Robot-assisted Lung Anatomic S e g m e n t e c t o m y : Technical Aspects Alessandro Pardolesi, MD*, Giulia Veronesi, MD KEYWORDS Anatomic lung segmentectomy Robot-assisted lung resection Early stage non–small cell lung cancer
KEY POINTS Robot-assisted anatomic lung segmentectomy for non–small cell lung cancer and lung metastases is feasible and safe. Segmentectomy allows assessment of hilar, bronchial, and vascular lymph nodes, which is important because lymph nodes can be involved even in clinical stage IA disease. With increasing use of lung cancer screening for high-risk individuals, more small early stage lung cancers will be detected. Robotic surgical systems have several advantages compared with traditional video-assisted thoracoscopic surgery, including three-dimensional field of view and more degrees of movement freedom for robotic arms, which replicate human arm and wrist movements.
Videos of upper segmentectomy right lower lobe, upper segmentectomy left lower lobe and trisegmentectomy of left upper lobe (lingula-sparing lobectomy) accompany this article at http:// www.thoracic.theclinics.com/
With the widespread use of computed tomography (CT) and the potential adoption of low-dose CT lung cancer screening for high-risk individuals, it is expected that the number of small early stage lung cancers diagnosed will increase. The optimal treatment of these small lesions may not be lobectomy, and extended or anatomic segmentectomy1–3 as well wedge resection4 have been investigated for small (1 cm) they are sent for intraoperative frozen section to rule out metastatic nodal disease. For culmen or lingular resections, lymph node dissection of the pulmonary window is performed first to facilitate dissection of the branches of the pulmonary artery and of the upper pulmonary vein. Hilar lymphadenectomy is performed while the hilum is being dissected.
IMMEDIATE POSTOPERATIVE CARE On completion of surgery, patients are extubated and pass 1 or 2 hours in the recovery room with cardiorespiratory monitoring. They are then transferred to the ward. Cardiorespiratory function, blood pressure, temperature, urine output, and hemoglobin saturation are monitored while in the ward. A chest radiograph is performed shortly after the end of the procedure.
REHABILITATION AND RECOVERY If there are no complications requiring specific treatment or intensive care, patients are mobilized and start eating on the first postoperative day. Intravenous fluid administration is generally maintained during the first 24 hours. Prophylactic antibiotics, started before surgery, are administered for not more than 72 hours, even if the chest tube remains in place. Postoperative pain is usually well controlled by a combination of local anesthetic (bupivacaine or ropivacaine infiltrated into the wounds), subcutaneous morphine (5 or 10 mg every 4 or 6 hours), and intravenous paracetamol (every 6 hours). The chest tube(s) is removed on the second or third postoperative day providing not more than 250 mL of fluid are collected over 24 hours, there is no air leak, and the lung is appears to be completely expanded on the chest radiograph. Patients undergo intensive lung rehabilitation starting on the first postoperative day and continuing until discharge.
Robotic Lung Anatomic Segmentectomy
Table 1 Characteristics of 17 patients who underwent robotic lung segmentectomy at the Memorial SloanKettering Cancer Center, European Institute of Oncology, and Hackensack University Medical Center between January 2008 and December 2010 Variable
Number
Percentage
Age (y); mean (range) Sex (M/F) Tumor size (cm); mean (range) Segmentectomy location/type Left lower lobe superior Right lower lobe superior Lingulectomy Left upper lobe trisegmentectomy (lingula sparing) Left lower lobe basal Right upper lobe anterior Primary lung cancer histology Adenocarcinoma Squamous cell carcinoma Bronchioloalveolar carcinoma Typical carcinoid Secondary lung cancer
68.2 (32–82) 7/10 1.11 (0.6–2.8)
— 41.2/58.8 —
4 3 3 2
23.5 17.6 17.6 11.9
4 1 10 5 1 2 2 7
23.5 5.9 58.8 — — — — 41.2
CLINICAL RESULTS IN THE LITERATURE Seventeen consecutive patients underwent robotic lung segmentectomy at the Memorial SloanKettering Cancer Center (New York), European Institute of Oncology (Milan, Italy), and Hackensack University Medical Center (New Jersey) from January 1, 2008, to December 1 2010. Ten were women, 7 were men. Mean age was 68.2 years (range 32–82 years). Mean operating time was 189 minutes (range 138–240 minutes) (Table 1).14 Most lesions (64.7%) affected the lower lobe. There were no conversions to either VATS or thoracotomy. Median postoperative stay was 5 days (range 2–14 days). Postoperative mortality was 0%. Early postoperative complications (17.6%) were minor: 1 (5.9%) pneumonia, 2 prolonged air leaks (11.9%). In 5 patients (29.4%) the diagnosis was obtained before surgery by fine-needle aspiration biopsy. Final pathology identified non–small cell lung cancer in 8 patients, typical carcinoid in 2, and lung metastases in 7. The metastases were histologically compatible with colon carcinoma in 3 patients, and breast cancer, gastrointestinal trophoblastic tumor adenoid cystic carcinoma, and osteogenic sarcoma in 1 patient each. Two of the primary lung cancers were pN1 and 6 were pN0. Median tumor size was 1.11 cm (range 0.6–2.8 cm). PET was performed in 12 cases; it was nor performed in 5 cases with clinically suspected
of lung metastases. PET was considered positive (visual assessment) in 9 (75%) cases.
SUMMARY Initial experience of anatomic robotic segmentectomy in patients with a single primary or metastatic lung lesion is encouraging. No major complications and no conversion to open surgery were reported, operating times were acceptable, and hospital stay was in line with that for VATS lung procedures.8 Anatomic robotic segmentectomy seems to offer all the advantages of minimally invasive surgery and provides the additional advantages of greater dexterity, three-dimensional vision, and greater surgeon comfort, thereby facilitating precise anatomic dissection, including lymphadenectomy, which promises to be oncologically radical. However, further studies are required to compare robotic segmentectomy with open and VATS approaches, and long-term follow-up is necessary to verify the oncologic efficacy of the robotic technique. If the advantages are confirmed by experience, it is expected that robotic procedures will be more widely adopted by thoracic surgeons than the more demanding VATS, even though the high cost of robotic units remains a problem. However, robotic technology is evolving quickly, and costs may decrease as the technology matures, competing manufacturers enter the field,
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Box 2 Summary Screening results in increased diagnosis of very early stage lung cancer disease Survival benefit of minimally invasive versus open procedures Randomized controlled trial ongoing in United States and Japan comparing limited resection with lobectomy for lung cancer for stage 1a disease less than 2 cm Robotic segmentectomy is feasible and safe Robotic technology has simplified complex minimally invasive procedures Future task: to show the superiority of robotics versus VATS
and more machines become available. The introduction of robotic staplers, aspirators, and 5-mm lung forceps will further increase precision (Box 2).
SUPPLEMENTARY DATA Videos related to this article can be found online at http://dx.doi.org/10.1016/j.thorsurg.2014.02.008.
REFERENCES 1. Yoshikawa K, Tsubota N, Kodama K, et al. Prospective study of extended segmentectomy for small lung tumors: the final report. Ann Thorac Surg 2002;73:1055–9. 2. Kodama K, Doi O, Higashiyama M, et al. Intentional limited resection for selected patients with T1 N0 M0 non-small-cell lung cancer: a single-institution study. J Thorac Cardiovasc Surg 1997;114:347–53. 3. Jensik RJ, Faber LP, Kittle CF. Segmental resection for bronchogenic carcinoma. Ann Thorac Surg 1979;28:475–83. 4. Peters RM. The role of limited resection in carcinoma of the lung. Am J Surg 1982;143:706–10.
5. Ginberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 nonsmall cell lung cancer. Ann Thorac Surg 1995;60: 615–23. 6. Keenan RJ, Landreneau RJ, Maley RH, et al. Segmental resection spares pulmonary function in patients with stage 1 lung cancer. Ann Thorac Surg 2004;78:228–33. 7. Harada H, Okada M, Sakamoto T, et al. Functional advantage after radical segmentectomy versus lobectomy for lung cancer. Ann Thorac Surg 2005; 80:2041–5. 8. Okada M, Yoshikawa K, Hatta T, et al. Is segmentectomy with lymph node assessment an alternative to lobectomy for non-small cell lung cancer of 2 cm or smaller? Ann Thorac Surg 2001;71: 956–61. 9. Koike T, Yamato Y, Yoshiya K, et al. Intentional limited pulmonary resection for peripheral T1 N0 M0 small-sized lung cancer. J Thorac Cardiovasc Surg 2003;125:924–8. 10. Petersen RP, Pham D, Burfeind WR, et al. Thoracoscopic lobectomy facilitates the delivery of chemotherapy after resection for lung cancer. Ann Thorac Surg 2007;83:1245–9. 11. Atkins BZ, Harpole DH, Magnum JH, et al. Pulmonary segmentectomy by thoracotomy or thoracoscopy: reduced hospital length of stay with a minimally-invasive approach. Ann Thorac Surg 2007;84:1107–12. 12. Whitson BA, Groth SS, Duval SJ, et al. Surgery for early-stage non-small cell lung cancer: a systematic review of the video-assisted thoracoscopic surgery versus thoracotomy approaches to lobectomy. Ann Thorac Surg 2008;86(6):2008–16. http:// dx.doi.org/10.1016/j.athoracsur.2008.07.009 [discussion: 2016–8]. 13. Veronesi G. Robotic surgery for the treatment of early-stage lung cancer. Curr Opin Oncol 2013; 25(2):107–14. 14. Pardolesi A, Park B, Petrella F, et al. Robotic anatomic segmentectomy of the lung: technical aspects and initial results. Ann Thorac Surg 2012;94(3):929–34. http://dx.doi.org/10.1016/j.athoracsur.2012.04.086.
KEY POINTS Robot-assisted anatomic lung segmentectomy for non–small cell lung cancer and lung metastases is feasible and safe. Segmentectomy allows assessment of hilar, bronchial, and vascular lymph nodes, which is important because lymph nodes can be involved even in clinical stage IA disease. With increasing use of lung cancer screening for high-risk individuals, more small early stage lung cancers will be detected. Robotic surgical systems have several advantages compared with traditional video-assisted thoracoscopic surgery, including three-dimensional field of view and more degrees of movement freedom for robotic arms, which replicate human arm and wrist movements.
Videos of upper segmentectomy right lower lobe, upper segmentectomy left lower lobe and trisegmentectomy of left upper lobe (lingula-sparing lobectomy) accompany this article at http:// www.thoracic.theclinics.com/
With the widespread use of computed tomography (CT) and the potential adoption of low-dose CT lung cancer screening for high-risk individuals, it is expected that the number of small early stage lung cancers diagnosed will increase. The optimal treatment of these small lesions may not be lobectomy, and extended or anatomic segmentectomy1–3 as well wedge resection4 have been investigated for small (1 cm) they are sent for intraoperative frozen section to rule out metastatic nodal disease. For culmen or lingular resections, lymph node dissection of the pulmonary window is performed first to facilitate dissection of the branches of the pulmonary artery and of the upper pulmonary vein. Hilar lymphadenectomy is performed while the hilum is being dissected.
IMMEDIATE POSTOPERATIVE CARE On completion of surgery, patients are extubated and pass 1 or 2 hours in the recovery room with cardiorespiratory monitoring. They are then transferred to the ward. Cardiorespiratory function, blood pressure, temperature, urine output, and hemoglobin saturation are monitored while in the ward. A chest radiograph is performed shortly after the end of the procedure.
REHABILITATION AND RECOVERY If there are no complications requiring specific treatment or intensive care, patients are mobilized and start eating on the first postoperative day. Intravenous fluid administration is generally maintained during the first 24 hours. Prophylactic antibiotics, started before surgery, are administered for not more than 72 hours, even if the chest tube remains in place. Postoperative pain is usually well controlled by a combination of local anesthetic (bupivacaine or ropivacaine infiltrated into the wounds), subcutaneous morphine (5 or 10 mg every 4 or 6 hours), and intravenous paracetamol (every 6 hours). The chest tube(s) is removed on the second or third postoperative day providing not more than 250 mL of fluid are collected over 24 hours, there is no air leak, and the lung is appears to be completely expanded on the chest radiograph. Patients undergo intensive lung rehabilitation starting on the first postoperative day and continuing until discharge.
Robotic Lung Anatomic Segmentectomy
Table 1 Characteristics of 17 patients who underwent robotic lung segmentectomy at the Memorial SloanKettering Cancer Center, European Institute of Oncology, and Hackensack University Medical Center between January 2008 and December 2010 Variable
Number
Percentage
Age (y); mean (range) Sex (M/F) Tumor size (cm); mean (range) Segmentectomy location/type Left lower lobe superior Right lower lobe superior Lingulectomy Left upper lobe trisegmentectomy (lingula sparing) Left lower lobe basal Right upper lobe anterior Primary lung cancer histology Adenocarcinoma Squamous cell carcinoma Bronchioloalveolar carcinoma Typical carcinoid Secondary lung cancer
68.2 (32–82) 7/10 1.11 (0.6–2.8)
— 41.2/58.8 —
4 3 3 2
23.5 17.6 17.6 11.9
4 1 10 5 1 2 2 7
23.5 5.9 58.8 — — — — 41.2
CLINICAL RESULTS IN THE LITERATURE Seventeen consecutive patients underwent robotic lung segmentectomy at the Memorial SloanKettering Cancer Center (New York), European Institute of Oncology (Milan, Italy), and Hackensack University Medical Center (New Jersey) from January 1, 2008, to December 1 2010. Ten were women, 7 were men. Mean age was 68.2 years (range 32–82 years). Mean operating time was 189 minutes (range 138–240 minutes) (Table 1).14 Most lesions (64.7%) affected the lower lobe. There were no conversions to either VATS or thoracotomy. Median postoperative stay was 5 days (range 2–14 days). Postoperative mortality was 0%. Early postoperative complications (17.6%) were minor: 1 (5.9%) pneumonia, 2 prolonged air leaks (11.9%). In 5 patients (29.4%) the diagnosis was obtained before surgery by fine-needle aspiration biopsy. Final pathology identified non–small cell lung cancer in 8 patients, typical carcinoid in 2, and lung metastases in 7. The metastases were histologically compatible with colon carcinoma in 3 patients, and breast cancer, gastrointestinal trophoblastic tumor adenoid cystic carcinoma, and osteogenic sarcoma in 1 patient each. Two of the primary lung cancers were pN1 and 6 were pN0. Median tumor size was 1.11 cm (range 0.6–2.8 cm). PET was performed in 12 cases; it was nor performed in 5 cases with clinically suspected
of lung metastases. PET was considered positive (visual assessment) in 9 (75%) cases.
SUMMARY Initial experience of anatomic robotic segmentectomy in patients with a single primary or metastatic lung lesion is encouraging. No major complications and no conversion to open surgery were reported, operating times were acceptable, and hospital stay was in line with that for VATS lung procedures.8 Anatomic robotic segmentectomy seems to offer all the advantages of minimally invasive surgery and provides the additional advantages of greater dexterity, three-dimensional vision, and greater surgeon comfort, thereby facilitating precise anatomic dissection, including lymphadenectomy, which promises to be oncologically radical. However, further studies are required to compare robotic segmentectomy with open and VATS approaches, and long-term follow-up is necessary to verify the oncologic efficacy of the robotic technique. If the advantages are confirmed by experience, it is expected that robotic procedures will be more widely adopted by thoracic surgeons than the more demanding VATS, even though the high cost of robotic units remains a problem. However, robotic technology is evolving quickly, and costs may decrease as the technology matures, competing manufacturers enter the field,
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Box 2 Summary Screening results in increased diagnosis of very early stage lung cancer disease Survival benefit of minimally invasive versus open procedures Randomized controlled trial ongoing in United States and Japan comparing limited resection with lobectomy for lung cancer for stage 1a disease less than 2 cm Robotic segmentectomy is feasible and safe Robotic technology has simplified complex minimally invasive procedures Future task: to show the superiority of robotics versus VATS
and more machines become available. The introduction of robotic staplers, aspirators, and 5-mm lung forceps will further increase precision (Box 2).
SUPPLEMENTARY DATA Videos related to this article can be found online at http://dx.doi.org/10.1016/j.thorsurg.2014.02.008.
REFERENCES 1. Yoshikawa K, Tsubota N, Kodama K, et al. Prospective study of extended segmentectomy for small lung tumors: the final report. Ann Thorac Surg 2002;73:1055–9. 2. Kodama K, Doi O, Higashiyama M, et al. Intentional limited resection for selected patients with T1 N0 M0 non-small-cell lung cancer: a single-institution study. J Thorac Cardiovasc Surg 1997;114:347–53. 3. Jensik RJ, Faber LP, Kittle CF. Segmental resection for bronchogenic carcinoma. Ann Thorac Surg 1979;28:475–83. 4. Peters RM. The role of limited resection in carcinoma of the lung. Am J Surg 1982;143:706–10.
5. Ginberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 nonsmall cell lung cancer. Ann Thorac Surg 1995;60: 615–23. 6. Keenan RJ, Landreneau RJ, Maley RH, et al. Segmental resection spares pulmonary function in patients with stage 1 lung cancer. Ann Thorac Surg 2004;78:228–33. 7. Harada H, Okada M, Sakamoto T, et al. Functional advantage after radical segmentectomy versus lobectomy for lung cancer. Ann Thorac Surg 2005; 80:2041–5. 8. Okada M, Yoshikawa K, Hatta T, et al. Is segmentectomy with lymph node assessment an alternative to lobectomy for non-small cell lung cancer of 2 cm or smaller? Ann Thorac Surg 2001;71: 956–61. 9. Koike T, Yamato Y, Yoshiya K, et al. Intentional limited pulmonary resection for peripheral T1 N0 M0 small-sized lung cancer. J Thorac Cardiovasc Surg 2003;125:924–8. 10. Petersen RP, Pham D, Burfeind WR, et al. Thoracoscopic lobectomy facilitates the delivery of chemotherapy after resection for lung cancer. Ann Thorac Surg 2007;83:1245–9. 11. Atkins BZ, Harpole DH, Magnum JH, et al. Pulmonary segmentectomy by thoracotomy or thoracoscopy: reduced hospital length of stay with a minimally-invasive approach. Ann Thorac Surg 2007;84:1107–12. 12. Whitson BA, Groth SS, Duval SJ, et al. Surgery for early-stage non-small cell lung cancer: a systematic review of the video-assisted thoracoscopic surgery versus thoracotomy approaches to lobectomy. Ann Thorac Surg 2008;86(6):2008–16. http:// dx.doi.org/10.1016/j.athoracsur.2008.07.009 [discussion: 2016–8]. 13. Veronesi G. Robotic surgery for the treatment of early-stage lung cancer. Curr Opin Oncol 2013; 25(2):107–14. 14. Pardolesi A, Park B, Petrella F, et al. Robotic anatomic segmentectomy of the lung: technical aspects and initial results. Ann Thorac Surg 2012;94(3):929–34. http://dx.doi.org/10.1016/j.athoracsur.2012.04.086.
