Faculty Advisor(s)

Cheryl Nimmo

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© 2019 Ananth Thitte


Thoracic surgery via video assisted thoracoscopic surgery (VATS) began in the early 1990s, as a minimally invasive alternative to open thoracotomy for performing lobectomies, wedge resections, and segmentectomies. It initially showed improved morbidity and mortality, decreased pain, and decreased length of stay when compared to traditional open thoracotomy (Zhang & Gao, 2015). To its detriment, VATS has a steep learning curve and manipulation of instruments has been described as non-intuitive. The video camera used provides a two-dimensional image, with limited depth perception compared to the naked eye in an open procedure. Due to these shortcomings, and in spite of its superiority in terms of measurable patient outcomes, VATS has been slow to acquire traction and the majority of thoracic surgeries are still performed via the open approach (Kent et al., 2014).

Robot assisted thoracoscopic surgery (RATS) was approved by the FDA for human use in 2001, and has seen rapid growth, especially in the United States in the last decade. Like VATS, it offers better patient outcomes, decreased complications, shorter length of stay and decreased pain. It also provides the practioner certain advantages: wristed instrument movement, stereoscopic three-dimensional view, and physiologic tremor control (Tchouta et al., 2017). These advances theoretically replicate the ease of performing thoracic surgery via open approach while conferring the improved outcomes of a VATS procedure to the patient. The main drawback of RATS is its prohibitive cost. The hospital must first acquire the multi-million-dollar robot platform itself and pay an annual maintenance and education fee, which is in itself tens of thousands of dollars per year. Additionally, the instruments used for robotic surgery are sold as single use, disposable items, which cost nearly two thousand dollars themselves to perform a lobectomy or resection (Kajiwara et al., 2018).

Recent studies attempted to understand the financial impact of robotic thoracic surgery, both in the settings of national health care schemes (Kajiwara et al., 2018), and at individual surgical centers (Novellis et al., 2018). Robotic thoracic surgery may, in fact be performed without incurring a debt on each case performed, but only if each robotic platform is used hundreds of times per year, at high volume centers with experienced and efficient operators and staff. Though many alternatives to the da Vinci platform, the prototypical robotic surgery platform, are still in their nascent stages and few have seen clinical use, competition may also serve to control costs (Peters, Armijo, Krause, Choudhury, & Oleynikov, 2018). The studies included in this review showed a clear advantage for both RATS and VATS over the open approach in terms of clinical outcomes, equivocal superiority in oncological outcomes for RATS, and a higher cost for both the patient and institution for robotic surgery compared to either alternative. Future research in this area needs to include large scale randomized trials, similar to those showing the superiority of robotic surgery for prostatectomies over the open approach. Only then can the utility of RATS be truly shown to be worth the cost.


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