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Department of Visceral, Transplant and Thoracic Surgery, Innsbruck Medical University, Anichstrasse 35, Innsbruck, 6020 Austria
(Email: johannes.bodner{at}i-med.ac.at).
Gharagozloo and colleagues [1] report a single institutional experience of a combined robotic (RATS) and video-assisted thoracoscopic surgical (VATS) approach for pulmonary lobectomies in 100 consecutive patients with early-stage non-small cell lung cancer. This large series on RATS lobectomies demonstrates the feasibility and safety of a hybrid technique using the robot for hilar and vascular dissection.
The concept of hybrid procedures, combining the specific advantages of the conventional and robotic minimally invasive approaches, is forward-looking and may represent the future for the robot in general thoracic surgery, where it has turned out that indications for completely robotic procedures are rare.
The question remains, however, whether a combined RATS-VATS approach for pulmonary lobectomy provides any benefit and thus should be used in this specific operation. Complete VATS lobectomies and complete RATS lobectomies were both shown to be feasible and safe [2, 3], and this study fails to demonstrate an added value of the robot when compared with a complete VATS lobectomy. Operative times, rates of complications and mortality, and length of stay were comparable or worse than in reported VATS series [4]. Oncologic lymph node dissection of N1 and N2 levels was also shown to be feasible by conventional VATS [5, 6] and the authors' conclusion that the robot enables a more accurate mediastinal lymph node dissection represents a personal appraisal rather than a proven fact.
In most RATS lobectomies, the surgeon has a tableside assistant perform some steps of the procedure, including the control of the main hilar structures with conventional stapler devices or the repeated repositioning of the lung. Thus, strictly speaking, any robotic lobectomy is a kind of hybrid procedure.
Although a RATS-VATS hybrid approach does not seem to provide relevant advantages for simple lobectomies, this may be different for advanced procedures like sleeve lobectomies. In a recently performed VATS right upper lobe sleeve lobectomy, the robot was used for the bronchial anastomosis only. The main characteristics of the robot—superior maneuverability of the instruments and 3-dimensional vision—significantly facilitated this critical step of the operation.
The introduction of robotic technology does have the potential to revolutionize minimally invasive surgery. Innovative, forward-looking surgeons like Gharagozloo and his group are trying to overcome current limitations of both VATS and RATS by performing hybrid procedures. This is an important step in the right direction and is meritorious. However, transducing the hybridization from the procedure to the instrument by implementing robotic micromechanic technology into hand-held, conventional VATS instruments might be even more effective.
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