Information about this new minimally invasive surgical technique

It's no surprise that minimally invasive surgical techniques are becoming ever more popular. Studies have shown that they're safe and effective for numerous medical conditions. And because they require much smaller incisions than traditional open surgery, recovery is typically speedier and less painful.

For patients with early-stage lung cancer, the minimally invasive laparoscopic technique known as video-assisted thorascopic surgery (VATS) has proven viable and is often preferable to open surgery. Now robot-assisted surgery, a relatively new innovation in minimally invasive surgery—used primarily for prostate and kidney procedures—is being evaluated to treat early-stage lung cancer.

Very few studies have been done on robots in lung cancer surgery, but preliminary results suggest that, like VATS, they are a feasible alternative to open surgery for early-stage disease. What remains to be seen, however, is whether robotic surgery is poised to replace VATS.

How Is Robotic Surgery Performed?

A unit containing the robot is placed at the side of the operating table, and the surgeon sits a few feet away at a control console. Known as the da Vinci Robotic System, it has four large arms. Three of the arms hold surgical instruments, and the fourth contains a tiny high-definition video camera.

The surgeon makes four to six dime-sized incisions, called operating ports, along the side of the chest. Small tubes, or trocars, are placed in the ports to allow passage of the video camera and surgical instruments. Using foot pedals and hand controls, the surgeon manipulates the robot's arms, making the instruments twist, turn, and rotate to cut tissue, remove tumors and lymph nodes, and sew up the incisions. A monitor displays in real time a highly magnified, full-color, high-definition, three-dimensional view of the patient’s lungs and chest cavity.

How Robot-Assisted Surgery Stacks Up

In 2009, The Journal of Thoracic and Cardiovascular Surgery published a study that compared surgical outcomes among 108 people with early-stage lung cancer. Half underwent traditional open surgery (in which the surgeon makes a six- to eight-inch incision in the side of the chest and uses a rib spreader to open the ribcage wide enough to gain access to the lungs); the other half had minimally invasive robotic surgery.

The outcomes were comparable in terms of postoperative complications like heart rhythm abnormalities and leakage of air into the chest cavity, and both procedures allowed for optimal lymph node removal (adequate removal of lymph nodes is important because they can contain cancer cells).

In addition, the robotic group required significantly less time in the hospital after the operation (4.5 versus 6 days), although the robotic procedure took more time to perform (217 versus 154 minutes). Long-term data on cancer recurrence and survival rates are not yet available, however.

How does robot-assisted surgery compare with VATS? With VATS, two to four small incisions are made in the side of the chest, the surgical tools and video camera are inserted through the ports, and the surgeon directly manipulates the tools at the operating table while viewing the lungs on a monitor. Although no researchers have performed a direct comparison of the two techniques, robotic surgery likely offers the following advantages over VATS:

  • Three-dimensional views as opposed to two-dimensional views of the internal organs and tissues. The robot's high-definition camera allows for depth perception that is not possible with VATS.
  • Enhanced dexterity and precision. The robotic arms, equipped with tiny instruments, can turn 360 degrees, rotating and bending as the surgeon dictates. This dexterity allows the instruments to navigate inside the body in ways a human hand cannot. A special wrist joint at the tip of the surgical instruments enhances the ability to perform subtle, complex movements such as maneuvering around delicate areas while cutting. The robotic arm also makes sewing up the incision easier.
  • No effect from minute hand tremors. Any slight unwanted hand movement when the surgeon is manipulating the robot's arm from the console is not translated to the instruments.

Drawbacks of Robot-Assisted Surgery for Lung Cancer

Robotic surgery is not without its drawbacks. Even in the hands of a surgeon with experience performing it, the procedure takes longer to complete than traditional surgery—about one hour more, according to the report in The Journal of Thoracic and Cardiovascular Surgery. In general, longer procedures are associated with an increased risk of complications and a poorer outcome.

In addition, the patient may be at greater risk if major bleeding occurs during the procedure, because the surgeon does not work at the patient's side and cannot respond as quickly to this complication.

The robotic system is also much more expensive than either VATS or open surgery. And it takes time and commitment for surgeons to learn the specific set of manual and eye-hand coordination skills necessary to operate the robot.

A 2009 study published in the Annals of Thoracic Surgery looked at 100 patients who underwent lung surgery that involved VATS and robotic techniques. The lobectomy portion of the procedure (in which part of the lung is removed) was done using VATS and the lymph node removal was performed robotically. The authors concluded that, while robotic techniques are superior when fine dissection is needed (as with lymph node removal), it's easier to manipulate the lung and obtain a wide-angle view of the chest cavity using the VATS procedure.

The Bottom Line on Robot-Assisted Surgery for Lung Cancer

Robotic surgery for lung cancer is still in its infancy, and more research is needed to determine its role. Currently, few surgeons in the United States are experienced in using the da Vinci Robotic System for lung cancer treatment.

Some researchers predict that the robot may eventually be most useful as an alternative to VATS in people with more advanced disease that requires more complicated dissection techniques.

For now, VATS is limited to patients with stage I disease. Until large, randomized, controlled trials show that the robotic surgery is more advantageous, VATS is likely to remain the minimally invasive procedure of choice.

Publication Review By: Peter B. Terry, M.D., M.A.

Published: 14 Sep 2011

Last Modified: 27 Jan 2015