment for resectable non-small cell lung cancer. However, newer, minimally invasive approaches, such as robotic surgery, have demonstrated similar safety and efficacy with potentially superior peri-operative outcomes. The present study aimed to quantitatively assess these outcomes through a meta-analysis. (2) Methods: A systematic review was performed using electronic databases to identify all of the relevant studies that compared robotic surgery with open thoracotomy for non-small cell lung cancer. Pooled data on the peri-operative outcomes were then meta-analyzed. (3) Results: Twenty-two studies involving 12,061 patients who underwent robotic lung resection and 92,411 patients who underwent open thoracotomy were included for analysis. Mortality rates and length of hospital stay were significantly lower in patients who underwent robotic resection. Compared to open thoracotomy, robotic surgery was also associated with significantly lower rates of overall complications, including atrial arrhythmia, post-operative blood transfusions, pneumonia and atelectasis. However, the operative times were significantly longer with robotic lung resection. (4) Conclusions: The present meta-analysis demonstrated superior post-operative morbidity and mortality outcomes with robotic lung resection compared to open thoracotomy for non-small cell lung cancer.