Robotic Assisted Thoracic Surgery Play by Play

Robotic thoracic surgery (RAS), also called robotic-assisted thoracic surgery, is a minimally invasive surgery used in thoracic procedures, including some lung cancer cases. This type of surgery can be used to remove diseased lung tissue and possibly surrounding lymph nodes. The three main types of lung surgery are:

• Wedge resection/biopsy (removes a small piece of lung)
• Segmentectomy (removes a segment of a lobe of a lung)
• Lobectomy (removes a whole lobe)

We spoke with Dr. Doug Adams, Cardiovascular and Thoracic Surgeon at TriHealth in Cincinnati, Ohio, about how robotic technology is typically used during lung surgery. He took us through the general steps that he follows with his patients at TriHealth, but patients should know that each institution may operate differently. You should talk with your surgeon about what you can expect.

Before RAS Surgery

• Before the procedure, you (the patient) will get information about how to prepare. When you arrive at the hospital on the day of surgery, you may go into a holding room where your information is confirmed, you meet with the anesthesiologist and lines are started in your body. Lines are tubes usually inserted into the hands that will allow the surgery team to monitor vital signs like blood pressure and also give you pain medication.
• Next you will be wheeled into the operating room and your identity and the procedure you are receiving are confirmed one more time.
• You will then be sedated by the anesthesiologist and placed on your side. You will be completely asleep during the procedure.
• While you are sleeping, the anesthesiologist places a special tube into your airway to collapse the lung that is not being operated on. This allows the surgeon to have more space to operate. The lung is reinflated before you wake up from surgery.

Getting the Robot Ready

• The surgeon then finds the right spots on your body for the robot ports. These ports are like docking stations for the robot. A small incision (cut) is made to place each port.
• The instruments and camera are attached to the robot and docked into the ports. This allows the surgeon to sit at a console and control the surgical robot in real time. As the surgeon’s hands move, the robot’s do as well.
• Once the connection is established, the surgeon takes a moment to review your anatomy and adjust the surgical plan. Each surgery has basically the same steps, but every patient’s body is different. The surgeon takes some time to get familiar with your body before beginning the operation.

Removing the Lung Tissue

• Your surgeon will sit at the console next to you in the operating room and control the instruments on the robotic surgical system. First, the small 3D high-definition camera is placed through one of the ports to provide a view of the inside of the chest cavity. Then robotic instruments are placed through the other ports made in between the ribs. The robotic instruments are completely controlled by the doctor’s hands at the console.
• The surgeon removes lung tissue through one of the incisions. The magnified view and wristed instruments allow the surgeon to make precise, controlled movements without having to make larger incisions to open up the chest or spread the ribs. Sometimes the anesthesiologist will inject a special liquid called ICG into the lung, which helps the surgeon see the anatomy of the lung more clearly.
• For patients with cancer, your surgeon may also remove lymph nodes. Surgical sampling of the lymph nodes is just as important as removing the diseased tissue because it helps the physician accurately stage the cancer. Often lung cancer will spread to the surrounding lymph nodes and sometimes the PET scan doesn’t catch the spread because it is so small. Removing the lymph nodes and having them looked at by the pathology department allows the cancer team to help determine your exact lung cancer stage, and what to do next.

After RAS Surgery

• When the lung surgery is over, a small chest tube (about the size of a pen) is inserted, and all of the ports are removed. You are moved to a recovery room where staff can monitor the amount of fluid and air leaks in your chest through the container attached to the chest tube. When there is no more fluid or air leaks, it usually means you have healed enough to go home.
• You will go home with post-surgical instructions from your care team.

The past decade has brought many advances in lung surgery. If you are facing lung surgery, be sure to talk to your doctor about all of your options, including robotic assisted surgery.

Support for this educational initiative is provided by Intuitive.