**1. Introduction**

The advent of minimally invasive surgery (MIS) has clearly changed the landscape for surgical practice worldwide. By combining multiple technological developments such as high-definition cameras and surgical microinstruments, surgeons are able to perform more and more complex procedures through small incisions [1]. Since the introduction of MIS, safe and feasible laparoscopic and thoracoscopic surgical procedures have been developed for a large variety of operations. For the majority of these procedures, studies have shown that the minimal-invasive approach results in fewer complications, reduced hospital stays, and faster return to normal functions compared to their respective open approach [2, 3]. However, despite these clear advantages of MIS, there are a number of drawbacks as well. Proficiency in MIS requires intensive, continuous training and often involves steep

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 and their outcome.

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 for occlusive disease [4, 9].

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