**2. Robotic-assisted thoracic surgery**

In the field of thoracic surgery, video-assisted thoracoscopic surgery (VATS) remains the gold standard approach for thoracic surgery, and it is performed for almost all thoracic surgical indications [4]. In the last few years, robotic-assisted thoracoscopic surgery (RATS) has gained popularity as alternative to VATS due to the flexibility of its endo-wrist instruments, the three-dimensional visualisation, and the more precise and intuitive movements [1, 11]. The majority of studies comparing RATS to VATS and/or thoracotomy have been performed in the field of thoracic oncology, in which the benefits of RATS have already largely been established [12]. However, there is an increasing amount of studies that show similar benefits of RATS in other (non-oncological) thoracic surgical procedures [13]. In this section, we will highlight and review the most commonly performed oncological and non-oncological RATS procedures.

**61**

12378 VATS lobectomies [26].

*Robotic Surgery for the Thoracic and Vascular Surgeon DOI: http://dx.doi.org/10.5772/intechopen.97598*

mortality rates due to earlier cancer detection [17, 18].

Lung cancer is worldwide the most common malignancy and one of the leading causes of cancer-related deaths [14]. Despite the widespread implementation of measures mitigating tobacco use, an overall increase in new cases of non-small cell lung cancer (NSCLC) has been noted, mainly due to rising incidence rates in developing countries [15]. The majority of these new lung cancer cases are diagnosed during advanced stages, resulting in low overall five-year survival rates [14]. In these advanced stages, treatment modalities are limited and have minimal effects on overall and disease-free survival. However, due to advancements in diagnostic techniques and imaging modalities, an increasing number of NSCLCs are being detected at earlier stages of disease [16]. In the near future, the number of newlydiagnosed early stage lung cancers will likely increase due to the implementation of lung cancer screening programmes. The NELSON-trial and the NLST-trial have both shown that screening patients with high-risks of developing lung cancer with low-dose chest computed tomography (CT) scans results in significantly lower

For early-stage NSCLC, the gold standard remains surgical management by means of lobectomy with hilar and mediastinal lymph node dissection [19, 20]. Currently, VATS lobectomy is the technique of choice for this procedure as several large-scale studies have shown that VATS results in fewer perioperative complications, less pain, and faster recovery times compared to the traditional open approach [21, 22]. However, in the last decade, RATS has been gaining popularity as a minimal invasive approach due to its ability to overcome the previously described drawbacks of conventional VATS [12]. Despite a lack of well-powered randomised controlled trials comparing RATS to VATS or open surgery for the treatment of (early stage) lung cancer, a growing body of literature has demonstrated a clear advantage of lobectomy by RATS over thoracotomy regarding perioperative blood loss, postoperative analgesia need, postoperative recovery, hospital length of stay (LOS), and 30-day mortality rates [13]. In contrast, results from studies comparing RATS to VATS are less conclusive and, often, contradictory. In a recent meta-analysis of 3239 patients comparing RATS to VATS, a lower 30-day mortality and conversion rate to open surgery was seen in favour of RATS [23]. Similar studies have also shown improved survival rates, fewer postoperative complications, and shorter hospital stays for RATS compared to VATS [24]. However, in a propensity-matched analysis by Oh et al., no difference in mortality was detected between VATS and RATS [25]. Similarly, no significant difference in survival was found in the database analysis of the Society of Thoracic Surgeons (STS) which included 1220 RATS and

Regarding oncological outcomes, only a limited number of studies have been performed comparing RATS to open surgery and/or VATS. There is evidence suggesting that RATS results in increased rates of nodal upstaging and yields higher numbers of nodal stations sampled. However, in a recent data analysis by Hennon et al., 64,676 patients with NSCLC from the National Cancer Database (NCDB) in the USA were analysed for lymph node yield and nodal upstaging. The results of their study did not show any significant difference between the three approaches. The authors concluded that both RATS and VATS are non-inferior to open thoracotomy for intraoperative lymph node evaluation [27]. In addition to the possible benefits regarding treatment and oncological outcomes for lobectomies, an increasing number of experts are advocating for the use of RATS in sublobar resections. For elderly patients, patients with comorbidities, or patients with limited pulmonary reserve, sublobar resections such as wedge resections and segmentectomies have been proposed as viable alternatives [11, 28]. Despite efforts to compare the oncological

**2.1 Lung cancer surgery**

## **2.1 Lung cancer surgery**

*Latest Developments in Medical Robotics Systems*

and their outcome.

for occlusive disease [4, 9].

**2. Robotic-assisted thoracic surgery**

cal and non-oncological RATS procedures.

learning curves for surgeons in training. Despite their training, the surgeons are often confronted with a number of drawbacks such as poor depth perception, reduced spatial coordination due to the two-dimensional optics, a lack of instrument flexibility, reduced force feedback while manipulating tissues, and counterintuitive movements [4, 5]. In addition, surgeons are often exposed to physical strains from standing in non-comfortable positions for extended periods of time. These difficulties can significantly amplify the complexity of surgical procedures

In more recent years, robotic-assisted surgery has emerged as a new minimalinvasive approach to surgery, integrating current technological advancements in 'traditional' MIS. The concept of robotic-assisted surgery is to enable the surgeon to control the laparoscopic/thoracoscopic instrumentation through a robotic device that is connected to a remote console. Using this technology allows for threedimensional optics, enhanced range of intuitive instrument motions (even more than the normal open situation), and improved ergonomics [3, 6]. This type of robotic-assisted surgery first gained prominence in the field of urology, mainly for performing radical prostatectomy and complex bladder operations [7]. Since its introduction, the applications for surgical robots has expanded into almost all surgical fields, resulting in its current wide-scale use. For thoracic and vascular surgeons, a growing number of studies have shown that robotic-assisted surgery is feasible and results in favourable outcomes as well [4, 8]. These benefits have mainly been shown in the field of mediastinal tumours and lung cancer surgery, however, the efficacy of robotic-assisted surgery has also been proven for other thoracic and vascular procedures such as first-rib resection, sympathectomy, diaphragmatic paralysis, median arcuate ligament release, and aorto/ilio-femoral bypass surgery

Despite these advantages and the increasing popularity of these robotic-assisted

In the field of thoracic surgery, video-assisted thoracoscopic surgery (VATS) remains the gold standard approach for thoracic surgery, and it is performed for almost all thoracic surgical indications [4]. In the last few years, robotic-assisted thoracoscopic surgery (RATS) has gained popularity as alternative to VATS due to the flexibility of its endo-wrist instruments, the three-dimensional visualisation, and the more precise and intuitive movements [1, 11]. The majority of studies comparing RATS to VATS and/or thoracotomy have been performed in the field of thoracic oncology, in which the benefits of RATS have already largely been established [12]. However, there is an increasing amount of studies that show similar benefits of RATS in other (non-oncological) thoracic surgical procedures [13]. In this section, we will highlight and review the most commonly performed oncologi-

approaches, there are still controversies regarding the implementation and the use of these approaches, such as the generally high operating costs, lack of haptic feedback, the size of the system, and longer total operative times due to installation of the robotic system [7, 10]. Furthermore, there is a lack of definite data from large prospective studies comparing short-term and long-term outcomes of open surgery with 'traditional' MIS and robotic-assisted surgery in all aspects, including the ergonomics for the surgeon. Nevertheless, these studies are necessary to truly demonstrate the effectiveness and superior outcomes of these emerging surgical approaches. In this chapter review, we summarise the latest data on surgical techniques and treatment outcomes for robotic-assisted thoracic and vascular surgery.

**60**

Lung cancer is worldwide the most common malignancy and one of the leading causes of cancer-related deaths [14]. Despite the widespread implementation of measures mitigating tobacco use, an overall increase in new cases of non-small cell lung cancer (NSCLC) has been noted, mainly due to rising incidence rates in developing countries [15]. The majority of these new lung cancer cases are diagnosed during advanced stages, resulting in low overall five-year survival rates [14]. In these advanced stages, treatment modalities are limited and have minimal effects on overall and disease-free survival. However, due to advancements in diagnostic techniques and imaging modalities, an increasing number of NSCLCs are being detected at earlier stages of disease [16]. In the near future, the number of newlydiagnosed early stage lung cancers will likely increase due to the implementation of lung cancer screening programmes. The NELSON-trial and the NLST-trial have both shown that screening patients with high-risks of developing lung cancer with low-dose chest computed tomography (CT) scans results in significantly lower mortality rates due to earlier cancer detection [17, 18].

For early-stage NSCLC, the gold standard remains surgical management by means of lobectomy with hilar and mediastinal lymph node dissection [19, 20]. Currently, VATS lobectomy is the technique of choice for this procedure as several large-scale studies have shown that VATS results in fewer perioperative complications, less pain, and faster recovery times compared to the traditional open approach [21, 22]. However, in the last decade, RATS has been gaining popularity as a minimal invasive approach due to its ability to overcome the previously described drawbacks of conventional VATS [12]. Despite a lack of well-powered randomised controlled trials comparing RATS to VATS or open surgery for the treatment of (early stage) lung cancer, a growing body of literature has demonstrated a clear advantage of lobectomy by RATS over thoracotomy regarding perioperative blood loss, postoperative analgesia need, postoperative recovery, hospital length of stay (LOS), and 30-day mortality rates [13]. In contrast, results from studies comparing RATS to VATS are less conclusive and, often, contradictory. In a recent meta-analysis of 3239 patients comparing RATS to VATS, a lower 30-day mortality and conversion rate to open surgery was seen in favour of RATS [23]. Similar studies have also shown improved survival rates, fewer postoperative complications, and shorter hospital stays for RATS compared to VATS [24]. However, in a propensity-matched analysis by Oh et al., no difference in mortality was detected between VATS and RATS [25]. Similarly, no significant difference in survival was found in the database analysis of the Society of Thoracic Surgeons (STS) which included 1220 RATS and 12378 VATS lobectomies [26].

Regarding oncological outcomes, only a limited number of studies have been performed comparing RATS to open surgery and/or VATS. There is evidence suggesting that RATS results in increased rates of nodal upstaging and yields higher numbers of nodal stations sampled. However, in a recent data analysis by Hennon et al., 64,676 patients with NSCLC from the National Cancer Database (NCDB) in the USA were analysed for lymph node yield and nodal upstaging. The results of their study did not show any significant difference between the three approaches. The authors concluded that both RATS and VATS are non-inferior to open thoracotomy for intraoperative lymph node evaluation [27]. In addition to the possible benefits regarding treatment and oncological outcomes for lobectomies, an increasing number of experts are advocating for the use of RATS in sublobar resections. For elderly patients, patients with comorbidities, or patients with limited pulmonary reserve, sublobar resections such as wedge resections and segmentectomies have been proposed as viable alternatives [11, 28]. Despite efforts to compare the oncological

and survival outcomes of sublobar resections to lobectomy, there is still no clear consensus on whether sublobar resections are indeed non-inferior to lobectomy. Some authors suggest that sublobar resections result in lower overall survival rates, higher positive resection margins, higher recurrence rates, and inadequate lymph node sampling [29]. However, there is a growing number of studies suggesting that segmentectomy has similar overall and disease-free survival rates as lobectomy [30]. Furthermore, sublobar resections have also been associated with improved postoperative quality of life (QoL) [16]. For robotic segmentectomy, the current data suggests that treatment outcomes and complication rates are similar to VATS. In a recent retrospective study by Xie et al., 215 patients that underwent atypical or anatomical segmentectomy by RATS or VATS were analysed for short-term treatment outcomes. The authors concluded that RATS was a safe approach and even resulted in higher lymph node sampling rates and fewer postoperative complications compared to VATS [31].

Even for treating centrally located NSCLC lesions, emerging evidence is suggesting that RATS may play a major role in the near future. A recent retrospective study by Qiu et al. compared treatment and oncological outcomes of RATS to VATS and open surgery in 188 patients undergoing sleeve lobectomy for centrally located NSCLC. RATS was non-inferior to both VATS and open surgery regarding oncological prognosis. However, the robotic group had significantly less blood loss, shorter operative times, and reduced tube drainage times compared to the two other groups. The authors concluded that robotic sleeve lobectomy is a safe, feasible and effective procedure for centrally located NSCLC [32]. Despite all these promising studies, these findings have not been demonstrated in large prospective series or randomised controlled trials (RCT).

## **2.2 Mediastinal masses**

Mediastinal masses in the anterior, middle or posterior compartment are a heterogeneous group that account for approximately 3% of all thoracic lesions. The most common mediastinal masses are thymomas, bronchogenic cysts, neurogenic tumours, and thyroid masses. These lesions derive from different germ layers located in various parts of the thoracic cavity [33]. In the past, surgical removal of these mediastinal masses was generally performed using a median sternotomy, posterolateral thoracotomy, or hemi-clamshell sternotomy, often resulting in significant postoperative morbidity [34]. However, the increasingly widespread use of minimal-invasive approaches in other surgical domains has resulted in a similar shift in treatment approaches for mediastinal tumours [35]. Thoracoscopic thymectomy was first described in 1993 and VATS has since become one of the standard approaches for thymic and non-thymic malignancies [35]. Earlier studies have shown that VATS is associated with less perioperative blood loss, shorter operation times, and less chest tube drainage compared to open procedures [36]. In the past two decades, robotic surgery has gained popularity in the treatment of mediastinal masses as well. Similar to the situation for lung cancer surgery, RATS has advantages over conventional VATS due to its three-dimensional image and multi-articulated instruments, providing easy access to the small mediastinal space and allowing safe removal of mediastinal masses [37, 38]. While comparisons of treatment outcomes and postoperative complications between open and MIS approaches have been performed before, few studies have directly compared VATS to RATS for mediastinal masses.

In a retrospective study by Qian et al., 123 patients with early-stage thymoma were analysed to compare treatment outcomes for VATS, RATS, and median sternotomy. The authors concluded that RATS and VATS are both feasible techniques

**63**

*Robotic Surgery for the Thoracic and Vascular Surgeon DOI: http://dx.doi.org/10.5772/intechopen.97598*

for early-stage thymomas with similar oncological outcomes compared to open surgery. However, their data did show more favourable outcomes for RATS regarding post-operative pleural drainage duration time, drainage volumes, and hospital LOS [39]. Other recent studies have corroborated these findings as well. Zeng et al. retrospectively analysed 274 patients that underwent multiportal VATS, uniportal VATS, or RATS resection of a mediastinal mass. Compared with multiportal VATS, uniportal VATS and RATS had a significantly shorter chest tube placement time and hospital LOS without increasing the incidence rate of complications. The RATS approach was associated with better intraoperative safety and was considered non-inferior regarding postoperative outcomes compared to multiportal VATS [40]. In a very recent retrospective cohort study using the National Inpatient Sample (NIS) database, an estimated total of 23,087 patients that underwent thymectomy were included to compare outcomes after open, VATS, and RATS thymectomy. The majority of patients were treated for thymoma or myasthenia gravis, with approximately 16,025 patients (69%) in the open surgery group, 4,119 (18%) in the VATS group, and 3,097 (13%) in the RATS group. In the analysed period of 2008–2014, trend analysis revealed a decline in open surgery, while the performance of VATS and RATS had increased. No significant differences in overall complication rates or hospital LOS were found in this study. However, RATS was associated with lower rates of cardiac complications and haemorrhage [41]. Even for the rarer posterior mediastinal tumours, recent data suggests that RATS may be superior in terms of

postoperative blood loss and hospital LOS compared to VATS [4].

tions such as brachial plexus injury or vascular injury [44].

Thoracic outlet syndrome (TOS) is a complex disorder that comprises a myriad of possible symptoms which arise from compression of the brachial plexus, subclavian artery, and/or the subclavian vein. This compression generally occurs in the triangular space referred to as the thoracic outlet, which is located between the first rib, the clavicle, and the scalene muscles [42]. The majority of patients with TOS can be treated with non-surgical measures such as medication, posture correction, physical therapy, or taping. However, in a relatively small number of patients, these conservative treatments fail to alleviate the symptoms, often resulting in significant morbidity [43]. In these patients, or when vascular structures are involved, surgical decompression with removal of the first rib is usually necessary. Over the last decades, several types of surgical approaches and techniques have been described. Historically, extrathoracic approaches have used a supraclavicular or transaxillary incision to resect the first rib. Despite their well-documented effectiveness, many authors have asserted that these approaches are regularly associated with complica-

The intrathoracic approach using VATS has been the most popular approach in the last decade, owing to the theoretical advantage of fewer postoperative neurovascular complications and incomplete resections [45]. In recent years, the roboticassisted approach has rapidly gained ground as a viable alternative to VATS due to its superior optics and instrument control [44]. However, this remains a relatively new field with only a limited number of studies published reporting outcomes of RATS first rib resections. Data from retrospective studies and case series from the last decade suggests that the robotic approach is safe, effective, and non-inferior to the VATS approach [46]. In a recent single-center, prospective study by Burt et al. RATS first rib resection was compared to the conventional supraclavicular approach in 116 patients (66 RATS and 50 open surgery). Postoperative pain and analgesia need was significantly lower in the robotic approach group. Furthermore, RATS was associated with fewer cases of brachial plexus palsy and overall complication

**2.3 First rib resection**

*Robotic Surgery for the Thoracic and Vascular Surgeon DOI: http://dx.doi.org/10.5772/intechopen.97598*

*Latest Developments in Medical Robotics Systems*

tions compared to VATS [31].

randomised controlled trials (RCT).

to RATS for mediastinal masses.

**2.2 Mediastinal masses**

and survival outcomes of sublobar resections to lobectomy, there is still no clear consensus on whether sublobar resections are indeed non-inferior to lobectomy. Some authors suggest that sublobar resections result in lower overall survival rates, higher positive resection margins, higher recurrence rates, and inadequate lymph node sampling [29]. However, there is a growing number of studies suggesting that segmentectomy has similar overall and disease-free survival rates as lobectomy [30]. Furthermore, sublobar resections have also been associated with improved postoperative quality of life (QoL) [16]. For robotic segmentectomy, the current data suggests that treatment outcomes and complication rates are similar to VATS. In a recent retrospective study by Xie et al., 215 patients that underwent atypical or anatomical segmentectomy by RATS or VATS were analysed for short-term treatment outcomes. The authors concluded that RATS was a safe approach and even resulted in higher lymph node sampling rates and fewer postoperative complica-

Even for treating centrally located NSCLC lesions, emerging evidence is suggesting that RATS may play a major role in the near future. A recent retrospective study by Qiu et al. compared treatment and oncological outcomes of RATS to VATS and open surgery in 188 patients undergoing sleeve lobectomy for centrally located NSCLC. RATS was non-inferior to both VATS and open surgery regarding oncological prognosis. However, the robotic group had significantly less blood loss, shorter operative times, and reduced tube drainage times compared to the two other groups. The authors concluded that robotic sleeve lobectomy is a safe, feasible and effective procedure for centrally located NSCLC [32]. Despite all these promising studies, these findings have not been demonstrated in large prospective series or

Mediastinal masses in the anterior, middle or posterior compartment are a heterogeneous group that account for approximately 3% of all thoracic lesions. The most common mediastinal masses are thymomas, bronchogenic cysts, neurogenic tumours, and thyroid masses. These lesions derive from different germ layers located in various parts of the thoracic cavity [33]. In the past, surgical removal of these mediastinal masses was generally performed using a median sternotomy, posterolateral thoracotomy, or hemi-clamshell sternotomy, often resulting in significant postoperative morbidity [34]. However, the increasingly widespread use of minimal-invasive approaches in other surgical domains has resulted in a similar shift in treatment approaches for mediastinal tumours [35]. Thoracoscopic thymectomy was first described in 1993 and VATS has since become one of the standard approaches for thymic and non-thymic malignancies [35]. Earlier studies have shown that VATS is associated with less perioperative blood loss, shorter operation times, and less chest tube drainage compared to open procedures [36]. In the past two decades, robotic surgery has gained popularity in the treatment of mediastinal masses as well. Similar to the situation for lung cancer surgery, RATS has advantages over conventional VATS due to its three-dimensional image and multi-articulated instruments, providing easy access to the small mediastinal space and allowing safe removal of mediastinal masses [37, 38]. While comparisons of treatment outcomes and postoperative complications between open and MIS approaches have been performed before, few studies have directly compared VATS

In a retrospective study by Qian et al., 123 patients with early-stage thymoma were analysed to compare treatment outcomes for VATS, RATS, and median sternotomy. The authors concluded that RATS and VATS are both feasible techniques

**62**

for early-stage thymomas with similar oncological outcomes compared to open surgery. However, their data did show more favourable outcomes for RATS regarding post-operative pleural drainage duration time, drainage volumes, and hospital LOS [39]. Other recent studies have corroborated these findings as well. Zeng et al. retrospectively analysed 274 patients that underwent multiportal VATS, uniportal VATS, or RATS resection of a mediastinal mass. Compared with multiportal VATS, uniportal VATS and RATS had a significantly shorter chest tube placement time and hospital LOS without increasing the incidence rate of complications. The RATS approach was associated with better intraoperative safety and was considered non-inferior regarding postoperative outcomes compared to multiportal VATS [40]. In a very recent retrospective cohort study using the National Inpatient Sample (NIS) database, an estimated total of 23,087 patients that underwent thymectomy were included to compare outcomes after open, VATS, and RATS thymectomy. The majority of patients were treated for thymoma or myasthenia gravis, with approximately 16,025 patients (69%) in the open surgery group, 4,119 (18%) in the VATS group, and 3,097 (13%) in the RATS group. In the analysed period of 2008–2014, trend analysis revealed a decline in open surgery, while the performance of VATS and RATS had increased. No significant differences in overall complication rates or hospital LOS were found in this study. However, RATS was associated with lower rates of cardiac complications and haemorrhage [41]. Even for the rarer posterior mediastinal tumours, recent data suggests that RATS may be superior in terms of postoperative blood loss and hospital LOS compared to VATS [4].
