Over the past two decades, minimally invasive surgery (MIS) has gained rapid popularity both for patient comfort and for cost. A rising interest in robotic surgery has prompted the successful execution of complex procedures in a variety of surgical disciplines. Expansion of this technology into the various thoracic specialties can be expected to continue over time. As thoracic surgeons become technologically skilled in robotics, new techniques will emerge, and established techniques will continue to be refined.

COMPUTER-ASSISTED SURGICAL SYSTEM

In the 1990s, the use of computer-assisted surgical systems or surgical robotics was approved by the U.S. Food and Drug Administration. Initially, two companies, Computer Motion, Inc. (Santa Barbara, CA), and Intuitive Surgical, Inc. (Sunnyvale, CA), developed machines that provided similar features: three-dimensional vision, high-definition visual clarity, and tremorless instrument motion with multiple arcs of rotational freedom. Today, the da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) is the only commercially available surgical robotic system.

First introduced in 1999, the da Vinci System consists of three separate components: (1) a 4-arm mounted platform from which extends a single arm for the three-dimensional videoscope and three additional arms on which interchanging operative instruments are inserted, (2) the surgeon console, and (3) the integrative control cart, which provides communication between the surgeon console and the robotic arms (Fig. 141-1). The da Vinci System uses rotating multiarticulated instruments (EndoWrist, Intuitive Surgical, Inc., Sunnyvale, CA) that have 7 degrees of rotational freedom and simulate normal wrist movements, thus differentiating robotic instruments (Fig. 141-2) from standard videoscopic instruments. Additionally, the three-dimensional imaging provided by the double optic system mounted on the camera arm (Fig. 141-3) permits depth perception and precision movements, which are especially important when performing complex procedures.

In 1998, Himpens and colleagues¹ performed the first robotic operation, a cholecystectomy. Since that time, chest surgeons have been reluctant to adopt robotic procedures, and there are few reports on robotics in the general thoracic surgery literature. The cost of the technology and lack of tactile (haptic) feedback have been cited as major deterrents to acceptance of the da Vinci System. However, as robotic technology is integrated into surgical training, the need for haptic feedback becomes less of an issue.^2,3

The reluctance of surgeons to accept technology that would appear to negate years of skill and training is understandable, yet there are sound physiologic and immunologic reasons for exploring robotic surgery. The published data support a favorable trend for lung resection by means of video-assisted thoracic surgery (VATS) technique over standard open technique in terms of reduced pain, hospital stay, and complications.^4–7 Using robotic methods to (1) minimize lung manipulation, (2) reduce surgical seeding, and (3) extend lymph node dissection may lead to improved survival.

TECHNICAL PRINCIPLES

The literature provides little guidance for the detailed planning needed to conduct an efficient thoracic robotic procedure. A tremendous amount of precision is commanded by the motion of the heart and lungs, which imparts a technical challenge not present in the abdomen and pelvis. Lower esophageal, periesophageal, and diaphragmatic procedures may be best approached transabdominally. Understanding laparoscopic technique and port placement is useful for planning robotic procedures. Robotic arm ports are placed at varying distances beneath each costal margin, and a videoscope is placed periumbilically to optimize the robotic transhiatal thoracic access. Through this approach, most procedures in the lower mediastinum can be performed, but the configuration of the arms and instruments in the current da Vinci System limits accessibility beyond the level of the middle mediastinum. For example, a transhiatal robotic esophagectomy with extensive lymphadenectomy would be very difficult to perform in most patients. These technical limitations will need to be addressed before the utility of robotic procedures can be improved.

Transthoracic robotics necessitates additional planning and concerns as compared with VATS procedures. The rigidity of the chest wall combined with the movement of the heart, lungs, and mediastinum presents technical challenges for the surgeon. Carefully positioning the patient in the supine, lateral decubitus, or prone position may improve visibility and enhance the efficiency of the dissection because the mediastinal structures are mobile and will fall from the chest by force of gravity, thereby exposing otherwise concealed areas. Other factors to consider when determining body position include pathology or tumor location, patient and chest size, chest wall adipose/muscular tissue, and pulmonary and cardiac function. Chest port-site location should be chosen in accordance with preoperative CT scanning, and robotic arm positioning should be selected to enable full dexterity of each robotic arm and instrument. If the port site or entry into the patient's chest is positioned too close to the robotic arm, significant arm and instrument function is lost. For children and small adults, positioning the ports the farthest distance possible from the pathology may aid in preserving full functional freedom. Patients who have had prior thoracic surgery or who have large tumors or marginal cardiorespiratory function may not be good candidates for robotic surgery.

Patient Positioning

Patient positioning is a critical factor that can be harnessed to quicken the pace of the robotic operation. Gravitational force on the mediastinum and lung exposes underlying areas normally concealed by these structures. This creates more room in which to perform the dissection and places additional tension on the dissection planes. The supine or slight decubitus position appears best suited for anterior mediastinal pathology. Additionally, CO₂ insufflation may further enhance visibility by distending the mediastinum toward the opposite chest and compressing the ipsilateral lung and diaphragm. For example, a 30-degree left decubitus (right side up) position and 10 mm Hg of CO₂ insufflation may improve the operative space and angles needed to resect a right anterior mediastinal tumor via a right transthoracic robotic approach. In general, anatomic lung resections and hilar dissections may be better approached by a near lateral decubitus position with 30 degrees anterior tilt for lower lung or hilar resections and 30 degrees of posterior tilt for upper lung and hilar resections (Fig. 141-4). For posterior mediastinal structures, including the esophagus, the nearly prone position provides better exposure (Fig. 141-5).

Port Placement

Proper port placement is critical to efficient case management. Once the patient has been positioned, the intended operative area should be drawn on the chest using the CT scan and surface landmarks as a guide. For a small mass, the scope of visibility may be small, but for a large mass, such as an extended thymectomy or esophagectomy, it can be broad and may present challenges. After the operative region is chosen, the videoport location is selected opposite to and at a sufficient distance from this site to permit adequate insertion and range of the scope; for small chests, the site may be toward the patient's back. Next, a triangle is drawn on the patient's chest, with the videoport site at the apex of the triangle, creating a "triangle of visibility" (Fig. 141-6). The location of the two robotic arms is chosen outside the triangle, whereas the robotic arms and videoscope are aimed toward the center of the target and the base of the robot chassis. Additional ports are placed, as necessary, for a fourth robotic arm or accessory instruments to be used by the surgical assistant for retraction or dissection assistance. Occasionally, the robotic arms and/or instruments do not reach the target. To improve the reach, maneuvers can be performed, such as inserting the trocars deeper into the chest, moving the trocar into a different intercostal space through the same skin incision, adding positive end-expiratory pressure to the opposing lung (which pushes the mediastinum closer to the reach of the robotic instruments), or removing some of the CO₂ pressure used during the procedure. To gain further advantage, the 0- or 30-degree upward- or downward-gaze videoscope may be chosen to view remote areas around unretractable structures. For better exposure, the partially open fan retractor (U.S. Surgical, Norwalk, CT) or the paddle retractor (U.S. Surgical) is safe and may provide sufficient retraction of the lung, the heart, and the great vessels. A thorough knowledge of chest anatomy, physiology, and pathology, as well as operation of the available video and robotic equipment, is necessary for an efficient surgical procedure.

USE OF ROBOTICS FOR SPECIFIC PROCEDURES

Esophagus

Gastric fundoplication for gastroesophageal reflux disease, esophageal myotomy, and other lower esophageal procedures were the first robotic procedures to be performed in thoracic surgery. The good outcomes obtained with these initial procedures led to a steady increase in clinical application of robotic technology.

At our institution, we have used robotic technology to perform Nissen, Dor, and Toupet fundoplications solely and in combination with other procedures. In our OR, where we are accustomed to performing these procedures, the setup time is minimal, rarely longer than 15 minutes, and does not add significantly to the duration of the operation. In addition, we find that despite the lack of tactile feedback with the robotic system, the increased visibility and dexterity more than compensate for this limitation.

Published data demonstrate that robotic fundoplications can be performed safely with operating times ranging from 1 to 2 hours (Table 141-1). Four prospective studies comparing the robotic Nissen fundoplication with the laparoscopic approach yielded similar operating times and lengths of hospital stay (Table 141-2). A retrospective review of robotic fundoplication in children concluded that while the operation was safe and feasible, the lack of availability of robotic instruments in pediatric sizes precluded universal adoption of this technology.⁸ These reports indicate that operative time with robotic fundoplication is not significantly longer than conventional techniques, and with surgical experience, they even may be shorter.

n = number of patients reported, NR = not reported.

*Median (range).

Mean (SD).

^‡Includes Heller myotomy, gastric banding, and Nissen.

n = number of patients reported, NR = not reported.

*Median (range).

Mean (SD).

The true advantage of the enhanced visibility and dexterity provided by the robotic system is found in its capacity to handle precision esophageal surgery, such as the Heller myotomy. Published case series have demonstrated results comparable with those of videoscopic approaches, with similar operative times and minimal to no complications^9–11 (Table 141-3). However, the distinctions are better clarified by prospective trials comparing robotic with laparoscopic Heller-Dor procedures (Table 141-4). The largest published trial¹² to date found that the robotics group had a lower average blood loss and shorter hospitalization than the laparoscopic group. Additionally, the authors reported no significant difference in operative time during the latter half of the study period as they became more experienced in the technology.

n = number of patients reported; NR = not reported.

n = number of patients reported; NR = not reported.

*Median (range).

Mean (SD). Estimated blood loss <100 mL.

The most profound asset of the robotic approach to Heller myotomy is the ability to preserve the mucosal integrity of the esophagus. In the largest prospective robotics trial to date, despite a history of prior endoscopic therapy in 85% of the population, there was no mucosal injury in the 59 robotics patients.¹² In contrast, the rate of mucosal injury in the laparoscopic group was 16%. Operative times for the Heller-Dor procedure range from 2 to 4 hours,^12–15 with similar results for the Toupet procedure.^11,13,16,17 Hence the robotic Heller procedure appears to result in fewer mucosal injuries than the laparoscopic procedure, and the operative times are similar.

Robotic esophagectomy has been performed for high-grade dysplasia, cancer, and severe surgically failed esophageal dysfunction. Robotics as a tool for esophagectomy in particular appears to improve the surgeon's ability to reach remote areas of the thorax by allowing precise and extensive dissection. Both transthoracic and transhiatal esophagectomies have been reported. Unfortunately, operative times are inconsistently defined and reported, making it difficult to determine the amount of time necessary for a robotic esophagectomy. Furthermore, the role of the robot in the procedure varies among investigators (Table 141-5). Some perform the procedure exclusively with the robot, whereas others use the robot for specific portions of the procedure. Thus the role of the robot and its impact on the surgical approach remain to be determined.

n = number of patients reported; NR = not reported.

*Median (range).

Mean (SD).

^‡In press, includes 14 patients reported in 2007 publication.

The conventional open or non-MIS esophagectomy has a reported morbidity of 40–80%.¹⁸ The published institutions have an in-hospital mortality of approximately 5%.¹⁸ In the largest published VATS esophagectomy series to date, the major and minor morbidity rates were 32% and 55%, respectively, and mortality was an impressive 1.4%.¹⁹ It is conceivable that the lower than expected complication rate with the minimally invasive approach even may be surpassed with robotics.

A series of 18 patients was reported by the group that performed the first successful transhiatal robotic esophagectomy, referred to as the robotically assisted transhiatal total esophagectomy (RATE) procedure.^20,21 With experience, the surgeons reduced their operative time by more than 20% in their last 5 patients compared with their earlier patients.²⁰ Morbidity in this series was low, and length of stay was comparable with that of VATS esophagectomy. Similar findings were reported in another series of six successful robotic esophagectomy patients.²²

The robotics approach appears to be oncologically sound, similar to that found in the open non-MIS esophagectomy patients. Approximately 75% of patients have R₀ resections, and the mean number of lymph nodes resected is 14 (range 7–27)²⁰ in one study and 20 (range 9–30) in another.²³ Survival at 3 and 5 years is approximately 26% and 21%, respectively. There is insufficient information to provide long-term survival rates in robotic esophagectomy patients, but one study reported an 87% survival at 17 months.²⁴ In another series of 18 patients, 66% were disease-free at 2 years.²⁰ Currently, there are insufficient data to make any conclusions, but as a tool, robotics has the potential to be as rigorous and sound as the more standard open cancer procedures.

Transthoracic and transabdominal resection of esophageal masses may be facilitated by a robotic approach. Six published cases of esophageal leiomyoma resection using robotics were reported with no incidence of esophageal mucosal injury and no complications (Table 141-6). In our review of the literature of reported MIS leiomyoma resections, mucosal injury was 4%, and it is likely higher in the nonreported patient population. The chief benefits of robotics, perhaps as a result of high-definition three-dimensional visibility and tremorless instrument dexterity, are the reduced esophageal mobilization required to gain exposure and the apparent reduced mucosal injury without increased operative time.

n = number of patients reported; NR = not reported.

Mediastinum and Thymectomy

Robotic resection of mediastinal masses appears safe and may be the treatment of choice for many because of the superior vision and precision provided by the approach. A number of posterior mediastinal masses, including bronchogenic cysts and paravertebral neurogenic tumors, have been resected using robotics. Table 141-7 summarizes the published cases, which report successful removal with low postoperative morbidity and no emergent conversions to open thoracotomy.^25–28 In the largest series of seven mediastinal lesions, one large hourglass-shaped tumor was too large to be grasped by either the robotic or the VATs equipment and required conversion to open thoracotomy.

n = number of patients reported; NR = not reported.

*Median (range).

Children, mean age 9.8 (2-17).

^‡In press; average estimated blood loss <50 mL.

^§Mean.

For myasthenia gravis (MG), the overall symptom improvement from the MIS thymectomy appears comparable with that found with the median sternotomy thymectomy patients.^29–32 For example, at 6 years in a single-institution retrospective comparison of 159 VATS extended thymectomies and 47 transsternal extended thymectomies, the approach in nonthymomatous MG, MIS or transsternal, was equally likely to result in complete remission (50.6% and 48.7%, respectively).³² However, the extent of thymus tissue resection is speculated to determine symptom improvement.²⁹ Moreover, it is difficult to make comparisons between surgeons and groups because there are details within the patients and approaches that may affect the probability of complete remission.

Although not demonstrated to date, robotic thymectomy may provide clinically superior results to other MIS approaches. A thymectomy performed by robotics has the potential to minimize tissue manipulation because, unlike VATS, the angles of approach are performed at the point of the dissection, not outside the chest. This reduces mediastinal organ retraction and thymus manipulation and may reduce the associated surgery-induced acute-phase response, potentially reducing the likelihood of a myasthenic crisis. To date, however, there is no evidence to substantiate this claim, and similar to the other thymectomy approaches, the results are patient- and surgeon-dependent.

Robotic thymectomy has been performed by the right and left transthoracic approach, by the combined approach (robot placed on one side and then the other in the same patient), and by the subxiphoid partially transthoracic approach (Table 141-8). We have performed all our thymectomies for MG using the right transthoracic approach. The right-sided approach permits resection of all the anterior mediastinal tissue. However, we are always prepared to add VATS or the left robotic approach when we cannot resect the left side adequately, specifically the area of the aortopulmonary window, or to add a transcervical approach if there is difficulty resecting the cervical thymus and perithymic tissue. We have found that use of the paddle retractor provides the slight amount of heart/pericardial rotation necessary to expose the left side. For the cervical exposure, as necessary, flexion of the neck with the addition of right internal mammary vein division permits adequate cervical-thyroid exposure to complete the extended thymectomy. In our hands, the mean operative time is approximately 1–1.5 hours, and 40% of our patients are discharged home on the same day. There have been no postoperative cases of myasthenic crisis. Other institutional case series highlight the safety of this technique and demonstrate minimal postoperative complications and hospital stay.^33–36

n = number of patients reported; NR = not reported; MG = myasthenia gravis; CSR = Myasthenia Gravis Foundation Association-defined complete stable remission.

*Median (range).

Robotic thymectomy has been retrospectively compared with thymectomy by median sternotomy and VATS (Table 141-9). Blood loss, length of stay, postoperative pain, and remission appear similar between robotic and VATS thymectomy. The length of stay appears longer when thymectomy is performed by median sternotomy.³⁷ Robotic technology doubles the OR costs, although with greater use of the robot, the depreciable costs will be shared to a lesser extent by each of the patients. Prospective, randomized, controlled trials and more long-term data are necessary to determine if robotics has an advantage over VATS.

n = number of patients reported; NR = not reported.

*Median (range).

Matched case series.

^‡Two patients out of total unknown n.

Lobectomy and Segmentectomy

Since the early 1990s,^38,39 a growing number of institutions have conducted VATS and robotic anatomic lung resections. Studies strongly suggest the safety and feasibility of VATS compared with open thoracotomy,^6,7,40 but there are few published reports on robotic anatomic lung resection. Data from several of the larger robotic lobectomy studies are listed in Table 141-10. It is important to note that most of these studies are small and retrospective in design, which limits the conclusions that can be drawn. However, many authors have concluded that they were able to demonstrate the safety and feasibility of the robotic with VATS approach. In the largest series of robotic lobectomies, 61 early-stage lung cancer patients underwent lobectomy with complete mediastinal nodal dissection.⁴¹ The procedure entailed a routine VATS procedure, followed by a robotic mediastinal dissection, a robotic pulmonary artery division, and a robotic anterior hilar dissection.⁴¹ There were no conversions to open technique. Operative times ranged from 3 to 6 hours, with a median of 4 hours. Length of stay was 3–42 days, with a median of 4 days. The 30-day mortality was 4.9% (3 deaths), and 10 patients were upstaged on pathologic examination. Fourteen patients had postoperative complications, with the most common being atrial fibrillation in 4 patients.

n = number of patients reported; NR = not reported.

*Median (range).

Mean (SD).

^‡The operative time is defined as the first skin incision to skin closure.

^§The OR time includes 1 hour of instrument setup and testing.

^¶Operative time is point of intubation until placement of dressings.

Many authors have described various techniques for lobectomy. Some, as described below, use a combination of VATS and robotic technique, others use minithoracotomy combined with robotics, and still others rely completely on robotic technique. In addition to studies on robotic lobectomy, this technology also has been applied to other anatomic lung resections, including pneumonectomy, bleb resection for spontaneous pneumothorax, segmentectomy, and bronchogenic cyst resection.^13,42

All these studies highlight the technical ease of the robotic approach, with particular reference to dexterity and visualization. Hence robotics has the potential to overcome some of the limitations of VATS lobectomy.^43,44Initial clinical reports also show potentially superior or comparable results to conventional techniques: shorter hospital times, less postoperative bleeding, and fewer complications.

Despite the enthusiasm for robotics in lung resection, however, the data are inconclusive, and many technical issues still need to be addressed. The use of robotics and VATS has not been universally adopted, and no standardized robotic or video-assisted approach exists. The number of incisions and their respective lengths vary across studies.^7,45,46 Robotic lobectomy also can be carried out by means of a utility incision or minithoracotomy. One study group has reported the use of conventional VATS lobectomy incisions,⁴⁴ and numerous reports underscore the difference between upper and lower lobectomy procedures.⁴⁶ The technical maneuvers and equipment necessary for an efficient resection remain to be determined.^7,47–50

From the current data, it would appear at this time that there is no advantage of robotic lobectomy over VATS lobectomy.^41,44 Issues of robot cost, training, safety, and efficacy have not been analyzed sufficiently. Based on the few published studies, operative times for robotic lobectomies are longer than with either a VATS or the open approach.^25,44,45 Two studies, however, have reported that comparable times can be achieved once sufficient experience is gained.^41,46 Another point of interest is the reported annual maintenance cost of $100,000 and total disposable cost of $730 per robotic lobectomy patient.⁴⁴ Although with the current state of the art, robotic lung resection can be cumbersome and costly, further studies and more experience are needed to surmount the learning curve, reduce the cost of the technology, and adequately define the role of robotics for anatomic lung resection.

Other Thoracic Procedures

Few reports have been published on sympathectomies,⁵¹ pericardial surgeries,^52,53 and phrenic nerve pacer implantations.^54,55 With improved technology and more experience, robotics has the potential to be used in a wide variety of complex surgical chest procedures.

SURGICAL TECHNIQUE FOR A ROBOTIC APPROACH TO LOBECTOMY

A double-lumen endotracheal tube is placed for single-lung ventilation. The patient is positioned in the left lateral decubitus position on the operating table and eventually in the reverse Trendelenburg position with the table tilted 15–30 degrees posteriorly for upper and middle lobectomies and 15–30 degrees anteriorly for lower lobectomies (Fig. 141-7). Reverse flexion is used to provide adequate exposure if the patient has particularly large hips. A 3-cm-diameter circle is drawn on the patient's chest just anterior to the tip of the scapula (Fig. 141-8). This targets the hilum and guides placement of the ports and the robot chassis. Typically, six port sites are marked on the patient's chest for later placement of thoracoports. Port placement differs for upper/middle versus lower lobectomies. For upper/middle lobectomies, the first port, the videoport, is placed at the eighth intercostal space approximately 10 cm lateral to the costal margin. A triangle then is lightly drawn between the videoscope site and the target, with the videoscope site at the top of the triangle. The marks for the 8-mm port sites are placed 10 cm away from the videoport site to the left and right, just outside the triangle. The more anterosuperior port site is placed at the level of the fourth intercostal space in the middle to lateral third clavicular line. The posterosuperior port site is placed at the fourth or fifth intercostal space just at the lateral portion of a longitudinal spinal muscle. The posteroinferior port site is placed at approximately the tenth intercostal space, also just lateral to the longitudinal spinal muscle.

The chest then is surgically prepped, the surgical drapes are applied, and single-lung ventilation is initiated. A small stab incision is made, and a tonsil clamp is used to carefully and gently enter the pleural space. The first 10- to 12-mm thoracoport is placed at this site. The videoscope then is placed to confirm that endothoracic port placement has been achieved. Once this is confirmed, carbon dioxide is infused to a level of 10–15 mm Hg of pressure. The remaining three 10- to 12-mm thoracoports are placed under direct vision. The posterosuperior port is placed into the chest at the previously marked site, making certain that the direction of entry is very medial such that it enters the chest at the level of the superior aspect of the lower lobe superior segment. The anteroposterior port site also should be directed very medially and should be at the most inferior aspect of the pleural space. The superoanterior port site then is guided into the fourth intercostal space or at the level of the minor fissure also very medially. The two 8-mm robotic arms are also placed under direct vision. Naturally, all thoracoports should be inserted on the cephalad aspect of the rib adjacent to the intercostal space to avoid injury to the intercostal bundle.

The robot is now ready to roll into place and, for upper/middle lobectomies, is positioned in an oblique fashion over the back of the shoulder and neck, aimed toward the videoport (Fig. 141-9). The base of the robot chassis, the target, and the videoport all should be positioned along the same line. The robot chassis and the first swivel joint of the videoport arm should be approximately 10–12 cm from the base of the unit. The videoport arm and two robotic arms then are attached to the appropriate thoracoports. The facet joint attachments for the robotic arms are positioned to obtain the greatest options of maneuverability, that is, as far upward and laterally as possible. After the 0-degree videoscope has been placed, the ProGrasp is placed under direct vision in the leftmost arm, and the Harmonic scalpel is placed in the right. For the remainder of the case, the ends of these instruments always should be kept in the surgeon's view. To gain anterior exposure to the hilum, a Landreneau clamp is placed through the posterosuperior port site. The pulmonary parenchyma is grasped firmly, stretching the tissues in the anterior aspect of the hilum and retracting the mushroom-like obstruction of the parenchyma, which prevents exposure to the hilum. Once completed, the dissection is performed en bloc. All the tissue is resected from the anterior hilum, taking care to avoid injury to the phrenic nerve. Both sharp dissection and blunt dissection then are performed to expose the superior pulmonary vein, and all adjacent mediastinal tissue in the circumference of the vein is taken with the specimen (Fig. 141-10). A heavy silk suture is passed around the vein, and a vascular Endostapler is directed from the inferoposterior port site to take the vein. Further dissection is done into the medial aspect of the hilum and mediastinum, and all mediastinal tissues are taken en bloc with the resected specimen. This dissection exposes the main trunk of the pulmonary artery and the main branches going to the right upper lobe, right middle lobe, and recurrent pulmonary artery. It is important to avoid grasping the pulmonary artery or the previously resected pulmonary vein with the ProGrasp. Using an Endostapler in the same fashion and from the same posteroinferior port, the surgeon ligates the pulmonary artery blood supply to the upper lobe. Once this is completed, the adjacent mediastinal nodal tissue is resected away from the anterior aspect of the main stem bronchus as well as the entire inferior aspect of the azygos vein. This exposes the right main stem bronchus and right upper lobe bronchial origin. Under direct vision, the posterior aspect of the right upper lobe bronchus is dissected clear and encircled with a heavy silk suture, and the right upper lobe bronchus is divided with an Endostapler from the posteroinferior port site. Once the posterior pleura has been incised, the minor fissure can be taken with the Endostapler directed through the anterosuperior and posterosuperior port sites after the Landreneau clamp has been removed. After the mediastinal node dissection is complete, the nodal groups and the lobe are brought out through the superoanterior port site, removing the thoracoport and enlarging the site as necessary. When there is a complete fissure between the middle and lower lobes, the middle lobe can be attached to the lower lobe using an Endostapler. The bronchial stump can be reinforced as necessary if a leak is found after the mediastinum is submerged beneath saline and the ipsilateral lung is ventilated. Vascular pedicle coverage also can be performed as necessary to cover and provide extra blood supply to the bronchial closure.

SUMMARY

Compared with other surgical approaches, robotics appears to offer superior visibility and capability to perform complex procedures in difficult to reach and visualize spaces in the chest. How this translates into clinical outcome remains to be fully determined. Perhaps, robotics will produce less tissue destruction and fewer complications. Further investigations of the robotic effect on immune, physiologic, and endocrine dynamics are warranted.

The potential of robotics awaits further development of technology and surgical expertise. As confidence with the instruments and techniques improves, we can expect an increase in the number and variety of procedures performed robotically. The use of virtual imaging, as opposed to ambient light, to visualize the operative field already permits opportunities for acquiring information that cannot be achieved with nonrobotic MIS. Preoperative imaging information from MRI, CT scanning, ultrasound, and nuclear emission imaging from PET, coupled with the videoscope, potentially could provide intraoperative approaches to better visualize areas of interest, such as primary or metastatic malignant processes. Future modifications in the equipment, such as multiple articulations in the videoscope to enhance one's ability to view around structures, would help to further improve visibility.

Other possible directions of advancement in robotics technology lie within virtual training programs, voice activation, and telemedicine. Virtual training programs potentially may achieve a standardization of surgical skills within specialties and improve assessment of competency for specialty certification. Voice-activation technology may reduce surgical staff and potentially reduce errors. Computer-derived equations and error probability would be more reliable and thus safer than the unpredictable variations that exist in current practice.

The potential of telesurgery/telemedicine potentially may improve the cost efficiency of this technology and reduce delays in treatment. A central robotics system that could perform procedures in remote locations via telesurgery would be an asset to both large and smaller community hospitals if resources were allotted to maintain certified surgical staff and nurses at each facility. This potential telesurgery system could provide full cost utility, increase volume, and offer specialized surgical care to underserved areas.

Questioning the validity of robotic chest surgery solely on the basis of operative time in comparison with laparoscopic or thoracoscopic procedures is shortsighted and premature. The lack of standardized reporting remains an obstacle to drawing legitimate conclusions about the differences in approach. The concept of team learning, especially in a completely new surgical field such as robotics thoracic surgery, is a relevant concern. The qualities required for a robotics team to achieve superior outcomes are currently unknown, but developing a team approach in robotics, perhaps more than with MIS, is essential to reducing preoperative preparation and intraoperative surgical time. Greater understanding of and access to the technology will provide more opportunities for thoracic surgeons to determine the role of robotics in chest surgery.

EDITOR'S COMMENT

The evolution of technology suggests that computer-assisted surgery will continue to contribute to surgery; many of these contributions are likely to be surprising and unexpected. From the viewpoint of surgical training, it is important to establish standards for computer-assisted systems and focus on skills that can be transferable between proprietary systems.

–SJM

REFERENCES