Application of the da Vinci in thoracic surgery

Surgical techniques have changed considerably over time, from large-incision open surgery to small-incision open surgery, and now to minimally invasive surgery (MIS), which is widely used. MIS reduces tissue trauma and pain, shortens the recovery time, minimizes complications and improves cosmetic results (1).

Minimally invasive thoracic surgery has been the focus of research in recent years. Video-assisted thoracoscopic surgery (VATS) has been used for more than 20 years in China and has gained broad acceptance for various thoracic diseases. Although VATS is recommended as the standard operation for radical lung resection by the National Comprehensive Cancer Network (2), its limitations include the restriction of sensory information to a two-dimensional image and difficulty in maneuvering tips of instrument. The da Vinci robotic Surgical System was introduced to overcome these limitations.

As early as 500 years ago, Leonardo da Vinci, the greatest European artist and inventor of the 15^th century, designed a humanoid robot on the drawings. In 1990s, Intuitive Inc. invented the da Vinci Surgical System, by applying the most advanced robotic arm used in the space program for clinical use. In 2000, the da Vinci Surgical System became the first automatic control system for endoscopic surgery approved by the U.S. Food and Drug Administration (3).

The da Vinci Surgical System consists of three major components (Figure 1): a console for the operating surgeon, the robotic arm cart, a vision cart including optical devices for the robotic camera. This system makes it possible for the surgeon sit at the console and trigger highly sensitive motion sensors that transfer the surgeon’s movements to the tips of the instruments, rather than directly operating on the patient with surgical instruments. The da Vinci Surgical System is clearly the next step for MIS after VATS. Ruijin Hospital adopted the da Vinci Surgical System for thoracic tumors early and has accumulated practical experience.

Figure 1 The components of da Vinci Surgical System.

Advantages of the da Vinci Surgical System

Compared with traditional MIS, the robotic arms of the da Vinci Surgical System effectively eliminate any hand tremor to improve the stability. The system also provides a clear and magnified three-dimensional operative field (4). The image and the instruments are kept in the same direction to optimize eye-hand coordination, which enables precise tissue dissection, hemostasis, and suturing. The flexible multi-joint arms and so-called “Endo Wrist technology” offer seven degrees of freedom, exceeding the capacity of the surgeon’s hand in open surgery. The surgeon can adjust the camera and manipulate the field of view simultaneously (5). The da Vinci Surgical System can reduce tissue trauma and shorten the recovery time, which is the advantage of precise MIS. In the future, telesurgery may become possible with this robotic system.

Application of the da Vinci Surgical System in thoracic surgery

The da Vinci Surgical System was approved for thoracic surgery in 2001 and was introduced in China in 2006 (3,5,6). This new technology has been used by many medical institutions for thoracic procedures, such as pulmonary lobectomy, esophagectomy, resection of mediastinal cystic and solid tumors, thymectomy, diaphragmatic hiatus repair, cardiomyotomy, and lymph node dissection, etc.

Conditions for use

• Strict indications: patients should undergo a full evaluation to determine the indication. Injuries caused by prolonged surgeries and anesthesia must be avoided.
• Experienced teams: a successful team includes skilled surgeons, anesthetists, and nurses to ensure efficiency, safety, and thoroughness.
• Flexibility: the surgical team should have the insight and decisiveness to rapidly respond to unexpected situations.

Lung surgery

Lobectomy with lymph node dissection is a major challenge in thoracic robotic surgery, and surgeons must also be familiar with open surgery and VATS (7). Surgeons usually choose small tumor to learn robotic surgery techniques and accumulate experience. When the tumor is large and adheres to blood vessels, open surgery is safe. Early in 2000, Okada et al. (8) used the Televox AESOP system and automatic traction control to perform right middle lobectomies and mediastinal lymph node dissections. Then AESOP was replaced by the da Vinci Surgical System. In 2002, Melfi et al. (9) used the da Vinci system for 12 lung surgeries: 5 lobectomies, 3 mass resections, and 4 pulmonary bullae resections. As the technology has developed, and surgeons have accumulated experience, especially with the second-generation da Vinci Surgical System, robotic lung surgery has become widely accepted by surgeons and patients (10,11). The system has a clear and magnified three-dimensional operative field, and its robotic arms effectively eliminate the hand tremor to improve stability, which enables precise segmental resection and sleeve resection (12,13). Robotic lung surgery was adopted late in China. In 2011, Yi et al. (14) completed 22 robotic surgeries on lung nodules. In 2013, Wang et al. (7) reported successful robotic lung surgeries and completed the first robotic surgery of the right lower lobe for central lung cancer, upper lobe dorsal segment resection, and lymph node dissection. The retrospective studies of Brooks (15) and Park (16) et al. showed that robotic-assisted lobectomies were feasible, safe and oncologically sound procedures for patients with stage IA or IB lung cancer, but noted that there is a steep learning curve. Mahieu et al. (17) reported that perioperative results for lung surgeries were comparable to results of robotic surgery and VATS. Numerous researchers consider robotic lung surgery to be comparable to VATS, or even superior to VATS regarding accuracy. However, multi-center and large randomized controlled studies are needed to compare the long-term outcomes of robotic-assisted lung surgery with those of conventional open surgery and VATS (18,19).

Esophagus surgery

Esophagus cancer operations are complex and multisite, which is a challenge in robotic surgery and they were attempted relatively late. The most important factors associated with long-term survival are local recurrence and lymph nodes recurrence. Therefore, lymph node dissection is important in esophagus cancer and the dissection range is from the apical chest to above the diaphragm. The da Vinci Surgical System offers convenience for lymph node dissection. In 2003, Horgan (20) reported the first robotic transhiatal esophageal resection and treated 15 patients with this procedure in the following 2 years. In 2004, Kernstine (21) reported the first robotic transthoracic esophageal resection. Other reports described primary experiences to demonstrate the feasibility of robotic esophageal resection. In 2011, Yi et al. (14) reported robotic esophageal resection in China. In recent years, some researchers tried using a semi-prone position rather than the traditional left lateral position to provide a clear operative field and convenient space for the surgeons (22). In 2013, Ishikawa et al. (23) reported the safety and feasibility of using semi-prone position for robotic surgery, and Dunn (24) reported similar results for a single-center clinical trial of 40 patients. Mori et al. (25,26) compared the robotic transthoracic esophageal resection with the traditional transthoracic approach and found that the robotic surgery was superior for lymph node dissection and resulted in a lower rate of postoperative infection. A study by Park (27) reported good safety and perioperative results of robotic esophageal resection with mediastinal lymph node dissection in 114 patients. However, prospective studies are still needed to compare the survival rates of traditional and robotic esophageal resection. As this new technology continues to develop, and surgeons accumulate experience, robotic esophageal resection will be more widely applied.

Mediastinal surgery

Midsternal incisions used for thymomas and other anterior mediastinal tumors fully expose tissues but can lead to serious complications. For that reason many medical institutions use VATS instead of open surgery. However, VATS is limited for superior mediastinal suprathoracic lesions. The magnified three-dimensional view and EndoWrist of the da Vinci system overcome the limitations of VATS. Thus, many European hospitals use the da Vinci Surgical System for thymectomies (28).

The da Vinci Surgical System has been used in mediastinal surgery for more than 10 years, especially for myasthenia gravis (29). In 2002, Yoshino et al. (30) reported the first robotic thymectomy. In 2009, Huang et al. (31) completed the first robotic thymectomy in China. After Bodner et al. (32,33) concluded that robotic thymectomy has obvious advantages, it became a routine surgery in many medical institutions. A study by Seong et al. (34) describing the treatment of anterior mediastinal tumors in 145 patients showed that robotic surgery is superior to open surgery and comparable to VATS. A retrospective study by Ding et al. (35) including 203 patients with mediastinal lesion showed that surgery time was comparable between robotic surgery and VATS. In addition, robotic surgery was superior to VATS regarding safety and recovery but costs more. Kajiwara et al. (36) also reported that the robotic surgery is comparable to traditional surgery but is safer and easier to perform than traditional surgery. Many medical institutions emphasize the importance of using a trocar, and the choice is dependent on the position of the tumor (31,34,35).

The flexible robotic arms can completely dissect the adipose tissue near the phrenic nerve completely. The superior vena cava and both innominate veins can be exposed safely and clearly, make it convenient and accurate to access the top of thymus, which has obvious advantages in the removal of superior mediastinal tumors and is comparable to open surgery (37). Thymic veins, which are the primary vessels that must be dealt with in thymectomies, can be easily clamped, ligatured, and sutured in robotic surgery. The structure of the anterior mediastinum can be demonstrated clearly (38-40). A case series involving more than 50 patients at Shenyang Military Hospital (37) showed that the robotic surgery considerably reduced postoperative pain and discomfort caused by the pleural drainage tube, minimizing trauma and accelerating recovery. Robotic thymectomy is also used in certain patient populations, such as children, obese patients, and the elderly.

Other surgery

There are limited reports about other surgeries, such as Hellers’ myotomy, hiatal hernia repair, diaphragmatic hernia repair, and esophagobronchial fistula repair. Tolboom et al. (41) reported that robotic surgery has no obvious advantage for hiatal hernia repair and gastroesophageal reflux surgery but has an advantage over a second surgery or huge hiatal hernia repair. Most of the reports were published in the early stage of robotic surgery use, and the primary aim was to accumulate experience.

Limitations

The maker of da Vinci Surgical System has a monopoly in the minimally invasive robotic surgery market. There are still some technical defects to overcome. For example, the mechanical fingers lack the force feedback (42) which make it difficult to judge tissue texture, elasticity, and vessel pulsatility and limits the determination of the tissue intersection and dissociation of vessels. This system is complex and carries a high possibility of operating problem that requires a specialized technician (43). Because the learning curve of the robotic system is relatively steep and prolonged, few surgeons have experience using this system. Wang et al. (7) concluded the surgeons should be skilled in VATS before learning robotic surgery, but Lee et al. (43) reported that was no advantage for surgeons with VATS experience in learning robotic surgery. It is still controversial whether robotic surgery should be used in children. Cundy et al. (44,45) reported that in the future, robotic surgery systems matched to specific populations(e.g., children) will be developed. In addition, the high cost is another limitation of the da Vinci Surgical System.

Prospects

The da Vinci Surgical System, which represents precise MIS, reflects that trend in MIS development. In our analysis, the da Vinci Surgical System produces less tissue trauma, reduces postoperative complications, and shortens the recovery time compared with traditional VATS. This system has a broad application in MIS and is worth promotion. In the future, the da Vinci Surgical System will likely be miniaturized and have force-feedback technology. In addition, the Intuitive Surgical Inc. is developing a small highly integrated uniportal surgical robot, which could be a technological breakthrough. Along with the increase in yield and the realization of localization, the problem of high cost will be solved when robotic surgery is popularized in China in the near future.

Acknowledgements

Funding: None.

Footnote

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/amj.2017.01.02). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. McKenna RJ Jr, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg 2006;81:421-5; discussion 425-6. [Crossref] [PubMed]
2. Detterbeck FC, Postmus PE, Tanoue LT. The stage classification of lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:e191S-210S.
3. Palep JH. Robotic assisted minimally invasive surgery. Journal of Minimal Access Surgery 2009;5:1-7. [Crossref] [PubMed]
4. Byrn JC, Schluender S, Divino CM, et al. Three-dimensional imaging improves surgical performance for both novice and experienced operators using the da Vinci Robot System. Am J Surg 2007;193:519-22. [Crossref] [PubMed]
5. Xiu C. Da Vinci surgical robot in thoracic surgery. Chin J Laparoscopic Surgery (Electronic Edition) 2010;(4):3-6.
6. Bodner J, Wykypiel H, Greiner A, et al. Early experience with robot-assisted surgery for mediastinal masses. Ann Thorac Surg 2004;78:259-65; discussion 265-6. [Crossref] [PubMed]
7. Wang S, Xu S, Tong X, et al. Robotic lobectomy for non-small cell lung cancer(NSCLC). Chin J Clin Thorac Cardiovasc Surg 2013;(3):308-11.
8. Okada S, Tanaba Y, Sugawara H, et al. Thoracoscopic major lung resection for primary lung cancer by a single surgeon with a voice-controlled robot and an instrument retraction system. J Thorac Cardiovasc Surg 2000;120:414-5. [Crossref] [PubMed]
9. Melfi FM, Menconi GF, Mariani AM, et al. Early experience with robotic technology for thoracoscopic surgery. Eur J Cardiothorac Surg 2002;21:864-8. [Crossref] [PubMed]
10. Park BJ. Robotic lobectomy for non-small cell lung cancer: long-term oncologic results. Thorac Surg Clin 2014;24:157-62. vi. [Crossref] [PubMed]
11. Hartwig MG, D'Amico TA. Thoracoscopic lobectomy: the gold standard for early-stage lung cancer? Ann Thorac Surg 2010;89:S2098-101. [Crossref] [PubMed]
12. Pardolesi A, Park B, Petrella F, et al. Robotic anatomic segmentectomy of the lung: technical aspects and initial results. Ann Thorac Surg 2012;94:929-34. [Crossref] [PubMed]
13. Schmid T, Augustin F, Kainz G, et al. Hybrid video-assisted thoracic surgery-robotic minimally invasive right upper lobe sleeve lobectomy. Ann Thorac Surg 2011;91:1961-5. [Crossref] [PubMed]
14. Yi J, Dong G, Xu B, et al. Application of da Vinci-S Surgical System to general thoracic surgery. J Med Postgra 2011;24:696-9.
15. Brooks P. Robotic-Assisted Thoracic Surgery for Early-Stage Lung Cancer: A Review. AORN J 2015;102:40-9. [Crossref] [PubMed]
16. Park BJ. Robotic lobectomy for non-small cell lung cancer (NSCLC): Multi-center registry study of long-term oncologic results. Ann Cardiothorac Surg 2012;1:24-6. [PubMed]
17. Mahieu J, Rinieri P, Bubenheim M, et al. Robot-Assisted Thoracoscopic Surgery versus Video-Assisted Thoracoscopic Surgery for Lung Lobectomy: Can a Robotic Approach Improve Short-Term Outcomes and Operative Safety? Thorac Cardiovasc Surg 2016;64:354-62. [PubMed]
18. Adams RD, Bolton WD, Stephenson JE, et al. Initial multicenter community robotic lobectomy experience: comparisons to a national database. Ann Thorac Surg 2014;97:1893-8; discussion 1899-900.
19. Swanson SJ, Miller DL, McKenna RJ Jr, 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. [Crossref] [PubMed]
20. Horgan S, Berger RA, Elli EF, et al. Robotic-assisted minimally invasive transhiatal esophagectomy. Am Surg 2003;69:624-6. [PubMed]
21. Kernstine KH, DeArmond DT, Karimi M, et al. The robotic, 2-stage, 3-field esophagolymphadenectomy. J Thorac Cardiovasc Surg 2004;127:1847-9. [Crossref] [PubMed]
22. Petri R, Zuccolo M, Brizzolari M, et al. Minimally invasive esophagectomy: thoracoscopic esophageal mobilization for esophageal cancer with the patient in prone position. Surg Endosc 2012;26:1102-7. [Crossref] [PubMed]
23. Ishikawa N, Kawaguchi M, Inaki N, et al. Robot-assisted thoracoscopic hybrid esophagectomy in the semi-prone position under pneumothorax. Artif Organs 2013;37:576-80. [Crossref] [PubMed]
24. Dunn DH, Johnson EM, Morphew JA, et al. Robot-assisted transhiatal esophagectomy: a 3-year single-center experience. Dis Esophagus 2013;26:159-66. [Crossref] [PubMed]
25. Mori K, Yamagata Y, Aikou S, et al. Short-term outcomes of robotic radical esophagectomy for esophageal cancer by a nontransthoracic approach compared with conventional transthoracic surgery. Dis Esophagus 2016;29:429-34. [Crossref] [PubMed]
26. Mori K, Yamagata Y, Wada I, et al. Robotic-assisted totally transhiatal lymphadenectomy in the middle mediastinum for esophageal cancer. J Robot Surg 2013;7:385-7. [Crossref] [PubMed]
27. Park SY, Kim DJ, Yu WS, et al. Robot-assisted thoracoscopic esophagectomy with extensive mediastinal lymphadenectomy: experience with 114 consecutive patients with intrathoracic esophageal cancer. Dis Esophagus 2016;29:326-32. [Crossref] [PubMed]
28. Chen X, Han B, Guo W, et al. Robotic thymectomy and thymoma resection surgery. Chin J Laparoscopic Surgery (Electronic Edition) 2011;(4):37-9.
29. Wang S, Li B, Xu S, et al. Robot-assisted Extended Thymectomy for Type I Myasthenia Gravis Using Da Vinci S System. Chin J Clin Thorac Cardiovasc Surg 2013;(6):679-82.
30. Yoshino I, Hashizume M, Shimada M, et al. Video-assisted thoracoscopic extirpation of a posterior mediastinal mass using the da Vinci computer enhanced surgical system. Ann Thorac Surg 2002;74:1235-7. [Crossref] [PubMed]
31. Huang J, Luo Q, Zhao X, et al. Application of Robotic-assisted thoracoscopy in thymectomy. Tumor 2009;29:796-8.
32. Bodner J, Wykypiel H, Wetscher G, et al. First experiences with the da Vinci operating robot in thoracic surgery. Eur J Cardiothorac Surg 2004;25:844-51. [Crossref] [PubMed]
33. Bodner JC, Zitt M, Ott H, et al. Robotic-assisted thoracoscopic surgery (RATS) for benign and malignant esophageal tumors. Ann Thorac Surg 2005;80:1202-6. [Crossref] [PubMed]
34. Seong YW, Kang CH, Choi JW, et al. Early clinical outcomes of robot-assisted surgery for anterior mediastinal mass: its superiority over a conventional sternotomy approach evaluated by propensity score matching. Eur J Cardiothorac Surg 2014;45:e68-73; discussion e73.
35. Ding R, Tong X, Xu S, et al. A comparative study of Da Vinci robot system with video-assisted thoracoscopy in the surgical treatment of mediastinal lesions. Zhongguo Fei Ai Za Zhi 2014;17:557-62. [PubMed]
36. Kajiwara N, Kakihana M, Kawate N, et al. Appropriate set-up of the da Vinci Surgical System in relation to the location of anterior and middle mediastinal tumors. Interact Cardiovasc Thorac Surg 2011;12:112-6. [Crossref] [PubMed]
37. Xu SG, Wang SM. Experience of da Vinci robot-assisted thoracic surgery of 500 patients. Chin J Clin Thorac Cardiovasc Surg 2015;22:895-900.
38. Augustin F, Schmid T, Sieb M, et al. Video-assisted thoracoscopic surgery versus robotic-assisted thoracoscopic surgery thymectomy. Ann Thorac Surg 2008;85:S768-71. [Crossref] [PubMed]
39. Rea F, Marulli G, Bortolotti L, et al. Experience with the "da Vinci" robotic system for thymectomy in patients with myasthenia gravis: report of 33 cases. Ann Thorac Surg 2006;81:455-9. [Crossref] [PubMed]
40. Cakar F, Werner P, Augustin F, et al. A comparison of outcomes after robotic open extended thymectomy for myasthenia gravis. Eur J Cardiothorac Surg 2007;31:501-4; discussion 504-5. [Crossref] [PubMed]
41. Tolboom RC, Broeders IA, Draaisma WA. Robot-assisted laparoscopic hiatal hernia and antireflux surgery. J Surg Oncol 2015;112:266-70. [Crossref] [PubMed]
42. Reiley CE, Akinbiyi T, Burschka D, et al. Effects of visual force feedback on robot-assisted surgical task performance. J Thorac Cardiovasc Surg 2008;135:196-202. [Crossref] [PubMed]
43. Lee BE, Korst RJ, Kletsman E, et al. Transitioning from video-assisted thoracic surgical lobectomy to robotics for lung cancer: are there outcomes advantages? J Thorac Cardiovasc Surg 2014;147:724-9. [Crossref] [PubMed]
44. Cundy TP, Marcus HJ, Hughes-Hallett A, et al. Robotic surgery in children: adopt now, await, or dismiss? Pediatr Surg Int 2015;31:1119-25. [Crossref] [PubMed]
45. Cundy TP, Shetty K, Clark J, et al. The first decade of robotic surgery in children. J Pediatr Surg 2013;48:858-65. [Crossref] [PubMed]