Video-assisted versus robot-assisted thoracoscopic lobectomy: style versus substance

Introduction

Background—history of lung resection

Lung cancer has been considered a disease of the modern world and explicably linked to the era of tobacco consumption made popular at the start of World War I. Up until the turn of the 20^th century, carcinoma of the lung has remained a rare enigma whose reports have been described intermittently in literature and occasionally in conjunction with toxic environmental exposure. By 1998, the age-adjusted death rate for lung cancer has increased to 77.2 per 100,000 from a mere 5 per 100,000 just a century prior (1,2). In 2022, pulmonary carcinoma is the number one cause of cancer deaths worldwide with a dismal 5-year overall survival (OS) of 22.9%. The majority of patients are diagnosed at an incurable stage where treatment options are limited to definitive or palliative chemoradiation (3). For stages I and IIA [based on the American Joint Commission on Cancer (AJCC) 8^th edition staging] non-small cell lung cancer (NSCLC) and limited-stage small cell lung cancer (SCLC), treatment primarily employ surgical resection (4,5). Anatomic pulmonary lobectomy with individual ligation of bronchial, pulmonary arterial and venous branches, division of pulmonary parenchyma, and mediastinal lymph node dissection is the recommended surgical approach (6). Evaluation for surgical candidacy are listed in Table 1 (7).

Rationale, knowledge gap, and objective

As surgical outcomes improved, minimally invasive (MI) approaches began to emerge and predominate. “Thoracoscopic” surgery was originally described by Professor Hans Christian Jacobaeus in 1910. It would take 80 more years of technological advancement before video-assisted thoracoscopic surgery, now known as VATS, was used to successfully perform an anatomic lung resection in 1993 (2,8). Ten years later, in 2003, Morgan et al. and Ashton et al. reported the first robot-assisted thoracoscopic (RATS) lobectomy (9,10). The next two decades saw a thrust and throttle in the integration of both VATS and RATS into academic and community practices and residency training. Hesitation in adoption center on safety, feasibility, adherence to oncologic principles, clinical applicability, outcomes, and costs. Over the years, these concerns have been discussed extensively in literature and the MI techniques are proven efficacious over thoracotomy in all regards. The comparisons between RATS or VATS versus open lobectomy are beyond the scope of this discussion.

Objective

The aim of this clinical practice review paper is to briefly review the various surgical approaches of VATS and RATS in the setting of pulmonary lobectomy, discuss the different advantages between VATS versus RATS in the treatment of NSCLC, and define their diverging roles in evolution of surgical training paradigm.

Methods

A literature search was performed on MEDLINE/PubMed for all thoracoscopic and robot-assisted pulmonary lobectomy and surgical outcomes from 1993 to present. Search terms included pulmonary lobectomy, thoracoscopic lobectomy, and robot-assisted lobectomy. Free text terms including surgical outcomes, cost, and conversions were included to further refine the search. Selection criteria included all papers comparing VATS and RATS lobectomy in retrospective or prospective nature, systematic reviews, and meta-analyses. Papers not involving lobectomy were excluded. Non-English articles, small case series, and case reports were excluded in the final review. Review of papers was performed independently by two authors and final selection was from consensus from the authors. All discussions regarding robotic instrumentations and platform are from the DaVinci Robotic System from Intuitive Surgical (Sunnyvale, CA, USA).

Surgical techniques

Techniques of video-assisted thoracoscopic lobectomy

Anatomic lobectomy requires general anesthesia and single-lung ventilation through either placement of a double lumen endotracheal tube or a bronchial blocker. The patient is placed in a lateral decubitus position and the surgical table is flexed at the anterior superior iliac spine (ASIS) to maximize ribs opening. Port placements diverge depending on the institution. The traditional port placement includes triangulation with a camera inserted at the seventh or eighth intercostal space at the posterior axillary line, one working port at the fifth intercostal space just posterior to the midclavicular line, and another working port at the tip of the scapula. Other rendition includes establishing a camera port at the eighth intercostal space just posterior to the midaxillary line. An access port, approximately 4 to 5 cm, is placed at the fifth intercostal space posterolateral to the lateral mammary fold (Figure 1). Mun et al. described a “upside-down monitor” setting in which the camera is moved to the 3^rd intercostal space and looking down onto the superior hilum. Dissection is facilitated through a posterior port in the 4^th intercostal space (just anterior to the scapula), an assistant port in the same space but located at the anterior axillary line, and a 3 cm access port in the 5^th intercostal space at the posterior axillary line (12). In contrast to the multi-port approaches, Gonzalez et al. described a uniport approach in which camera, dissection, retraction, and extraction are all performed through an anterior access incision placed at the 5^th intercostal space (13).

Figure 1 Incisions for video-assisted thoracoscopy. Preferred incision for video-assisted thoracoscopy. An access incision, approximately 4–5 cm, is created in the 5^th ICS at the anterior axillary line. A port/camera incision is created at the 7^th to 8^th ICS at the posterior axillary line. Stapling can be performed from the posterior port incision and moving the camera to the anterior port incision. Specimen retrieval is performed through the access incision. ICS, intercostal space. Published with permission from Burfeind and D'Amico (11).

The bronchus and hilar vessels are dissected and divided individually (Figures 2,3). Hilar lymph nodes are systematically collected. Mediastinal lymphadenectomy is performed collecting levels 2R, 4R and 7 for right-sided resection and 5, 6, and 7 for left-sided resection. Levels 8 and 9 are added when lower lobectomies are performed. One hilar and three mediastinal lymph node stations are required to be compliant with metrics as set out by the Society of Thoracic Surgeons (STS) (6).

Figure 2 Video-assisted thoracoscopic dissection of hilar structure in right lower lobectomy. Circumferential dissection of hilar structures in right lower lobectomy. The inferior pulmonary vein (A) and ongoing pulmonary artery (B) are isolated and ready to be divided. The posterior hilar dissection allows for exposure of the right lower lobe bronchus (C) which can be divided with the staplers through the access port and camera in the posterior port.

Figure 3 Video-assisted thoracoscopic dissection of hilar structures in left upper lobectomy. Circumferential dissection of hilar structures in a left upper lobectomy can be achieved using the two port VATS technique. The superior pulmonary vein (A) can be divided with camera in the anterior port and stapler inserted through the camera/posterior port. The truncal branches of the pulmonary artery (B) can then be dissected and ligated in a similar fashion. The left upper lobe bronchus (C) is then exposed and division can be accomplished with the stapler in the posterior port. VATS, video-assisted thoracoscopic surgery.

Techniques of robot-assisted thoracoscopic lobectomy

Similar to VATS lobectomy, robot-assisted resection also requires lung isolation and lateral decubitus positioning. However, the ASIS in a robotic case should be vertically in-line with the height of the rib cage to maximize maneuverability of the robotic arms. CO₂ insufflation aids in exposure and visibility and allows room for the robotic instruments. Port placements typically line up in the same intercostal space (Figure 4). Variations of which intercostal space to use depends on whether an upper or lower lobectomy is being performed (Figure 4). Resection of the middle lobe or lingula follows the port placement of an upper lobectomy (Figure 5). The camera is placed at the 8^th or 9^th intercostal space and the fissures are visualized. The targeting feature of the DaVinci Xi robot (Intuitive Surgical) is helpful to line up the rest of the arms in position for the remainder of the docking process. Three more ports are placed in the same intercostal space starting at the spine and moving anteriorly. The most anterior port is often used for the stapler and can often be placed one intercostal space caudad to the remaining ports. We advocate using a 12 mm port in either the most anterior or posterior port and accommodating the rest of the robotic instruments in this arm via the reducer. An assistant port is placed just above the diaphragm as anteriorly as possible for specimen retrieval, usually two intercostal spaces from the robotic ports (14). Other port placement variation include shifting the posterior and camera ports more cephalad, achieving a “look-down” approach, similar to what Mun et al. had described for thoracoscopy. This essentially placed a robotic port in multiple intercostal spaces, spanning from the 4^th (most cephalad and posterior) to the 7^th intercostal space (most anterior) with an extraction port in the 10^th intercostal region (15,16). Conversely, Ninan et al. advocated for total robotic port placements in which all robotic ports are placed in the same intercostal space located over the mid-fissure. The assistant and extraction port are placed in the anterior subcostal region and therefore avoiding entering in through another intercostal space (17). There are currently no studies examining any superiority of one robotic port placement over another.

Figure 4 Incisions for robot-assisted thoracoscopy. Placement of incision for robot-assisted thoracoscopy. Most of the ports are aligned within the same intercostal space with the assistant port placed slightly anterior to the anterior axillary line and is one to two intercostal space below the robotic ports (A). The 12 mm ports are placed to aide in stapling of the hilar structures with the most beneficial angles depending on the anatomy/case. Intraoperative view of robotic port placement (B) note that the ports are at least 8 mm apart to allow for maximal movement of the robotic arms.

Figure 5 Robot-assisted thoracoscopic dissection of hilar structures in right middle lobectomy. Circumferential dissection of hilar structures during a right middle lobectomy (A). The middle lobe vein as a branch of the superior pulmonary vein is identified and stapled (B). This aide in the exposure of the right middle lobe artery (C) and subsequent ligation (D) by the robotic stapler on the Xi platform (rather than a handheld stapler controlled by an assistant). Divisions of the fissure (E), dissection of the sump node (F), and division of the bronchus (G) can similar be accomplished using the robotic stapler platform.

Results and discussion

Outcomes of interest included intraoperative factors such as operative duration, rate of blood transfusion, and conversion to thoracotomy are used to measure feasibility and safety of technical aspect of the operation. Perioperative outcomes include hospital length of stay (LOS), duration of chest tube, wound infection, pneumonia, air leaks, cardiopulmonary complications, and in-hospital mortality. Finally, oncologic assessment typically focuses on margin status, number of lymph nodes harvest, nodal upstaging, and overall and disease-free survival. The utilization of the robotic platform also spurred a plethora of studies regarding costs. These metrics provide a framework to analyze the safety and efficacy of this surgical technique.

Perioperative outcomes

The feasibility and safety of RATS lobectomy has been extensively studied and published. Early single-institution report by Park et al. affirmed the feasibility of RATS lobectomy. Median operative time was 218 minutes, median chest tube duration was three days, and conversion to thoracotomy occurred in 12% of cases. Zero out of 34 patients within the series had operative, in-hospital, and perioperative death (18). Following these smaller series, a retrospective multi-institution by Park et al. analyzed 325 lobectomies performed between 2002 to 2010. Median operative time was 206 minutes, overall morbidity rate was 25.2%, major complication rate was 3.7%, has a median LOS of 5 days and one in-hospital death (0.3%). Median chest tube duration was three days and overall conversion rate to thoracotomy was 8.3% (19). These results are comparable to early VATS data from Kirby et al. in 1995 followed by the CALGB 39802 study published in 2007 (20,21). In the latter prospective, multi-institution study, VATS cases had a median operative time of 130 minutes, a thoracotomy conversion rate of 10.8%, median chest tube durations of 3 days, 7.4% overall complication rate, and 2.7% perioperative mortality (21). Yang et al. pulled data from the National Cancer Database (NCDB) from 2010 to 2012 and identified 20,040 lobectomies. The authors grouped VATS and RATS in the same category, propensity-matched the comparison to thoracotomy, and noted that the MI group had a decreased LOS, similar 30-day mortality rate, and longer 2-year OS (22). The results from these early studies laid the groundwork to solidify the robotic platform in the operative management of early-stage lung cancer.

Compared to VATS, RATS have been shown to have similar perioperative outcomes (23-25). Results from MD Anderson documented no differences in morbidity or mortality between RATS and VATS. The authors also found that despite having longer operating room (OR) time, RATS had less blood loss and shorter LOS. Outside of the findings of specialized, high-volume centers, outcomes are still consistently equivalent between these MI techniques (24). A propensity-matched population analysis from the NCDB by Rajaram et al. (2017) showed no difference in margin status, 30-day unplanned readmission rate, or 30-day and 90-day mortality. This data was corroborated by Yang et al. Interestingly, while Rajaram et al. found that VATS have shorter median LOS than RATS (5.9 versus 6.1 days, P=0.019), Yang et al. noted the median LOS to be 5 days in both groups. The discordant finding is attributed to different matching algorithms as both groups studied the same database during the same time period (2010 to 2012) (22,25).

Following early single and multi-institution reports, query of administrative datasets including the Nationwide Readmission Database, State Inpatient Database, Premier Database, and Nationwide Inpatient Sample all reached the same conclusions: perioperative outcomes, most notably morbidity and mortality, are similar between RATS and VATS (26-31). There are minor differences including higher rates of iatrogenic bleeding complications with RATS based on the Nationwide Inpatient Sample study although these data are from earlier time period in the adoption of robotic resection, lower LOS with RATS based on the Premier Database but similar LOS based on the Nationwide Readmissions Database, and greater direct discharges to home in the RATS group based on the Nationwide Readmissions Database but more likelihood to be discharge to a facility based on the Nationwide Inpatient Sample. The summary of these studies is found in Table 2. The main criticism of the national database analyses is the inherent limitation of large, centralized datasets: the lack of specific perioperative outcomes (e.g., blood transfusions, airleaks, pulmonary complications), the lack of relevant clinical correlates, and the quality and heterogeneity of the data. Based on this, analysis of the STS database (which also excludes general surgeons performing thoracic operations) appeared prudent given the extensive collection of outcome variables (36,42). STS data was pooled between 2009 to 2013 and identified 1,220 RATS and 12,378 VATS cases (36). Operative duration was longer for RATS but perioperative variables, complications, and 30-day mortality were similar between the two groups. Similarly, systematic reviews and meta-analyses saw, on average, longer OR time in RATS but no differences in estimated blood loss, airleaks, chest tube duration, or LOS (34,40,41,48).

In 2022, the results of a prospective, randomized clinical trial from a single institution (RVlob trial) was published confirming the findings of the retrospective studies. The trial enrolled 320 patients from 2017 to 2020 and saw no differences in perioperative complications (P=0.45) or LOS (P=0.76) (46). The following year, Kent et al. published the results of the Pulmonary Open, Robotic, and Thoracoscopic Lobectomy (PORTaL) study, a retrospective analysis of all pulmonary resections performed between 2013 and 2019 across 21 institutions by surgeons who have performed at least 50 total lobectomies (32). Findings revealed no differences in the number or type of postoperative complications between RATS and VATS including unplanned return to the OR. The most frequent complications encountered were all pulmonary-related (i.e., pneumonia, prolonged airleak, and need for bronchoscopy). RATS lobectomy was associated with shorter operative time, chest tube duration, shorter LOS, and lower amount of postoperative blood transfusions. There were no differences in in-hospital or 30-day mortality. Both these trials confirmed the noninferiority of RATS compared to VATS (32,46).

The results from both the RVlob trial and PORTaL study are attributed to the fact that study periods are the most recent out of all publications cited here. It is surmised that the learning curve for RATS lobectomy have been surmounted by all participants, and variability in surgical abilities are controlled at the time of publication. As such, the improved perioperative outcomes are expected. Similarly, meta-analyses published in 2019 noted that RATS in inferior to VATS in terms of operative duration [weighted mean difference (WMD) 4.98, P<0.001] (41). In contrast, meta-analyses published in 2022 suggested that the difference in operative time has dissipated [mean difference −0.61 (−16.86, 15.64)] (40). An additional report by Alwatari et al. analyzed outcomes as a function of time and found that thoracic complications and LOS decreased significantly after 2018 as compared to prior years (P<0.005) (30). Collectively, this suggested that as time progresses and surgeons become more comfortable with the robotic technologies (i.e., case volume related), perioperative differences between RATS and VATS become negligible, if not favorable towards RATS lobectomy.

The strongest risk factors for adverse outcomes in both robotic and thoracoscopic resections include age (greater than 75 years old for RATS and older than 80 years for VATS) (42,49). Modifiable risk factor includes current tobacco use. Comorbid conditions such as chronic obstructive pulmonary disease (COPD), and peripheral vascular diseases, forced expiratory volume in 1 second (FEV1), and diffusing capacity of the lungs for carbon monoxide (DLCO) were all independent predictors of outcomes in robotic lobectomies in univariate analysis. However, on multivariate analysis, the aforementioned factors are no longer significant. Kneuertz et al. noted that RATS is an independent predictor of postoperative outcomes [hazard ratio (HR) 0.54, P=0.008]. Consistent with previous studies analyzing VATS lobectomy, Kneuertz et al. concluded that RATS lobectomy has the greatest benefit in high-risk patients (42,50). It is noteworthy to mention that these studies compared MI lobectomy (VATS or RATS) against open lobectomy. To date, there has not been any study identifying independent predictors of postoperative outcomes between RATS and VATS.

Case conversion to thoracotomy

Conversion from a MI approach to thoracotomy occurs due to a variety of reasons and can occur electively or emergently. It should be noted that for RATS cases, there is an option to convert to VATS rather than to thoracotomy. These instances occur rarely and thus will not be discussed (37). Etiologies for VATS conversions ranged from calcified lymphadenopathy (40.6%), vascular injury (29%), extensive tumor involvement (15.9%), incomplete fissures (4%), and inability to tolerate prolonged one-lung ventilation (2.2%). Similarly, RATS conversions occurred for the same reasons although iatrogenic intraoperative vascular injuries is the predominant reason in these cases (odds ratio 2.64, P<0.05) (37,45,51). Early studies reported conversion rates from VATS to thoracotomy of 11% and from RATS to thoracotomy of 8% (18,20,21,52). Over time, these rates have declined to 6–7% and 4% for VATS and RATS respectively (19,31,53). According to an analysis of the STS database, advanced stage (stage II/III), left-sided resection, and FEV1 were associated with higher conversion rates for VATS and RATS. Interestingly, body mass index (BMI) and induction therapy are predictors for conversion in VATS but not RATS cases (37). Conversely, a recent publication by Herrera et al. looking at conversion rates in the PORTaL trial noted that neoadjuvant therapy, BMI, and tumor size were significant predictors for conversions in both RATS and VATS. Other factors were consistent with previous studies which included FEV1, congestive heart failure and COPD (presumably leading to inability to tolerate one-lung ventilation), and previous cardiac surgery (37,45). Sidedness was not a predictor although it is interesting to note that the PORTaL study cited the right upper lobe as the most common lobe in converted cases for both VATS and RATS (45). Since both the STS analysis and the PORTaL study garnered patients around the same time period, these different outcomes are attributed to surgeons’ experiences as the latter included only surgeons who performed more than 50 lobectomies in either platform.

In general, cases that required conversion are associated with increased major complications, intraoperative and postoperative transfusions, and overall mortality. However, analysis of the STS database noted that there is no significant difference in mortality between converted cases (RATS versus VATS). According to Servais et al., conversion to open thoracotomy from VATS does have a shorter overall operative time compared to conversion from RATS although this difference was not statistically significant in the PORTaL study (37,45). This time difference has previously been attributed to removing the robotic instruments, undocking the robot, and any other added logistics of converting a RATS case to an open lobectomy. Presumably, in centers with higher volumes such as those evaluated in PORTaL, the efficiency of conversions (especially emergency conversions) may be secondary to the function of a well-trained OR team rather than dependent on various technical aspects of the case. However, there are no data variables that have validated this finding.

Studies from the National Inpatient Database, Premier Database, PORTaL all noted a lower overall conversion rate in RATS versus VATS. However, the rate of emergency conversions is still higher in the RATS group (9% versus 5%, P<0.012). The rate of conversion after an event is also higher in RATS (19% versus 9.6%, P<0.012) (45). This data suggested that while the robotic platform may confer advantages in cases with difficult anatomy, vascular injuries still predominates the reasons for conversions irrespective of the ability to control the event prior to the thoracotomy. Meanwhile, VATS cases may not require a conversion after an event (9.6% in VATS versus 19% in RATS, P<0.012). It is unclear whether or not this is due to surgeon’s comfort versus extent of injury and the data is not granular enough to determine the difference. It is noteworthy to mention that most conversions in recent studies have been categorized as elective rather than emergent (28,31,32,37,45,51). This, once again, reaffirms that the fact that surgeon comfort with new technology is key in mitigating intraoperative technical issues leading to emergent conversions.

Long-term and oncologic outcomes

Long-term outcomes and oncologic efficacy are comparable between VATS and RATS across many studies, though some nuances do exist. In terms of nodal staging, RATS cases reportedly have higher number of lymph node stations examined when compared to VATS (5 versus 3, P<0.001) at Memorial Sloan Kettering (43). A study from MD Anderson corroborated these findings: both the number of lymph nodes [mediastinal (8 versus 6, P=0.017), hilar (9 versus 6, P<0.001)] and the number of nodal stations [mediastinal (3.1 versus 2.4), P<0.001), hilar (2.5 versus 1.8, P<0.001)] were higher in RATS lobectomy (24). Similarly, Ureña et al. found that RATS lobectomy had significantly higher number of mediastinal stations and mediastinal lymph nodes (P<0.001) (54). The RVlob trial reported that the number of lymph nodes (11 versus 10, P=0.02) and the number of lymph node station (6 versus 5, P<0.001) were significantly higher in the RATS group (46).

The number of both lymph nodes and lymph node station harvest in conjunction with the overall rate of pathologic nodal upstaging has been used as a surrogate to determine accurate staging and hence oncologic quality. However, the data remains heterogeneous. Previous studies have noted an improved rate of nodal upstaging with RATS while others larger retrospective analyses noted equivalent findings (12 versus 12, P=0.992) (36,46,47,55-57). Regardless of the cN0 to cN1 rates, there were no significant differences in OS. Park et al. reported a 3-year OS of 43% for stage IIIA and 5-year OS of 80% for stage I NSCLC which is comparable to previous VATS report (19). Similarly, a meta-analysis by Zhang et al. noted no difference in R0 resection, tumor size, lymph node station, lymph node harvest, 5-year OS, or recurrence rate between the two techniques (40). Interestingly, data from the PORTaL study suggested that there is an OS advantage to RATS lobectomy compared to VATS (HR 0.79, P<0.007) despite equivalent nodal upstaging (47). It is important to note that all studies found that thoracotomy has the highest rate of nodal upstaging when compared to the MI approach yet the open approach has been shown to have worse OS. At this point, the true impact of nodal harvest and upstaging on OS is likely multifactorial and remains unclear.

Impact of volume on surgical resection

The impact of volume on perioperative outcomes has been a topic of debate for various operations. In terms of lobectomy, higher case volume has been shown to be associated with decreased conversion rate, LOS, and mortality rate. Multivariate analysis of the National Inpatient Sample database noted that hospital volume was an independent prognostic factor for mortality (odds ratio 0.134, P<0.001) and LOS [0.2 days; standard error (SE) 0.05, P<0.001]. There were no difference in complication rates (29,30). There is little data in terms of direct comparison between a high-performing RATS versus VATS institution. However, it can be extrapolated from the PORTaL study that in high-volume centers where surgeons have performed at least 50 lobectomies regardless of approaches, RATS cases have better perioperative outcomes and survival than VATS (47).

The salient point of discussion in terms of volume is whether or not there is a defined number of cases to reach proficiency regardless of the previous operative experience of the surgeon. Previous studies by various groups have concluded a learning curve at approximately 20 cases for RATS (52,58,59). Meanwhile, literature has quoted a case volume of approximately 100 cases for VATS (60). The large differences in the number of cases required for proficiency may be due to the fact that robotic surgeons have likely learned MI techniques (i.e., VATS) before transitioning to a new platform (61,62). Conversely, transitioning from open to VATS required learning a different skill set. In addition, VATS operations also required skilled operators of the camera (60). Meanwhile, the camera and the stapler are both under the control of the surgeon for RATS cases. To analyze whether previous experiences impact the transition and ultimately the number of cases to achieve proficiency, Feczko et al. analyzed the STS General Thoracic Surgery Database (GTSD) and separated the surgeons into three cohorts: open-to-robotic, VATS-to-robotic, and de novo surgeons whose first lobectomies were performed robotically. The authors found that VATS-to-robotic surgeons reached proficiency faster than open-to-robotic surgeons. Interestingly, de novo surgeons (those whose first cases were RATS as recorded by the STS database), reached proficiency the fastest. Regardless, the number of cases to reach proficiency was 20 lobectomies (58). The lower number of cases required for proficiency may lead to faster and wider adoption of RATS than VATS.

Cost analysis

The emergence of new technologies inevitably leads to discussion of costs. Beyond the initial investment in the robotic console, purchasing proprietary robotic instrument contributes to additional costs for RATS that is not seen with VATS or open lobectomy. The advantages of MI resection include decreased LOS, complications, readmissions, and decreased ICU stay which translates to cost-savings compared to open procedures (7,63). However, cost comparisons between two MI techniques will largely depend on the instrumentations and OR time since the perioperative outcomes are similar. Uniformly, analyses have concluded that RATS lobectomy have a higher cost than VATS (26,29,64-68). Bailey et al. reported an index cost of $23,870 per case for RATS versus $20,279 per case for VATS based on the Nationwide Readmissions Database (26). According to the analysis of the Premier Database, the average total hospital costs for RATS versus VATS were $25,040.70 versus $20,476.60 (P<0.0001) (38). Breakdown of costs including OR and total hospital costs were uniformly higher in the robotic group (P<0.05). Most notably, the OR supply cost difference is the highest amongst all of the direct fixed and variable costs ($5,757 versus $2,804, P<0.0001). Despite the modest increase in cost, RATS lobectomy is still profitable, generating $4,750 per patient, for the hospital (38).

Discussion of costs often involve market drivers that are independent of clinical factors, namely competition. To date, there are few competitors to the DaVinci platform as it is the most commonly used robotic tool in thoracic surgery. As such, the impact of potential competitors to the Intuitive Surgical DaVinci system on total hospital costs would be difficult to analyze given factors including distribution, utilization, and outcomes. Comprehensive market analysis between the Intuitive surgical platform and others (Medtronic Hugo RAS, Cambridge Medical Robotics Versius, Medrobotics Corp Flex Robotic System, Asensus Senhance ALF-X, Meerecompany Inc. Revo-I, Wego Micro Hand S) is beyond the scope of this review.

Within the confines of the current system, It is unclear at this point if the cost of RATS lobectomy will decrease despite the increase utilization of the robot independent of competition. This is attributed to the fact that the costs of instrumentations and supply will remain constant until there are incentives to reduce these prices. As the robotic platform changed and new instrumentations are required with each new iteration of the Intuitive Surgical Consoles (Si, Xi, SP), costs are unlikely to decrease to the level of VATS lobectomy. The affordability of these systems may also prevent its widespread adoption in institutions that may not have consoles for just thoracic surgery.

Conclusions

MI lobectomy is rapidly becoming the standard of care of early-stage NSCLC. The technology has evolved from video-assisted thoracoscopy to robot-assisted thoracoscopy. The results are clear: both surgical approaches have equivalent perioperative outcomes, comparable oncology outcomes, and in some cases, RATS confer a survival benefit with high-volume surgeons and centers. The superiority of robotic visualization and instrument articulations coupled with more segmental resection may propel robotic lobectomy to become the more prominent surgical approach for pulmonary resections in centers that can afford the increased cost. Worldwide, adoption of robotic technology may stall due to pricing and availability. The next challenge would be to integrate RATS into residency training curriculum while maintaining the trainee’s proficiency in both open and VATS techniques for the cases that require conversions.

Acknowledgments

Funding: None.

Footnote

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-23-55/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-23-55/coif). D.P.C. serves as an unpaid editorial board member of Video-Assisted Thoracic Surgery from April 2022 to March 2024. L.Y.S.B. serves on advisory board of Intuitive Surgical and is a speaker with payment/honoraria of Intuitive Surgical. D.P.C. is a consultant for Astra-Zeneca, Medtronic, and Cook Medical. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were performed in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patients for the publication of this article and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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