ABSTRACT
Objective: Concomitant chest wall resection for locally advanced lung cancer is traditionally performed via an open approach. The safety and effectiveness of minimally invasive approaches for chest wall resections are unknown. Methods: We used the National Cancer Database to identify patients undergoing lobectomy/bi-lobectomy with concomitant chest wall resection from 2010 to 2020. We stratified patients into those undergoing a minimally invasive resection (video-assisted thoracoscopic surgery [VATS]/robotic) or open, while accounting for conversions. We also compared VATS with robotic approaches. The main outcomes were length of stay, mortality, readmissions, and overall survival. We used multivariable, Kaplan-Meier and Cox proportional models to identify associations. Results: Of 2837 patients, 756 procedures (26.6%) were started minimally invasive, of which 23.1% were robotic. There were 237 (31.3%) conversions. Patients undergoing a minimally invasive operation were similar in terms of age (65.2 ± 9.8 years vs 66.0 ± 9.9 years), sex, race, tumor histology, and location (all P > .05) but had smaller cancers (5.4 ± 2.6 cm vs 6.2 ± 4.3 cm; P < .001) compared with those undergoing open. They also had shorter length of stay (8.6 ± 7.6 days vs 9.7 ± 9.3 days; P < .001) but similar unadjusted 90-day mortality (8.2% vs 8.0%; P = .999). Neoadjuvant therapy was associated with less minimally invasive approaches (adjusted odds ratio, 0.69; P ≤ .001). Larger cancers were associated with less minimally invasive operations and greater rates of conversions. However, the robotic approach was associated with lower conversion rates than VATS across all tumor sizes. Overall survival was equivalent. Conclusions: The use of minimally invasive approaches to concomitant chest wall resection is increasing. Although conversions to open are common, this approach is safe and is associated with shorter hospital stays. Overall survival is equivalent to the open approach.
ABSTRACT
Background and Objective: The adoption of robotic surgery for general thoracic surgery has rapidly progressed over the last two decades from its application in basic operations to complex pathologies. As such, the purpose of this narrative review is to highlight the collective experience of tackling complex thoracic surgical operations with minimally invasive robotic solutions. Methods: Electronic searches of PubMed were conducted for each subtopic, using specific keywords and inclusion criteria. Once identified, the articles were screened through the abstract, introduction, results and conclusion for relevancy, and included based on a standard narrative review inclusion criteria. Key Content and Findings: The role of the robotic approach has increased in thoracic outlet syndrome, chest wall resection, tracheobronchomalacia, airway and sleeve lung surgery, lobectomy after neoadjuvant therapy, complex segmentectomy, giant paraesophageal hernia repair, esophagectomy and esophageal enucleation, mediastinal masses and thymectomy and lung transplantation. Robotic surgery has several advantages when compared to video-assisted and open thoracoscopic surgery. These include better pain control and aesthetic outcome, improved handling of complex anatomy, enhanced access to lymph nodes, and faster recovery rates. Although it is associated with longer operative time, robotic surgery has comparable morbidity rates. Conclusions: The robotic approach to complex thoracic problems is safe, effective, and associated with improved patient outcomes. To encourage wider adoption of robotic technology, increased training and expanded research efforts are essential, alongside improved worldwide access to this technology.