Robotic Techniques in Thoracic Surgery

Background: Minimally invasive techniques for thoracic surgery are safe and result in fewer complications compared with traditional open surgery. There may be advantages in adopting robotic thoracic surgery compared to video-assisted thoracoscopic surgery (VATS). Despite the surge in robotic thoracic surgery in the UK, good quality evidence is needed to substantiate the associated high capital costs and service fees. Aims: To assess the impact of introducing a robotic thoracic surgery programme at Liverpool Heart and Chest Hospital (LHCH) and determine the clinical benefit and cost associated with robotic surgery for lung cancer resection; as well as mediastinal mass resection and lung volume reduction surgery (LVRS), compared to the more commonly used surgical approaches (open and VATS). This research reports on LHCH preparations for the COLT trial; a multicentre prospective cohort study comparing robotic, VATS and open techniques for lobectomy for early-stage lung cancer. The COLT pilot addresses potential issues concerning data collection and provides recommendations for the main COLT trial. Methods: Three retrospective studies were undertaken to compare surgical approaches for lung cancer resection mediastinal mass resection and LVRS. The COLT pilot study was conducted prospectively for 2 months prior to being cut short by COVID-19. Results: 90 lobectomy cases were included in COLT pilot (98.1% data completeness). Rates of minimally invasive surgery for lung cancer were high (75.6%). Post-operative outcomes were similar between robotic and VATS lobectomy with small differences between VATS and open lobectomy, regarding length of stay and pain. This was the first published series on robotic LVRS. Patients undergoing robotic LVRS required less IV morphine post-operatively (13.8mg vs 58.0mg, p=0.026) and were less likely to be admitted to critical care (8.3% vs 70.8%, p=0.001), compared with VATS LVRS. Robotic LVRS was marginally cheaper than VATS LVRS (£5421.63 vs £5695.46) due to reduced length of hospitalisation and critical care stay. Robotic LVRS had a short learning curve; operative time plateaued after 6 cases, similar to VATS LVRS. Introducing robotic mediastinal surgery resulted in significant increase in mediastinal masses being resected by a minimal invasive surgery (20% to 45%). Minimally invasive mediastinal surgery resulted in a shorter length of stay (4 vs 2 vs 2 days, open vs VATS vs robotic, p<0.0001) and less post-operative critical care admissions (88.64% v 27.59%, p