For most people, surgery is still the best option to cure cancers of the chest such as lung cancer, esophageal cancer, and mediastinal tumors (located in the area of the chest between the lungs). For a long time the only method was to make a large incision and spread the ribs apart or saw open the breastbone to get access to the chest cavity and the tumor. In fact, this is still the most common technique used in operating rooms around the globe. Thanks to new technology and surgical innovations, however, an increasing number of patients at Memorial Sloan Kettering and other hospitals have the option to undergo removal of thoracic tumors through minimally invasive robotic surgery.
The use of video-assisted thoracic surgery (VATS, or thoracoscopy) to perform more complex procedures was first described in the mid-1990s. With the aid of a telescopic camera, light source, and specialized instruments, a surgeon operates through small incisions in the chest that do not require spreading of the ribs.
A decade later, thoracic surgeons at MSK pioneered the use of telerobotic technology consisting of a three-dimensional, high-definition visual system and precise robotic arms to further enhance the minimally invasive approach.
We asked Bernard Park, attending thoracic surgeon and Deputy Chief of Clinical Affairs, to explain why he feels robotic assistance is “the highest technological form of minimally invasive surgery” and, in many ways, the optimal choice for removing lung and other chest cancers.
Less Trauma, Faster Recovery
“We need to be able to offer people curative surgery without resorting to making large, rib spreading cuts,” says Dr. Park, “and if robotic surgery enables us to accomplish that, it’s well worth it. Patients get all the benefits of minimally invasive surgery — less damage from incisions, faster recovery, fewer complications — and a more rapid ability to either return to their pre-surgical condition or move on with additional treatment if necessary.” By using robotic technology, surgeons can retain the advantages of open surgery, such as full exposure and depth perception. Because these advantages are particularly heightened in tight spaces, it makes sense that robotics initially became widely adopted for operations such as radical prostatectomy and hysterectomy, performed in the small and narrow confines of the pelvis.
Within the chest cavity, heightened visualization and dexterity are crucial as well.
“With conventional minimally invasive surgery, such as VATS, the surgeon currently must use straight instruments with a two-dimensional image,” says Dr. Park. “While many skilled surgeons can overcome this limitation, if there is a platform that levels the playing field, why not take advantage of it?” When Dr. Park performs robotic surgery, he sits next to the patient at a console that allows him to see the surgical field and control all of the instruments. “The beauty of the system is the ability of the surgeon to control nearly all elements of the procedure at the touch of a finger,” he says. “My movements at the console are simply and elegantly translated to movements of the instruments.”
With robotics, the instruments are also “wristed,” meaning “they have seven degrees of freedom that approximates the human hand,” Dr. Park explains. “This means you can work in a very confined space. You can have precise movements and depth perception that allows for more precise ability to execute the necessary steps of the operation.”
Dr. Park also notes that a major issue when operating in the chest is the danger of working around the lung vessels, which are very delicate and where injuries can cause life-threatening bleeding. “With robotics, you're able to better see and dissect around these vessels and to prevent those kinds of injuries.”
He adds that “because of this overall level of control, if there are patients with more complicated tumors that would traditionally only be offered open surgery, we are able to offer the benefits of a minimally invasive approach while still achieving optimal surgical treatment.”
Why Experience Still Matters
While robotics is a powerful technology and can confer benefits to patients and surgeons, it’s ultimately just a tool. A person’s outcome hinges more on the skill and experience of the surgeon and knowing when it’s appropriate to use the technology than on the tool itself, says Dr. Park.
“If you have superior technology without superior judgment and experience, then it’s never going to make up for the lack of skill or poor decision-making,” he says. “That said, I think that the robotic technology can make surgeons who understand the strengths and limitations better. In the end, the responsibility is on the surgeon to use the technology appropriately.”
To find a chest surgeon who is skilled in robotics, Dr. Park recommends carefully evaluating the quality of the institution at which the doctor works, whether he or she has an established track record with robotic surgery, and how many cases he or she performs in a year using the technology. For lung cancer, one of the most common cancers in men and women, look for someone who performs at least 50 major lung resections a year, he explains. For less common diseases, such as thymoma, the number will be lower.
Even more reason, he notes, to schedule your operation at a place such as MSK, where robotic surgeries such as this are done all the time.