Robotics in thoracic surgery: Applications and outcomes
2006; Elsevier BV; Volume: 131; Issue: 1 Linguagem: Inglês
10.1016/j.jtcvs.2005.09.007
ISSN1097-685X
Autores Tópico(s)Soft Robotics and Applications
ResumoRobotics has been used in numerous surgical procedures, but with few exceptions, this technologic advance has not been translated into improved outcomes. Many robotic applications have been unveiled as the manifestation a new idea in search of an application. The principal advantages of robotic assistance in surgical intervention are the greater degree of instrumental articulation and motion scaling.1Prasad S.M. Prasad S.M. Maniar H.S. Chu C. Schuessler R.B. Damiano Jr, R.J. Surgical robotics impact of motion scaling on task performance.J Am Coll Surg. 2004; 199: 863-868Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar However, despite these recognized technical advantages, the demonstration of superior results has been disappointing.See related article on page 54. See related article on page 54. A significant clinical application for surgical robotics has been for resection of prostate cancer. In a prospective nonrandomized trial comparing robotic with conventional radical retropubic prostatectomy among 60 patients, Menon and colleaguesr2Menon M. Tewari A. Baize B. Guillonneau B. Vallancien G. Prospective comparison of radical retropubic prostatectomy and robot-assisted anatomic prostatectomy the Vattikuti Urology Institute experience.Urology. 2002; 60: 864-868Abstract Full Text Full Text PDF PubMed Scopus (360) Google Scholar found that the robotic approach significantly reduced intraoperative blood loss and postoperative pain compared with the open approach. Furthermore, although the mean length of stay for patients in the conventional group was 4 days, two thirds of men undergoing robotic prostatectomy were discharged in less than 23 hours. Robotic mitral valve surgery is also gaining acceptance, although there are no randomized studies that demonstrate superiority compared with the conventional approaches. In a recently published prospective series of 38 consecutive patients, Nifong and associates3Nifong L.W. Chu V.F. Bailey B.M. Maziarz D.M. Sorrell V.L. Holbert D. et al.Robotic mitral valve repair experience with the da Vinci system.Ann Thorac Surg. 2003; 75: 438-442Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar reported no operative deaths, strokes, or conversions to open sternotomy. The average total operative time was less than 5 hours, and the mean length of stay was 4 days.3Nifong L.W. Chu V.F. Bailey B.M. Maziarz D.M. Sorrell V.L. Holbert D. et al.Robotic mitral valve repair experience with the da Vinci system.Ann Thorac Surg. 2003; 75: 438-442Abstract Full Text Full Text PDF PubMed Scopus (164) Google Scholar In a recent phase II multicenter trial of robotic mitral valve surgery, total robot, aortic crossclamp, and cardiopulmonary bypass times were 78 minutes, 2.1 hours, and 2.8 hours, respectively. At 1 month of transthoracic echocardiography, only 8% had grade 2 mitral regurgitation. There were no deaths, strokes, or device-related complications.4Nifong L.W. Chitwood W.R. Pappas P.S. Smith C.R. Argenziano M. Starnes V.A. et al.Robotic mitral valve surgery a United States multicenter trial.J Thorac Cardiovasc Surg. 2005; 129: 1395-1404Abstract Full Text Full Text PDF PubMed Scopus (198) Google Scholar The use of robotics is also being studied in general thoracic surgery, including lobectomy,5Ashton R.C. Connery C.P. Swistel D.G. DeRose J.J. Robot-assisted lobectomy.Ann Thorac Surg. 2004; 78: 259-265Abstract Full Text Full Text PDF PubMed Scopus (119) Google Scholar esophagectomy,6Espat N.J. Jacobsen G. Horgan S. Donahue P. Minimally invasive treatment of esophageal cancer laparoscopic staging to robotic esophagectomy.Cancer J. 2005; 11: 10-17Crossref PubMed Scopus (41) Google Scholar and various other procedures,7Bodner J. Wykypiel H. Wetscher G. Schmid T. First experiences with the da Vinci operating robot in thoracic surgery.Eur J Cardiothorac Surg. 2004; 25: 844-851Crossref PubMed Scopus (246) Google Scholar demonstrating safety and feasibility. The study by Park and coworkers8Park B.J. Flores R.M. Rusch V.W. Robotic-assistance for video-assisted thoracic surgical lobectomy technique and initial results.J Thorac Cardiovasc Surg. 2006; 131: 54-59Abstract Full Text Full Text PDF PubMed Scopus (229) Google Scholar in this issue of the Journal describes their experience in developing a standardized approach to robotic lobectomy. As with most thoracic procedures that can be performed robotically, the potential advantages of articulation in 7 degrees and motion stability are probably not fully realized in robotic lobectomy. The growing experience with thoracoscopic lobectomy suggests that the limitations imposed by the thoracoscopic technique, such as port placement and visualization, are easily overcome.9Daniels L.J. Balderson S.S. Onaitis M.W. D’Amico T.A. Thoracoscopic lobectomy a safe and effective strategy for patients with stage I lung cancer.Ann Thorac Surg. 2002; 74: 860-864Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar, 10Demmy T.L. James T.A. Swanson S.J. McKenna Jr, R.J. D’Amico T.A. Troubleshooting VATS lobectomy.Ann Thorac Surg. 2005; 79: 1744-1753Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar However, there are several disadvantage of the robotic system. One important disadvantage is the loss of tactile sense in current systems. Although thoracoscopic lobectomy might alter tactile feedback compared with open thoracotomy, much information is nevertheless communicated to the surgeon’s hands. The significance of this feedback is difficult to quantify, and it is possible that robotic systems will be designed to transmit tactile information in the future. In addition, the instrumentation that is available for use robotically is limited in comparison with the instrumentation available for thoracoscopic or open lobectomy. It is unlikely that the same spectrum of instrumentation will be developed for the robot. Perhaps the superior articulation of the robotic system will compensate for the inferior selection of instrumentation. Also, the time required to assemble the robotic instrumentation is significant, as is the increase in the overall operative time. In this study the median operative time was 218 minutes, and the median room time was 306 minutes.8Park B.J. Flores R.M. Rusch V.W. Robotic-assistance for video-assisted thoracic surgical lobectomy technique and initial results.J Thorac Cardiovasc Surg. 2006; 131: 54-59Abstract Full Text Full Text PDF PubMed Scopus (229) Google Scholar Although the total operative times are likely to decrease with experience, as they have with thoracoscopic lobectomy,9Daniels L.J. Balderson S.S. Onaitis M.W. D’Amico T.A. Thoracoscopic lobectomy a safe and effective strategy for patients with stage I lung cancer.Ann Thorac Surg. 2002; 74: 860-864Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar, 10Demmy T.L. James T.A. Swanson S.J. McKenna Jr, R.J. D’Amico T.A. Troubleshooting VATS lobectomy.Ann Thorac Surg. 2005; 79: 1744-1753Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar the mandatory set-up time seems prohibitive for most surgeons. Currently, the robotic technique appears to require 3 experienced surgeons8Park B.J. Flores R.M. Rusch V.W. Robotic-assistance for video-assisted thoracic surgical lobectomy technique and initial results.J Thorac Cardiovasc Surg. 2006; 131: 54-59Abstract Full Text Full Text PDF PubMed Scopus (229) Google Scholar compared with 1 for the thoracoscopic technique.9Daniels L.J. Balderson S.S. Onaitis M.W. D’Amico T.A. Thoracoscopic lobectomy a safe and effective strategy for patients with stage I lung cancer.Ann Thorac Surg. 2002; 74: 860-864Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar, 10Demmy T.L. James T.A. Swanson S.J. McKenna Jr, R.J. D’Amico T.A. Troubleshooting VATS lobectomy.Ann Thorac Surg. 2005; 79: 1744-1753Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar In the short term this will negatively affect resident training at institutions that favor the robotic approach. In addition, the introduction of robotic and other technology into the operating room has necessitated the development of training programs to teach surgeons how to use the technology. It will be important for surgeons to demonstrate mastery of these techniques before including them in practice. In summary, the analysis by Park and coworkers8Park B.J. Flores R.M. Rusch V.W. Robotic-assistance for video-assisted thoracic surgical lobectomy technique and initial results.J Thorac Cardiovasc Surg. 2006; 131: 54-59Abstract Full Text Full Text PDF PubMed Scopus (229) Google Scholar is an important and commendable effort to study and standardize the robotic technique. The outcomes of the robotic technique should be compared with thoracoscopic techniques, which are associated with significant advantages vis a vis thoracotomy, including shorter length of stay, less pain, preserved pulmonary function, and faster return to full activity.9Daniels L.J. Balderson S.S. Onaitis M.W. D’Amico T.A. Thoracoscopic lobectomy a safe and effective strategy for patients with stage I lung cancer.Ann Thorac Surg. 2002; 74: 860-864Abstract Full Text Full Text PDF PubMed Scopus (132) Google Scholar, 10Demmy T.L. James T.A. Swanson S.J. McKenna Jr, R.J. D’Amico T.A. Troubleshooting VATS lobectomy.Ann Thorac Surg. 2005; 79: 1744-1753Abstract Full Text Full Text PDF PubMed Scopus (70) Google Scholar As experience with robotic lobectomy improves, the disadvantages might become less important, and the advantages might become more well defined. Although it is not likely that a randomized study would be funded to compare robotic lobectomy with alternatives, some appraisal must be made to assess overall effectiveness, including cost-effectiveness. Surgeons who study technologic advances, such as robotic lobectomy, will be better prepared to adapt, to lead the field, to develop more effective techniques, and to improve surgical outcomes.1Prasad S.M. Prasad S.M. Maniar H.S. Chu C. Schuessler R.B. Damiano Jr, R.J. Surgical robotics impact of motion scaling on task performance.J Am Coll Surg. 2004; 199: 863-868Abstract Full Text Full Text PDF PubMed Scopus (99) Google Scholar Robotic assistance for video-assisted thoracic surgical lobectomy: Technique and initial resultsThe Journal of Thoracic and Cardiovascular SurgeryVol. 131Issue 1PreviewThere is little experience with telerobotic assistance for video-assisted thoracic surgical lobectomy. We developed a technique for robotic assistance during video-assisted thoracic surgical lobectomy and report our initial results. Full-Text PDF
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