Robot-assisted surgery for lung cancer: State of the art and perspectives.

The robotic surgical system is the result of a long process of development aimed at producing a natural extension of the surgeon's eyes and hands via the intermediation of a computer. In this way, the ease of movement obtained with open surgery is summated with the advantages of the minimally invasive technique. Since 2000, when the first robotic system for surgery was introduced, robot-assisted thoracic surgery (RATS) has been adopted by an increasing number of centres around the world, and today is used in ∼10% of lobectomies in the US. Here, we review the characteristics and function of the robotic system available today (namely, Intuitive Surgical Inc.'s da Vinci Surgical System), outline the different techniques for major lung resection via RATS, compare RATS with video-assisted thoracoscopic surgery (VATS) and thoracotomy, and speculate on future developments. To date, no randomized trials have reported comparative data on RATS vs. VATS/thoracotomy for lung cancer. Retrospective analysis comparing RATS vs. thoracotomy have revealed advantages for the former, especially shorter hospital stays and a lower complication rate, but RATS produces similar or only slightly better results to VATS, the two being minimally invasive techniques with no need for rib separation. A few studies have reported RATS to be safer than VATS, with less conversions for bleeding, less complications; in others, it was associated with lower postoperative consumption of pain killers and quicker return of patients to normal activity. In addition, lymphnode upstaging has been shown to be higher with RATS than with VATS, with a similar rate as thoracotomy. The main disadvantage of RATS is the higher costs of instrumentation. Nevertheless, the future will probably see reductions in the costs and improvements in the instrumentation, integration with 3D imaging to improve virtual reality, and more patients benefitting from minimally invasive procedures for lung malignancies.