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 Table of Contents     
Year : 2022  |  Volume : 18  |  Issue : 3  |  Page : 415-419

Robotic-assisted lobectomy for malignant lung tumors

1 Department of Surgery, Mount Sinai Medical Center, FL, USA
2 Department of Surgery; Division of Thoracic and Cardiovascular Surgery, Mount Sinai Medical Center, FL, USA

Date of Submission14-Aug-2021
Date of Acceptance06-Oct-2021
Date of Web Publication04-Jan-2022

Correspondence Address:
Dr. Jessica Emilia Wahi
Department of Surgery; Division of Thoracic and Cardiovascular Surgery, Mount Sinai Medical Center, 4300 Alton Road, FL
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.jmas_266_21

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 ¤ Abstract 

Objectives: For patients with lung cancer, surgical resection remains the best curative option and is associated with the longest disease-free survival. We present our institutional outcomes treating pulmonary malignancy with robotic lobectomy over the course of 1 year.
Methods: A retrospective review was conducted on patients who underwent robotic pulmonary lobectomy for malignancy at a single institution in 2018.
Results: Over the course of 1 year, 166 patients underwent robotic lobectomy for pulmonary neoplasm. The mean age of the patients was 75 years; 73% were current or prior smokers and 52% of the patients were male. The mean body mass index was 28 kg/m2. Conversion to open thoracotomy occurred in 7% of patients. The mean total hospital length of stay (LOS) was 3 days. Histopathological examination revealed a mean tumour size of 2.7 cm with 11 lymph nodes harvested. Left-sided tumours had a significantly higher number of lymph nodes harvested when compared to right-sided tumours (11.6 vs. 9.8, P = 0.01), despite sampling the recommended minimum of three N2 stations. The most common pathology was adenocarcinoma (65%), followed by squamous cell carcinoma (17%) The 30-day operative mortality was 0.6%.
Conclusions: Robotic video-assisted thoracoscopic surgery is a safe, feasible and oncologically adequate procedure for lung malignancies. Comparison of our outcomes to previously reported national averages suggests a similar hospital LOS, lymph node harvest, conversion rate to open thoracotomy and 30-day mortality rate. We acknowledge the limitations of this non-randomised, retrospective study. Future research on robotic lobectomies is encouraged.

Keywords: Lung cancer, oncological surgery, robotics, thoracic surgery

How to cite this article:
Wahi JE, Ajabshir N, Williams R, Bustamante H, Safdie FM. Robotic-assisted lobectomy for malignant lung tumors. J Min Access Surg 2022;18:415-9

How to cite this URL:
Wahi JE, Ajabshir N, Williams R, Bustamante H, Safdie FM. Robotic-assisted lobectomy for malignant lung tumors. J Min Access Surg [serial online] 2022 [cited 2022 Aug 19];18:415-9. Available from:

 ¤ Introduction Top

Lung cancer continues to be the leading cause of cancer-related mortality in the United States and worldwide. For operable patients with clinical stage I and II non-small cell lung carcinoma, surgical resection remains the best curative option and is associated with the longest disease-free survival.[1] Pulmonary resections by video-assisted thoracoscopic surgery (VATS) have firmly been established as a safe and favourable approach for resection of pulmonary neoplasm when compared to the traditional open thoracotomy. Several studies have shown improved post-operative outcomes with comparable long-term efficacy and survival of VATS when compared to thoracotomy.[2],[3],[4],[5]

Nevertheless, the two-dimensional visualisation and the limited range of motion of thoracoscopic instruments make VATS lobectomy technically challenging. Robotic surgery with the da Vinci robot (Intuitive Surgical, Sunnyvale, CA, USA) offers several technical advantages including a high definition, three-dimensional field of view, improved dexterity and tremor filtration. Given these advantages, the implementation of robotic technology in thoracic surgery continues to increase with recent studies, suggesting equivalence to VATS as a minimally invasive approach.[6],[7],[8],[9],[10]

Our objective in this study was to review the outcomes of our single-centre, high-volume tertiary community healthcare institution and identify the benefits of using the robotic-assisted technology in highly complex thoracic procedures such as pulmonary anatomic resections.

 ¤ Methods Top

Data source

After approval from the institutional review board, a retrospective departmental database was established for patients who underwent robotic lobectomy for pulmonary malignancy in 2018. All patients selected for pulmonary lobectomy underwent pre-operative workup with computed tomography (CT) scan of the chest and/or positive emission tomography (PET) scan. Pulmonary function tests were routinely utilised to predict the post-operative pulmonary function. Cases were performed by one of two surgeons. Robotic lobectomy was performed using the da Vinci surgical robot Xi platform. Carbon dioxide insufflation was universally used and a four-port system was utilised in most operations. A complete mediastinal lymph node dissection was routinely performed followed by separate ligation and division of the lobar vessels and bronchi.

Statistical analysis

Data are organised by the anatomic lobe resected – right upper lobe, right middle lobe (RML), right lower lobe, left upper lobe and left lower lobe. The data are expressed as n, percentage or as the mean ± standard deviations. Continuous data were compared using either Student's t-test or analysis of variance. A P < 0.05 was considered statistically significant. Data were analysed using Microsoft Office Excel (Microsoft, Redmond, WA, USA).

 ¤ Results Top

Over the course of 1 year, a total of 166 patients underwent robotic lobectomy for malignant pulmonary disease. There was a fairly even distribution of gender, with 52% of patients being male. A majority 73% of the patents were current or former smokers. The mean age of the patients was 75 years (74.6 ± 9.6) and the average body mass index (BMI) was 28 kg/m2 (27.5 ± 6.2). Pre-operative patient characteristics are delineated in [Table 1]. For patients, the mean length of stay (LOS) in the intensive care unit was 1 day (1.1 ± 0.3). The mean hospital LOS was 4 days (3.6 ± 2.3), with a median LOS of 3 days. Thirty-six per cent of patients were discharged home within the first 48 h. Typically, one chest tube was placed at the time of surgery and the mean duration of time that this remained in place was 3 days (3.0 ± 2.1) with a median duration of 2 days.
Table 1: Pre-operative characteristics of patients organised by anatomic lobe compared to all patients overall

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The average tumour size was 2.7 cm [2.7 ± 2.8, [Figure 1]]. All procedures included a mediastinal lymph node dissection with enlarged or suspicious lymph nodes resected. The mean number of complete lymph nodes harvested without nodal subdivision was 11 [10.6 ± 3.5, [Figure 2]]. No single anatomic lobe had a significant difference in the number of lymph nodes harvested when compared to the overall mean. However, left-sided tumours had a significantly higher number of lymph nodes harvested when compared to right-sided tumours (11.6 vs. 9.8, P = 0.01).
Figure 1: Mean tumour size organised by anatomic lobe with a cumulative mean size of 2.7 cm (2.7 ± 2.8)

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Figure 2: Mean number of lymph nodes harvested from each operation, organised by anatomic lobe. On average, each operation yielded a total of 11 lymph nodes (10.6 ± 3.5)

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The conversion rate to open thoracotomy was 7% of all procedures (12, 7.2%). Emergent conversion for bleeding was encountered in only one patient with the remaining semi-elective conversions driven by poor lung isolation or significant air trapping in patients with severe emphysema or anatomic vascular abnormalities. The RML was the only anatomic lobe that was able to be resected robotically with no procedures converted to open. The most common pathology encountered was adenocarcinoma (108, 65%), followed by squamous cell carcinoma (28, 17%) and then carcinoid (12, 7%). Nine patients (5%) had metastatic disease from distant primary sites. The remaining 5% of patients had large cell (4, 2%), adenosquamous (4, 2%) or small cell lung carcinoma (1, 1%). These data are organised as shown in [Figure 3]. There was only one death within 30 days of operative date, making the 30-day mortality rate 0.6%. This particular patient developed an acute stroke post-operatively requiring an additional intervention, which was complicated by respiratory failure at which point the family decided to pursue withdrawal of care.
Figure 3: Pathology encountered in tumours resected from each anatomic lobe

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 ¤ Conclusions Top

After its initial description in the 1990s, the adoption of VATS has played a key role in the advancements in thoracic surgery. Several studies have supported the use of VATS when compared to open thoracotomy for pulmonary resection.[2],[3],[4],[5] VATS is associated with a decreased hospital LOS, improved post-operative pulmonary function, decreased pain and lower morbidity.[3] Given these advantages, the utilisation of minimally invasive techniques in thoracic surgery continues to increase. Data from the Society of Thoracic Surgeons General Thoracic Surgery Database reveal an increase in VATS for anatomic lung resection from 8% in 2003 to 43% in 2009.[11] More recent data show that 62% of anatomic lung resections were completed either via VATS or RVATS in 2012–2014.[12]

The use of robotic systems has further enhanced the development of minimally invasive thoracic surgery. The wristed robotic instruments allow for an increased ranged of motion when compared to the straight thoracoscopic instruments, which is especially advantageous during dissection within the confines of the bony thoracic cavity. In addition, the superior high definition visualisation, increased tremor filtration and improved ergonomics make robotic surgery a favourable alternative to VATS.

There is a growing body of literature that recognises both the safety and feasibility of RVATS for pulmonary lobectomy. Several large nationwide series suggest similar morbidity and mortality rates of RVATS when compared to VATS.[13],[14],[15],[16],[17] Rajaram et al. analysed outcomes of robotic lobectomies between 2010 and 2012 from the National Cancer Data Base.[18] Examination of this nationwide series reveals comparable results to data from our cohort. The mean hospital LOS in our cohort is 4 days compared to the previously recorded national mean of 6.1 days.[18] Further analysis revealed a median LOS of 3 days; the increased mean LOS likely represents those patients who remained hospitalised with a chest tube due to a prolonged air leak. In our cohort, 36% of patients were discharged home within the first 48 h. The mean number of lymph nodes examined in our robotic lobectomies was 10.6 compared to the national mean of 9.9. The conversion rate to open thoracotomy was seen in 7% of procedures in our experience, which appears comparable to historical reports documenting a conversion rate between 2% and 13%.[19],[20],[21]

When compared to VATS, RVATS has been largely shown to have similar oncologic outcomes including nodal harvest, surgical resection margins and long-term survival.[13],[14],[18],[22] However, a few select studies have suggested that RVATS is associated with improved nodal harvest when compared to VATS.[23],[24],[25],[26] In our cohort, the left-sided tumours had a higher number of lymph nodes harvested when compared to the right-sided tumours. Data from the American College of Surgeons Oncology Group Z0030 trial that analysed differences between patients who underwent VATS lobectomy to those who underwent thoracotomy revealed no statistical difference in the overall number of lymph nodes harvested between right- and left-sided tumours.[27] Previous studies have reported a 30-day mortality rate range of 0.2%–2.5%, which places our operative mortality rate of 0.6% on the lower end of this spectrum.[28],[29]

Scepticism about robotic surgery includes the significant costs associated with the technology such as the upfront capital costs of the machine itself as well as the increased costs associated with the supplies and maintenance. There is an on-going discussion regarding the costs associated with robotic surgery in comparison to the money saved with possibly decreased hospital LOS and complications.[30] A limitation of this study is not reviewing costs. Cost of procedure and overall cost-effectiveness of RVATS were not within the scope of this study.

This study is limited by its non-randomised retrospective analysis of patients undergoing RVATS without a matching cohort as a control group. The study design does not allow for a direct comparison to be done between RVATS, conventional VATS and open thoracotomy. In addition, as different surgical approaches are adopted by different surgeons, it is difficult to delineate which outcomes may be surgeon-specific compared to the surgical approach. Surgical outcomes may be more related to a surgeon rather than the operative approach.

Despite the limitations of this study, we believe that the results from our institution support the notion that RVATS can safely and reliably be used to perform a minimally invasive lung resection with systematic lymphadenectomy. The technique of robotic lobectomy continues to be an evolving technique, and further studies are needed to fully analyse the added value of robotic surgery in the field of thoracic surgery.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

 ¤ References Top

Ettinger DS, Wood DE, Aggarwal C, Aisner DL, Akerley W, Bauman JR, et al. NCCN Guidelines Insights: Non-Small Cell Lung Cancer, Version 1.2020. J Natl Compr Canc Netw 2019;17:1464-72.  Back to cited text no. 1
Cao C, Zhu ZH, Yan TD, Wang Q, Jiang G, Liu L, et al. Video-assisted thoracic surgery versus open thoracotomy for non-small-cell lung cancer: A propensity score analysis based on a multi-institutional registry. Eur J Cardiothorac Surg 2013;44:849-54.  Back to cited text no. 2
Yan TD, Black D, Bannon PG, McCaughan BC. Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer. J Clin Oncol 2009;27:2553-62.  Back to cited text no. 3
Paul S, Altorki NK, Sheng S, Lee PC, Harpole DH, Onaitis MW, et al. Thoracoscopic lobectomy is associated with lower morbidity than open lobectomy: A propensity-matched analysis from the STS database. J Thorac Cardiovasc Surg 2010;139:366-78.  Back to cited text no. 4
Kent M, Wang T, Whyte R, Curran T, Flores R, Gangadharan S. Open, video-assisted thoracic surgery, and robotic lobectomy: Review of a national database. Ann Thorac Surg 2014;97:236-42.  Back to cited text no. 5
Reddy RM, Gorrepati ML, Oh DS, Mehendale S, Reed MF. Robotic-assisted versus thoracoscopic lobectomy outcomes from high-volume thoracic surgeons. Ann Thorac Surg 2018;106:902-8.  Back to cited text no. 6
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Veronesi G, Novellis P, Voulaz E, Alloisio M. Robot-assisted surgery for lung cancer: State of the art and perspectives. Lung Cancer 2016;101:28-34.  Back to cited text no. 8
Lee BE, Korst RJ, Kletsman E, Rutledge JR. Transitioning from video-assisted thoracic surgical lobectomy to robotics for lung cancer: Are there outcomes advantages? J Thorac Cardiovasc Surg 2014;147:724-9.  Back to cited text no. 9
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Ceppa DP, Kosinski AS, Berry MF, Tong BC, Harpole DH, Mitchell JD, et al. Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: A society of Thoracic Surgeons database analysis. Ann Surg 2012;256:487-93.  Back to cited text no. 12
Louie BE, Wilson JL, Kim S, Cerfolio RJ, Park BJ, Farivar AS, et al. Comparison of video-assisted thoracoscopic surgery and robotic approaches for clinical stage I and stage II non-small cell lung cancer using the Society of Thoracic Surgeons database. Ann Thorac Surg 2016;102:917-24.  Back to cited text no. 13
Yang CL, Wang W, Mo LL, Zhang L, Peng GL, Yu ZW, et al. Short-term outcome of three-dimensional versus two-dimensional video-assisted thoracic surgery for benign pulmonary diseases. Ann Thorac Surg 2016;101:1297-302.  Back to cited text no. 14
Swanson SJ, Miller DL, McKenna RJ Jr., Howington J, Marshall MB, Yoo AC, et al. Comparing robot-assisted thoracic surgical lobectomy with conventional video-assisted thoracic surgical lobectomy and wedge resection: Results from a multihospital database (Premier). J Thorac Cardiovasc Surg 2014;147:929-37.  Back to cited text no. 15
Arnold BN, Thomas DC, Narayan R, Blasberg JD, Detterbeck FC, Boffa DJ, et al. Robotic-assisted lobectomies in the national cancer database. J Am Coll Surg 2018;226:1052-62.e15.  Back to cited text no. 16
Oh DS, Reddy RM, Gorrepati ML, Mehendale S, Reed MF. Robotic-assisted, video-assisted thoracoscopic and open lobectomy: Propensity-matched analysis of recent premier data. Ann Thorac Surg 2017;104:1733-40.  Back to cited text no. 17
Rajaram R, Mohanty S, Bentrem DJ, Pavey ES, Odell DD, Bharat A, et al. Nationwide assessment of robotic lobectomy for non-small cell lung cancer. Ann Thorac Surg 2017;103:1092-100.  Back to cited text no. 18
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Yang HX, Woo KM, Sima CS, Bains MS, Adusumilli PS, Huang J, et al. Long-term survival based on the surgical approach to lobectomy for clinical stage I nonsmall cell lung cancer: Comparison of robotic, video-assisted thoracic surgery, and thoracotomy lobectomy. Ann Surg 2017;265:431-7.  Back to cited text no. 23
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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1]


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