By Dr Kriti Sharma, Paediatric Surgical Registrar, and Mr Sanjay Sharma, Cardiothoracic Surgeon
Pulmonary lobectomy has been the mainstay of treatment for early-stage lung cancer, but video-assisted thoroscopic surgery (VATS) has essentially replaced open thoracotomy for smaller tumours.
This is due to lower amounts a pain, a shorter length of stay, lower bleeding/transfusion rates, and less air leak with equivalent oncological outcomes.
Rates of 90% five-year survival can be achieved with early-stage lesions. More recently robotic-assisted thoracic surgery (RATS) has been used for lung resection.
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With the commencement of the National Lung Cancer Screening Program from July this year, there will be increased requirement for surgical resection.
The hope is to find patients with lower stage lung cancer in high-risk smoking cohorts and to improve survival rates with more surgical intervention. RATS is slowly becoming more available to patients in Perth with increased access to the Da Vinci Robot.
Upskilling with robots
The migration from open surgery to VATS required radical changes in surgeon perceptions, strategies and surgical skills – including loss of precision due to lack of wristed instruments – resulting in a slow adoption of the technique.
In contrast, the learning curve from VATS to robotic surgical lobectomy has been exponentially quicker with some studies reporting 20-30 procedures being sufficient to achieve proficiency for surgeons who are expert in VATS.
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A multitude of retrospective studies demonstrate that robotic techniques result in fewer pulmonary complications, shorter length of hospital stay, shorter chest tube duration and quicker recovery than VATS.
Others describe, at the very least, non-inferiority of robotic lobectomy when compared with VATS, with no significant difference in operative time, blood loss, or overall complications.
With long-term outcomes only recently maturing, robotic surgery is showing excellent and equivalent cancer survival and recurrence rates when compared to VATS.
Despite the potential advantages of robotic surgery, opponents of this newer surgical approach cite major barriers, namely higher cost, lack of access and lack of high-quality prospective data.
Benefits of robotic surgery
The ability to sit and adjust the robot consul allows for better surgical ergonomics. This has the potential to extend the surgeon’s career.
The surgeon has magnified 3D imaging allowing for extraordinary accuracy and precision. Wristed instruments improve dexterity that leads to greater lymph node harvesting, which improves staging and potentially oncological outcome.
Robotics also allows for sublobar resection leading to lung conserving resection.
No prospective studies have yet been published, however data collection is currently underway for the ‘RAVAL’ trial, the first prospective randomised controlled trial comparing VATS and RATS assisted lobectomy for early-stage lung cancer, with research protocol published in 2022.
Overall, RATS offers many surgical advantages over VATS, including superior visualisation, enhanced dexterity, and potentially faster recovery times with equivalent oncological outcomes to VATS.
Further robust prospective research is underway in this exciting field to further characterise the benefits of robotic lobectomy over VATS and its long-term oncological outcomes.
Author competing interests – nil
Key messages
- With the introduction of the Lung Cancer Screening Program, increased surgical resection will be required
- RATS lung resection offers advantages over VATS – including better visualisation, ergonomics, less pain and bleeding, and shorter length of hospital stays
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