The evolution and current status of robotic-assisted thoracic surgery (RATS)

As a thoracic surgeon who has witnessed the evolution of robotic-assisted thoracic surgery (RATS) over the past two decades, I cannot help but marvel at how far we have come. It seems like just yesterday when we first heard about this futuristic approach to surgery, and now it has become an integral part of our practice.

I remember the skepticism that surrounded RATS in its early days. Many of my colleagues dismissed it as a passing fad, too complex and expensive to ever replace traditional methods. But those of us who saw its potential knew we were on the cusp of something revolutionary.

The journey has not been without its challenges, of course. Learning to operate the Da Vinci^® (Intuitive Surgical, Inc., Sunnyvale, California, USA) was like learning surgery all over again. The countless hours spent in training, the frustration of mastering new techniques, and the initial longer operating times—it all tested our patience and resolve. But the benefits for our patients made it all worthwhile.

I will never forget the first time I performed a complex pulmonary resection using RATS. The precision and control I had were unlike anything I had experienced before. It was as if I had miniaturized myself and was working directly inside the patient’s chest cavity. The ability to navigate tight spaces and perform intricate maneuvers with such ease was truly game-changing.

Of course, the high costs associated with robotic systems have been a constant source of debate in our field. I have had many heated discussions with hospital administrators (and colleagues) about the value of investing in this technology. It has been gratifying to see new players like Medtronic Hugo™ (Medtronic plc, Dublin, Ireland) and Cambridge Medical Robotics (CMR) Surgical Versius^® (CMR Surgical Ltd., Cambridge, UK) enter the market, challenging Intuitive’s monopoly and potentially making robotic assisted surgery more accessible to smaller hospitals.

Despite the advancements and increasing availability of robotic platforms, their implementation faces divergent challenges. For instance, the Hugo™ system does not appear to have European conformity certification (CE) specifically for thoracic surgery, while the Versius^® system seems to be more focused on gynecological and general surgical procedures. Although both the Versius^® and Hugo™ systems offer enhanced mobility compared to the Da Vinci^® system, with the Versius^® being portable and the Hugo™ being modular, both platforms are still under evaluation for their suitability in complex thoracic procedures. As a result, it remains uncertain whether they can truly compete with the more established Da Vinci^® system in the realm of thoracic surgery.

The introduction of the Shurui^® system (Beijing, China) is particularly exciting. It is currently not CE-certified for thoracic surgery but is expected to obtain certification by the end of 2025. I recently had the opportunity to test it at a conference, and I must say, I was impressed. Its single-port functionality and thinner robotic arms allow for better maneuverability in tight spaces, making it a promising option for minimally invasive thoracic procedures. It reminds me of the leaps we made from open surgery to video-assisted thoracoscopic surgery (VATS) and from multiportal to uniportal VATS—another transition that faced initial resistance but ultimately transformed our field.

Another interesting platform that offers a feature many surgeons have been eagerly awaiting is the Saroa^® Riverfield system (Riverfield Inc., Tokyo, Japan). This surgical assist robotic platform is likely the first to incorporate haptic feedback, a groundbreaking development in the field of robotic surgery. Despite the promising early reports from surgeons who have used the Saroa^® Riverfield system, it is important to note that the platform is not yet widely available in Europe or the United States. Information regarding its CE and Food and Drug Administration (FDA) approval status is currently lacking, which may limit its adoption in these markets in the near term.

Speaking of transitions, the move towards uniportal and two-port RATS techniques has been fascinating to watch. I remember when Diego Gonzalez-Rivas first presented his uniportal RATS technique (1)—it seemed almost impossible at the time. But seeing the improved outcomes for patients, particularly in terms of reduced pain and faster recovery, has convinced many of us to adopt these approaches.

The integration of advanced reconstruction software and indocyanine green (ICG) fluorescence imaging has been another quantum leap forward (2). It is hard to overstate how much these tools have improved our ability to perform precise segmental resections. I often think back to my early days as a surgeon, relying solely on tactile feedback and visual cues, and marvel at how technology has enhanced our capabilities.

Looking ahead, I am excited about the potential for artificial intelligence (AI) and machine learning to further refine our techniques and decision-making processes (3). The idea of having an AI assistant providing real-time guidance during surgery would have seemed like science fiction not too long ago, but now it feels like an inevitability.

As I near the latter part of my career, I feel incredibly fortunate to have been part of this transformative era in thoracic surgery. The advancements we have seen in RATS have not only improved outcomes for our patients but have also reinvigorated the field, attracting brilliant young minds to thoracic surgery.

To my younger colleagues just starting their careers, I say this: embrace these technological advancements, but never forget the fundamental surgical principles that underpin our practice. Despite the remarkable advancements in robotic technology, it is essential to emphasize the irreplaceable role of human touch in surgery. Robots are tools designed to assist surgeons, but it is the human hands controlling the instruments and the human heart guiding decisions that ultimately heal patients. Surgical precision, decision-making, and empathy for patients remain the cornerstone of effective care.

The future of RATS is bright, and I cannot wait to see where it goes next. Who knows? Maybe in another 20 years, we will be performing surgery with nothing more than our thoughts and a holographic interface. In this field, anything seems possible.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Video-Assisted Thoracic Surgery. The article has undergone external peer review.

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-24-27/prf

Funding: None.

Conflicts of interest: The author has completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-24-27/coif). The author has no conflicts of interest to declare.

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References

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3. Sadeghi AH, Maat APWM, Taverne YJHJ, et al. Virtual reality and artificial intelligence for 3-dimensional planning of lung segmentectomies. JTCVS Tech 2021;7:309-21. [Crossref] [PubMed]