The Value Of The Da Vinci Surgical System In The Resection Of Lung Cancer

BACKGROUND:The incidence and mortality rate of primary lung cancer are on the top list these years in china.To the early stage lung cancer,lobectomy with lymph node dissection is the main surgical procedure.When compared with the conventional thoracotomy,minimal invasive surgery shows much more advantages such as reducing intraoperative blood loss,less postoperative complications,less in-hospital stay,and with similar oncological results.In the meanwhile,patients could recover quickly with better life quality,and could get adjuvant therapy in time.Thus,the video assisted thoracic surgery(VATS)has developed very fast in the past 30 years,and have become the most popular minimal invasive surgical procedure for lung cancer.The da Vinci surgical system was the newly developed surgical platform these years.The 3-D view,10 times magnification of high quality lens and wristed instruments could facilitate the exposure and greatly enhance the maneuverability.But the robotic surgery costs much more than VATS surgery,and whether it is necessary to perform the robotic surgery for the early stage lung cancer still need to be investigated.Here,we try to compare the safety,completeness and survival between robotic and VATS lobectomy for early stage lung cancerMETHODS:A retrospective review of all 102 robotic lobectomy cases for clinical I stage lung adenocarcinoma from Jan 2015 to Dec 2015 according to the inclusion and exclusion standard.102 VATS lobectomy cases were 1:1 matched on the basis of nearest estimated propensity score to minimize bias by using R software.The feasibility(morbidity and mortality,etc),completeness(lymph node dissection and lymph node upstage,etc),recovery(length of postoperative stay,etc),prognosis(overall survival and disease free survival)and medical cost were compared between two groupsRESULTS:The mortality rate(0%vs 0%,P=1.00)and complication rate(16.67%vs 15.69%,P=1.00)between robotic and VATS showed no difference.The operative time(99.26 vs 107.31min,P=0.133),conversion rate(1.96%vs 1.96%,P=1.00)and intraoperative massive bleeding(1.96%vs 1.96%,P=1.00)showed no difference.The postoperative length of stay(4.94 vs 6.25 days,P<0.001)and chest tube duration(3.68 vs 4.82 days,P<0.001)was significantly shorter in robotic group than in VATS group There was no difference of dissected lymph node station(5.95 vs 5.75 stations,P=0.345)between two groups.But the dissected lymph node number(11.56 vs 9.08,P<0.001)and number/station ratio(1.95 vs1.58,P<0.001)of robotic group was significantly higher than VATS group.In the subgroup analysis,the dissected lymph node station also showed no difference(left,6.02 vs 5.49 stations,P=0.100;right,5.89 vs 5.95 stations,P=0.863);but the dissected lymph node number(left,11.07 vs 8.42,P<0.001;right,11.95 vs 9.60,P=0.007)and number/station ratio(left,1.84 vs 1.60,P=0.002;right,2.04vs 1.58,P<0.001)were significantly more in robotic group than in VATS group.The overall node upstage(cN0 to pN1-2)showed no difference(11.77%vs 9.80%,P=0.822).N1 node(8.82%vs 7.84%,P=1.000)and N2 node(6.86%vs 5.88%,P=1.000)upstage also showed no difference.In the subgroup analysis of mixed GGO(1.64%vs 1.64%,P=1.000)and solid nodule group(26.82%vs 21.95%,P=0.798),the overall node upstage both showed no difference.In the nodule(>2cm on CT)and(?2cm on CT)subgroup analysis,the node upstage also showed no difference(13.46%vs 15.00%,P=1.000;10%vs 6.45%,P=0.509).The 3-year overall survival rate was 88%,91%in robotic and VATS group,and the survival curve showed no difference(P=0.358).The 3-year disease free survival rate was 88%,68%in robotic and VATS group,and the survival curve showed no difference(P=0.218).Cox regression model showed the TNM stage(HR,16.80;95%CI,5.48-51.52;P<0.001)was the only independent risk factor for overall survival.The TNM stage(HR,6.53;95%CI,2.32-18.43;P<0.001)and pT stage(HR,4.19;95%CI,1.43-12.25;P=0.009)were the independent risk factor for disease free survivalCONCLUSION:The robotic lobectomy showed some advantages over VATS lobectomy in lymph node dissection.Patients in the robotic group recovered more quickly with less postoperative stay.The robotic and VATS surgery carried the similar prognosis on early stage lung cancerBACKGROUND:Lung cancer is one of the most common malignancy,the incidence and mortality rate are both on the top list these years in china.To the peripheral early stage lung cancer,minimal invasive surgery remains the most popular surgical procedure.The safety and reliability are already guaranteed from the previous reports To the central lung cancer,especially for those requiring bronchoplastic or vasculoplastic surgery,thoracotomy still remains the first choice.There were some publications about the feasibility of VATS(video assisted thoracic surgery,VATS)bronchial or bronchial/pulmonary artery sleeve resection,but most of the publications were the case reports or small case series.The reasons of the reality were partly caused by the disadvantage of VATS platform such as 2-D surgical view,long rigid instrument lacking maneuverability,etc.The da Vinci surgical system was the newly developed surgical platform with the great advantages of 3-D view,10-time magnification of high quality lens,and wristed instruments.The exposure was much more clear and the operation was in accordance with human practice.We have previously performed some robotic single and double sleeve resection cases.Our publication has been the largest case series about robotic sleeve resection till now.And we have identified the key technical point,established the safety and feasibility.At last,here we compared the complications and outcomes between robotic sleeve resection and open sleeve resection cases in the same period.As far as we know,it is the first report about comparing the results between the robotic and open sleeve resection casesMETHODS:According to the inclusion and exclusion criteria,21 robotic sleeve resection(including 4 double sleeve cases)and 86 open bronchial sleeve resection cases from Sep 2014 to Sep 2015 were retrospectively reviewed.Firstly,the safety and reliability of robotic sleeve resection were evaluated,the key technical points were introduced.Secondly,the safety(morbidity,mortality,etc),recovery(length of stay etc)and prognosis(overall survival,disease free survival,etc)were compared between robotic and open bronchial sleeve resection casesRESULTS:In the respects of the feasibility of robotic sleeve resection,the 30-day mortality rate was 4.8%(1/21).The mean console time was 120.4±37.3 min.The mean operation time was 158.4±42 min.The mean blood loss was 157.1 ±97.8ml.the conversion rate was 4.8%(1/21).There was no massive bleeding during operation and no intraoperative death.The overall complication rate was 19.0%.Subcutaneous emphysema was the commonest complication(14.4%).The negative stump rate was 90.5%and the mean postoperative stay was 10.7±7.6 days.When comparing the robotic bronchial sleeve resection and open bronchial sleeve resection cases,the operation time(155.06 vs 150.30min,P=0.709),the intraoperative blood loss(164.71 vs 233.73ml,P=0.188),the intraoperative massive bleeding(0%vs 3.5%,P=1.000),the dissected lymph node number(15.76 vs 16.03,P=0.861),the dissected lymph node stations(7.24 vs 7.20 stations,P=0.954),the positive stump rate(5.9%vs 10.5%,P=1.000),the overall complication rate(23.5%vs 25.6%,P=1.000),the 30-day mortality rate(5.9%vs 2.3%,P=0.426),the chest tube duration(9.24 vs 6.59 days,P=0.260),the postoperative length of stay(11.24 vs 9.50 days,P=0.417)showed no difference.In the univariate analysis,the overall survival(P=0.598)and the disease free survival(P=0.164)showed no difference between robotic and open group.In the Cox multivariate analysis,the T stage(HR,4.788;95%CI,2.448-9.365;P<0.001)and the ICU stay(HR,1.231;95%CI,1.124-1.348;P<0.001)were the independent risk factor of overall survival.The tumor size(HR,1.846;95%CI,1.404-2.431;P=0.001)and adjuvant radiotherapy(HR,4.088;95%CI,1.872-8.931;P<0.001)were the independent risk factors of disease free survivalCONCLUSION:Robotic bronchial(or with pulmonary artery)sleeve resection is technically feasible.It is a safe and reliable minimal invasive surgical procedure and we establish the key technical points in this paper.The safety,recovery,short and middle term prognosis has showed no difference between robotic bronchial sleeve and open bronchial sleeve resection cases.