TY - JOUR
AU - Okada,, Morihito
AB - Abstract Objective Anatomical segmentectomy has the potential to replace lobectomy as the standard procedure for early stage non-small cell lung cancer. We investigated the safety and feasibility of robotic anatomical segmentectomy for non-small cell lung cancer. Methods Overall 20 patients underwent robotic anatomical segmentectomy at Hiroshima University Hospital between January 2014 and January 2018. The clinicopathological characteristics, surgical outcomes, complications and prognosis were analyzed. Results The median age was 68 (range 42–86) years, and 15 patients were female. Six patients were non-smokers. The most common clinical stage was IA1 (nine patients). Complex segmentectomies were performed in four patients (one right S3 segmentectomy, two right S8 segmentectomies and one left S8 + S9 segmentectomy). The median operation time was 163.5 (range, 114–314) minutes, and the median console time was 104 (range, 60–246) minutes. The median blood loss was 26.5 (range, 5–247) ml. The median resection margin and number of dissected lymph node were 15 (range, 2–60) mm and 5 (range, 1–15), respectively. Although five (25.0%) patients had grade IIIa complications (pleurodesis for prolonged air leakage) and one (5.0%) had a grade IIIb complication (reoperation for prolonged air leakage), no post-operative deaths occurred. The surgical outcomes were comparable with those of anatomical segmentectomy performed under hybrid video-assisted thoracoscopic surgery during the same period. Conclusion In our initial experience of robotic anatomical segmentectomy for early stage non-small cell lung cancer, the procedure seems to be safe and feasible. lung cancer, robot-assisted surgery, minimally invasive surgery, segmentectomy, complex segmentectomy Introduction Recently, through the improvement of high-resolution computed tomography (CT) or 18-fluorodeoxyglucose positron emission tomography/CT, early stage lung cancer is becoming more frequently detected (1). Although the standard procedure for non-small cell lung cancer (NSCLC) is lobectomy according to the results of a randomized trial (2), many studies have reported the safety and oncologically acceptable results of segmentectomy for small size NSCLC since the 2000s (3–5). Moreover, several benefits of segmentectomy on post-operative respiratory function or patient’s quality of life have been reported (6, 7). Segmentectomy was thought to be a complex procedure because the pulmonary artery, pulmonary vein and bronchus must be identified peripherally than lobectomy and the intersegmental planes are dissected. However, the low incidence of complications arising from segmentectomy, including complex segmentectomy, has been shown by several reports (8, 9). Although a large-sized randomized control trial, currently being carried out by the Japan Clinical Oncology Group and the West Japan Oncology Group, which compares lobectomy and segmentectomy (JCOG0802/WJOG4607L) (10) has not been concluded, preliminary results suggest that segmentectomy may replace lobectomy as the standard procedure for early stage NSCLC because of its safety and oncological outcome. Robotic surgery has advanced and has become popular in many fields. Robotic lobectomy was first reported in the field of thoracic surgery, and has become a common surgical procedure with good outcomes (11–13). Segmentectomy, which is considered as a more complex surgery than lobectomy or other surgery, was rarely performed under robotic assistance. However, outcomes of robotic segmentectomy including long-term prognosis were reported recently (14, 15). These results seem to be feasible and safe compared with results of surgery under thoracotomy or video-assisted thoracoscopic surgery (VATS). Therefore, robotic anatomical segmentectomy is likely to become one of the standard procedures for early stage NSCLC. Other countries have conducted studies and reported findings about robotic segmentectomy; on the other hand, there are no studies from Japan, because Japanese public insurance covered lobectomy and mediastinal tumor resection, but not segmentectomy. Therefore, we report the safety and feasibility of the robotic anatomical segmentectomy performed as an exploratory treatment. Patients and methods Patients The Institutional Review Board of Hiroshima University Hospital approved this retrospective study and waived the requirement for informed consent from individual patients. Patients who underwent robotic anatomical segmentectomy at our institute between January 2014 and January 2018 were included in this study. We analyzed their characteristics, operation data, intra- and post-operative complications and prognosis. Staging was determined according to the TNM Classification of Malignant Tumors, eighth edition (16). Patient data were analyzed retrospectively in the present study. The preoperative examinations included chest CT, whole body positron emission tomography-CT brain magnetic resonance imaging and pulmonary function test to determine clinical stage and treatment strategy. Surgical procedure The da Vinci Surgical system Si® (Intuitive Surgical, Sunnyvale, USA) was rolled in from the head side of the patient. The pictures of the port placement are shown in Figure 1. First, a port is made in the eighth or ninth intercostal space (ICS) on the middle axillary line for use as a camera port (Fig. 1a). Next, ports for robotic arms are made in the fifth or sixth ICS on the anterior axillary line (Fig. 1b) and in the eighth or ninth ICS on the posterior axillary line (Fig. 1c). A fourth port is made in the 10th ICS on the posterior axillary line and is used by the assistant (Fig. 1d). The pulmonary artery and vein for the target segment are identified and cut by autosutures or energy devices. The central intersegmental plane is marked along the intersegmental vein. The remaining intersegmental plane is revealed from the inflate–deflate line made by jet ventilation from the target bronchus. Usually, the intersegmental plane was cut by electrocautery. After the water-sealing test, the intersegmental plane is enforced by fibulin glue (Beriplast P Combi-Set Tissue adhesion®, CSL Behring, Tokyo, Japan) and a polyglycolic acid sheet (NEOVEIL sheet®, GUNZE MEDICAL JAPAN, Osaka, Japan). A chest tube (19 Fr BLAKE drain®, Johnson & Johnson, New Brunswick, USA) was placed in the apex of the thoracic cavity before the chest was closed. Surgical procedures are shown in Figure 2. Figure 1. Open in new tabDownload slide The images of port placement. The skin insicions for port placement are shown in Figure 1A. A port is made in the eighth or ninth ICS on the middle axillary line, and is used as a camera port (a). The ports for robotic arms are made in the fifth or sixth ICS on the anterior axillary line (b), and in the eighth or ninth ICS on the posterior axillary line (c). A fourth port is made in the 10th ICS on the posterior axillary line and is used by the assistant (d). The ports with wound protection devices before docking of the da Vinci are shown in Figure 1B. Figure 1C is a picture taken from abdominal side after docking of the da Vinch. Figure 1D is a picture taken from back side after docking of the da Vinch. There are no inconveniences for performing surgery in theses port placements. Figure 1. Open in new tabDownload slide The images of port placement. The skin insicions for port placement are shown in Figure 1A. A port is made in the eighth or ninth ICS on the middle axillary line, and is used as a camera port (a). The ports for robotic arms are made in the fifth or sixth ICS on the anterior axillary line (b), and in the eighth or ninth ICS on the posterior axillary line (c). A fourth port is made in the 10th ICS on the posterior axillary line and is used by the assistant (d). The ports with wound protection devices before docking of the da Vinci are shown in Figure 1B. Figure 1C is a picture taken from abdominal side after docking of the da Vinch. Figure 1D is a picture taken from back side after docking of the da Vinch. There are no inconveniences for performing surgery in theses port placements. Figure 2. Open in new tabDownload slide Operation procedure of robotic segmentectomy. After insertion of robotic arms, pulmonary vein and artery for target segment are identified (Figure 2A and B). Then, central intersegmental plane is marked along the intersegmental vein (Figure 2A, white arrows). After cutting vessels by auto sutures or energy devices, target bronchus is identified (Figure 2C). The remaining intersegmental plane is revealed from the inflation–deflation line made by jet ventilation (white triangles) from the target bronchus. Then, cut the bronchus by auto suture and dissect intersegmental plane by electrocautery (Figure 2D). The intersegmental plane is reinforced using fibulin glue and polyglycolic acid sheets. Figure 2. Open in new tabDownload slide Operation procedure of robotic segmentectomy. After insertion of robotic arms, pulmonary vein and artery for target segment are identified (Figure 2A and B). Then, central intersegmental plane is marked along the intersegmental vein (Figure 2A, white arrows). After cutting vessels by auto sutures or energy devices, target bronchus is identified (Figure 2C). The remaining intersegmental plane is revealed from the inflation–deflation line made by jet ventilation (white triangles) from the target bronchus. Then, cut the bronchus by auto suture and dissect intersegmental plane by electrocautery (Figure 2D). The intersegmental plane is reinforced using fibulin glue and polyglycolic acid sheets. Follow-up evaluation Post-operative complications were evaluated according to the Clavien–Dindo classification (17). Post-operative follow-up procedures, including a physical examination and a chest CT examination every 6 months, were performed for 5 years after surgical resection. Statistical analysis The Statistical Package for the Social Sciences (SPSS version 20.0 for Windows; IBM corp, Armonk, USA) was used for evaluation of recurrence-free survival (RFS) and overall survival (OS). The RFS was defined as the time from the date of surgery until the time of recurrence or death or the last follow-up visit. The OS was defined as the time from the date of surgery until the time of death due to any causes or the last follow-up visit. The ground glass opacity (GGO) ratio was defined as the percentage of GGO to the total tumor diameter. The clinicopathological characteristics, surgical outcomes, complications and prognosis were analyzed. Moreover, to clarify the advantages and disadvantages of robotic anatomical segmentectomy, patient characteristics and surgical outcomes were compared between robotic and hybrid VATS segmentectomy, which we usually use as an approach method (18), performed during same period for the entire cohort and matched cohort. The matched cohort were made adjusting for age, sex smoking history, pulmonary comorbidities, respiratory function and frequency of complex segmentectomy using propensity score matching. Categorical variables and continuous variables of the entire cohort were compared using Chi-square and t tests, respectively. Categorical variables and continuous variables of the matched cohort were compared using McNemar and paired t tests, respectively. A P value < 0.05 was considered statistically significant for all analyses. Results Between January 2014 and January 2018, 20 patients underwent robotic anatomical segmentectomy. Patient characteristics are shown in Table 1. The median age was 68 (range 42–86) years, and 15 patients were female. Six patients were non-smokers. Respiratory function and lung condition were within normal range. The most common clinical stage was IA1 (nine patients, 45%), and the median total tumor size was 16 (range, 8–35) mm. The median size of the solid component was 7.8 (range, 0–23) mm and the GGO ratio was 50%. Seven patients had a pure solid nodule. Table 1 Patient characteristics Variables . Number . Total number of patients 20 Age (range) 68 (42–86) Sex  Male 5  Female 15 Smoking history 6 Respiratory function  %VC (%) (range) 101 (82.6–131.5)  %DLCO (%) (range) 85.0 (50.4–107.9) Comorbidities  Emphysema 2  Interstitial pneumonia 1  Diabetes mellitus 1  Atrial fibrillation 1  Aortic regurgitation 1 Total tumor size (mm) (range) 16 (8–35) Solid component size (mm) (range) 7.8 (0–23) GGO ratio (%) (range) 50 (0–100) Clinical stage  0 3  IA1 9  IA2 6  IA3 2 Tumor location  Right  S3 1  S6 3  S8 2  Left  S1 + S2 6  S3 3  S4 1  S6 3  S8 1 Variables . Number . Total number of patients 20 Age (range) 68 (42–86) Sex  Male 5  Female 15 Smoking history 6 Respiratory function  %VC (%) (range) 101 (82.6–131.5)  %DLCO (%) (range) 85.0 (50.4–107.9) Comorbidities  Emphysema 2  Interstitial pneumonia 1  Diabetes mellitus 1  Atrial fibrillation 1  Aortic regurgitation 1 Total tumor size (mm) (range) 16 (8–35) Solid component size (mm) (range) 7.8 (0–23) GGO ratio (%) (range) 50 (0–100) Clinical stage  0 3  IA1 9  IA2 6  IA3 2 Tumor location  Right  S3 1  S6 3  S8 2  Left  S1 + S2 6  S3 3  S4 1  S6 3  S8 1 VC; vital capacity, DLCO; diffuse diffusing capacity for carbon monoxide and GGO; ground glass opacity. Open in new tab Table 1 Patient characteristics Variables . Number . Total number of patients 20 Age (range) 68 (42–86) Sex  Male 5  Female 15 Smoking history 6 Respiratory function  %VC (%) (range) 101 (82.6–131.5)  %DLCO (%) (range) 85.0 (50.4–107.9) Comorbidities  Emphysema 2  Interstitial pneumonia 1  Diabetes mellitus 1  Atrial fibrillation 1  Aortic regurgitation 1 Total tumor size (mm) (range) 16 (8–35) Solid component size (mm) (range) 7.8 (0–23) GGO ratio (%) (range) 50 (0–100) Clinical stage  0 3  IA1 9  IA2 6  IA3 2 Tumor location  Right  S3 1  S6 3  S8 2  Left  S1 + S2 6  S3 3  S4 1  S6 3  S8 1 Variables . Number . Total number of patients 20 Age (range) 68 (42–86) Sex  Male 5  Female 15 Smoking history 6 Respiratory function  %VC (%) (range) 101 (82.6–131.5)  %DLCO (%) (range) 85.0 (50.4–107.9) Comorbidities  Emphysema 2  Interstitial pneumonia 1  Diabetes mellitus 1  Atrial fibrillation 1  Aortic regurgitation 1 Total tumor size (mm) (range) 16 (8–35) Solid component size (mm) (range) 7.8 (0–23) GGO ratio (%) (range) 50 (0–100) Clinical stage  0 3  IA1 9  IA2 6  IA3 2 Tumor location  Right  S3 1  S6 3  S8 2  Left  S1 + S2 6  S3 3  S4 1  S6 3  S8 1 VC; vital capacity, DLCO; diffuse diffusing capacity for carbon monoxide and GGO; ground glass opacity. Open in new tab Table 2 shows surgical outcomes. Complex segmentectomies which create several intricate intersegmental planes were performed in four patients (one right S3 segmentectomy, two right S8 segmentectomies and one left S8 + S9 segmentectomy). The median operation time was 163.5 (range, 114–314) minutes, and the median console time was 104 (range, 60–246) minutes (Fig. 3). There were no intra-operative complications and no conversions to thoracotomy. The median blood loss was 26.5 (range, 5–247) ml (Fig. 4). There were four patients with more than 100 ml of bleeding. However, there was no bleeding from the pulmonary artery or other large vessels. The median resection margin was 15 (range, 2–60) mm and all patients achieved complete resection. The median number of lymph nodes dissected was five (range, 1–15) and there were no metastatic lymph nodes. Table 2 Surgical outcomes Variables . Number . Operation time (min) (range) 163.5 (114–314) Console time (min) (range) 104 (60–246) Blood loss (ml) (range) 26.5 (5–247) Surgical procedure  Right   S3 segmentectomy 1   S6 segmentectomy 3   S8 segmentectomy 2  Left   Upper segmentectomy 9   Lingular segmentectomy 1   S6 segmentectomy 3   S8 + S9 segmentectomy 1 Conversion to thoracotomy 0 Resection margin (mm) (range) 15 (2–60) Dissected lymph node (range) 5 (1–15) R0 resection 20 Variables . Number . Operation time (min) (range) 163.5 (114–314) Console time (min) (range) 104 (60–246) Blood loss (ml) (range) 26.5 (5–247) Surgical procedure  Right   S3 segmentectomy 1   S6 segmentectomy 3   S8 segmentectomy 2  Left   Upper segmentectomy 9   Lingular segmentectomy 1   S6 segmentectomy 3   S8 + S9 segmentectomy 1 Conversion to thoracotomy 0 Resection margin (mm) (range) 15 (2–60) Dissected lymph node (range) 5 (1–15) R0 resection 20 Open in new tab Table 2 Surgical outcomes Variables . Number . Operation time (min) (range) 163.5 (114–314) Console time (min) (range) 104 (60–246) Blood loss (ml) (range) 26.5 (5–247) Surgical procedure  Right   S3 segmentectomy 1   S6 segmentectomy 3   S8 segmentectomy 2  Left   Upper segmentectomy 9   Lingular segmentectomy 1   S6 segmentectomy 3   S8 + S9 segmentectomy 1 Conversion to thoracotomy 0 Resection margin (mm) (range) 15 (2–60) Dissected lymph node (range) 5 (1–15) R0 resection 20 Variables . Number . Operation time (min) (range) 163.5 (114–314) Console time (min) (range) 104 (60–246) Blood loss (ml) (range) 26.5 (5–247) Surgical procedure  Right   S3 segmentectomy 1   S6 segmentectomy 3   S8 segmentectomy 2  Left   Upper segmentectomy 9   Lingular segmentectomy 1   S6 segmentectomy 3   S8 + S9 segmentectomy 1 Conversion to thoracotomy 0 Resection margin (mm) (range) 15 (2–60) Dissected lymph node (range) 5 (1–15) R0 resection 20 Open in new tab Post-operative outcomes are shown in Table 3. The median duration of chest tube drainage was 3 (range, 2–23) days. The median length of hospital stay was 7.5 (range, 4–24) days. Five (25%) patients experienced complications. Of those, four patients (20%) experienced pleurodesis for air leakage (grade IIIa), and one patient (5%) experienced pleurodesis for air leakage and heart failure. Although heart failure was improved by intravenous injection of furosemide and carperitide (grade II), air leakage continued after pleurodesis. Consequently, the patient underwent a second operation for prolonged air leakage from the pulmonary fistula (grade IIIb). This patient was discharged on the fifth day after the second surgery without additional complications. One patient (5%) with pleomorphic carcinoma experienced recurrence and death from lung cancer, and the other 19 patients survived without recurrences (median follow up; 36 months) (Supplemental Fig. 1). Figure 3. Open in new tabDownload slide Operation time and console time of each patient. The blue bar means console time. Total scale of the blue bar and the yellow bar means total operation time. Median operation time was 163.5 minutes. Median console time was 104 minutes. Figure 3. Open in new tabDownload slide Operation time and console time of each patient. The blue bar means console time. Total scale of the blue bar and the yellow bar means total operation time. Median operation time was 163.5 minutes. Median console time was 104 minutes. Figure 4. Open in new tabDownload slide Blood loss of each patient. Two patients have over 200 ml of blood loss. Most included patients can complete the surgery with less bleeding. Figure 4. Open in new tabDownload slide Blood loss of each patient. Two patients have over 200 ml of blood loss. Most included patients can complete the surgery with less bleeding. Table 3 Post-operative outcomes Variables . Number . Chest tube duration (days) (range) 3 (2–23) Hospital stay (days) (range) 7.5 (4–24) 30-day mortality 0 90-day mortality 0 Complications  No 15  Yes 5   Pleurodesis for air leakage (Grade IIIa) 4   Reoperation for air leakage and heart failure    (Grade IIIb) 1 pStage  0 3  IA1 8  IA2 8  IA3 1 Histology  Adenocarcinoma 19  Leomorphic carcinoma 1 Variables . Number . Chest tube duration (days) (range) 3 (2–23) Hospital stay (days) (range) 7.5 (4–24) 30-day mortality 0 90-day mortality 0 Complications  No 15  Yes 5   Pleurodesis for air leakage (Grade IIIa) 4   Reoperation for air leakage and heart failure    (Grade IIIb) 1 pStage  0 3  IA1 8  IA2 8  IA3 1 Histology  Adenocarcinoma 19  Leomorphic carcinoma 1 Open in new tab Table 3 Post-operative outcomes Variables . Number . Chest tube duration (days) (range) 3 (2–23) Hospital stay (days) (range) 7.5 (4–24) 30-day mortality 0 90-day mortality 0 Complications  No 15  Yes 5   Pleurodesis for air leakage (Grade IIIa) 4   Reoperation for air leakage and heart failure    (Grade IIIb) 1 pStage  0 3  IA1 8  IA2 8  IA3 1 Histology  Adenocarcinoma 19  Leomorphic carcinoma 1 Variables . Number . Chest tube duration (days) (range) 3 (2–23) Hospital stay (days) (range) 7.5 (4–24) 30-day mortality 0 90-day mortality 0 Complications  No 15  Yes 5   Pleurodesis for air leakage (Grade IIIa) 4   Reoperation for air leakage and heart failure    (Grade IIIb) 1 pStage  0 3  IA1 8  IA2 8  IA3 1 Histology  Adenocarcinoma 19  Leomorphic carcinoma 1 Open in new tab In the comparison of robotic anatomical segmentectomy and hybrid VATS segmentectomy, although there were some differences in patient characteristics such as age, sex, smoking history, pulmonary comorbidities, respiratory function and frequency of complex segmentectomy, there were no significant differences in operation time (P = 0.987) and blood loss (P = 0.697). There were also no differences in post-operative outcomes such as drainage duration (P = 0.483), hospital stay (P = 0.208) and frequency of complications (P = 0.341) (Supplemental Table 1). To account for confounding variables, we compared surgical outcomes between the matched cohort. Patient characteristics and outcomes are shown in Table 4. After adjusting for age, sex smoking history, pulmonary comorbidities, respiratory function and frequency of complex segmentectomy, there were no significant differences in patient characteristics. Surgical outcomes such as operation time (P = 0.447), blood loss (P = 0.330), drainage duration (P = 0.828), hospital stay (P = 0.906) and frequency of complications (P = 0.168) were not significantly different between robotic segmentectomy and hybrid VATS segmentectomy. Table 4 Patient characteristics, surgical outcomes and post-operative outcomes of the matched cohort Variables . RATS . Hybrid VATS . P value . Total number of patients 20 20 Age (range) 68 (42–86) 67 (45–85) 0.327 Sex 0.489  Male 5 (25.0%) 7 (35.0%)  Female 15 (75.0%) 13 (65.0%) Smoking history 6 (30.0%) 9 (45.0%) 0.225 Respiratory function  %Vital capacity (range) 101 (82.6–131.5) 105.9 (80.8–143.0) 0.158  %DLCO (range) 85.0 (50.4–107.9) 78.5 (45.5–135.1) 0.452 Comorbidities  Emphysema 2 (10.0%) 3 (15.0%) 0.632  Interstitial pneumonia 1 (5.0%) 2 (10.0%) 0.548 Total tumor size (mm) (range) 16 (8–35) 15 (8–42.7) 0.685 Solid component size (mm) (range) 7.8 (0–23) 6.9 (0–24) 0.153 GGO ratio (%) (range) 50 (0–100) 66.5 (0–100) 0.239 Clinical stage 0.889  0 3 (15.0%) 3 (15.0%)  IA1 9 (45.0%) 11 (55.0%)  IA2 6 (30.0%) 5 (25.0%)  IA3 2 (10.0%) 1 (5.0%) Operation time (min) 163.5 (114–314) 147 (75–259) 0.447 Console time (min) 104 (60–246) Blood loss (ml) 26.5 (5–247) 33.5 (10–263) 0.330 Surgical procedure 0.677  Simple segmentectomy 16 (75.0%) 17 (85.0%)  Complex segmentectomy 4 (25.0%) 3 (15.0%) Conversion to thoracotomy 0 (0%) 0 (0%) NA Resection margin (mm) (range) 15 (2–65) 22.5 (1–35) 0.837 Dissected lymph node (range) 5 (1–15) 6 (3–18) 0.451 R0 resection 20 (100.0%) 20 (100.0%) NA Chest tube time (range) 3 (2–23) 3 (2–10) 0.828 Hospital stay (range) 7.5 (4–24) 7.5 (5–13) 0.906 30-day mortality 0 (0%) 0 (0%) NA 90-day mortality 0 (0%) 0 (0%) NA Complications 0.168  No 15 (75.0%) 16 (80.0%)  Yes 5 (25.0%) 4 (20.0%)  Grade IIIb or severe 0 (0%) 0 (0%) 0.311 Variables . RATS . Hybrid VATS . P value . Total number of patients 20 20 Age (range) 68 (42–86) 67 (45–85) 0.327 Sex 0.489  Male 5 (25.0%) 7 (35.0%)  Female 15 (75.0%) 13 (65.0%) Smoking history 6 (30.0%) 9 (45.0%) 0.225 Respiratory function  %Vital capacity (range) 101 (82.6–131.5) 105.9 (80.8–143.0) 0.158  %DLCO (range) 85.0 (50.4–107.9) 78.5 (45.5–135.1) 0.452 Comorbidities  Emphysema 2 (10.0%) 3 (15.0%) 0.632  Interstitial pneumonia 1 (5.0%) 2 (10.0%) 0.548 Total tumor size (mm) (range) 16 (8–35) 15 (8–42.7) 0.685 Solid component size (mm) (range) 7.8 (0–23) 6.9 (0–24) 0.153 GGO ratio (%) (range) 50 (0–100) 66.5 (0–100) 0.239 Clinical stage 0.889  0 3 (15.0%) 3 (15.0%)  IA1 9 (45.0%) 11 (55.0%)  IA2 6 (30.0%) 5 (25.0%)  IA3 2 (10.0%) 1 (5.0%) Operation time (min) 163.5 (114–314) 147 (75–259) 0.447 Console time (min) 104 (60–246) Blood loss (ml) 26.5 (5–247) 33.5 (10–263) 0.330 Surgical procedure 0.677  Simple segmentectomy 16 (75.0%) 17 (85.0%)  Complex segmentectomy 4 (25.0%) 3 (15.0%) Conversion to thoracotomy 0 (0%) 0 (0%) NA Resection margin (mm) (range) 15 (2–65) 22.5 (1–35) 0.837 Dissected lymph node (range) 5 (1–15) 6 (3–18) 0.451 R0 resection 20 (100.0%) 20 (100.0%) NA Chest tube time (range) 3 (2–23) 3 (2–10) 0.828 Hospital stay (range) 7.5 (4–24) 7.5 (5–13) 0.906 30-day mortality 0 (0%) 0 (0%) NA 90-day mortality 0 (0%) 0 (0%) NA Complications 0.168  No 15 (75.0%) 16 (80.0%)  Yes 5 (25.0%) 4 (20.0%)  Grade IIIb or severe 0 (0%) 0 (0%) 0.311 RATS; robot-assisted surgery and VATS; video-assisted thoracoscopic surgery. Open in new tab Table 4 Patient characteristics, surgical outcomes and post-operative outcomes of the matched cohort Variables . RATS . Hybrid VATS . P value . Total number of patients 20 20 Age (range) 68 (42–86) 67 (45–85) 0.327 Sex 0.489  Male 5 (25.0%) 7 (35.0%)  Female 15 (75.0%) 13 (65.0%) Smoking history 6 (30.0%) 9 (45.0%) 0.225 Respiratory function  %Vital capacity (range) 101 (82.6–131.5) 105.9 (80.8–143.0) 0.158  %DLCO (range) 85.0 (50.4–107.9) 78.5 (45.5–135.1) 0.452 Comorbidities  Emphysema 2 (10.0%) 3 (15.0%) 0.632  Interstitial pneumonia 1 (5.0%) 2 (10.0%) 0.548 Total tumor size (mm) (range) 16 (8–35) 15 (8–42.7) 0.685 Solid component size (mm) (range) 7.8 (0–23) 6.9 (0–24) 0.153 GGO ratio (%) (range) 50 (0–100) 66.5 (0–100) 0.239 Clinical stage 0.889  0 3 (15.0%) 3 (15.0%)  IA1 9 (45.0%) 11 (55.0%)  IA2 6 (30.0%) 5 (25.0%)  IA3 2 (10.0%) 1 (5.0%) Operation time (min) 163.5 (114–314) 147 (75–259) 0.447 Console time (min) 104 (60–246) Blood loss (ml) 26.5 (5–247) 33.5 (10–263) 0.330 Surgical procedure 0.677  Simple segmentectomy 16 (75.0%) 17 (85.0%)  Complex segmentectomy 4 (25.0%) 3 (15.0%) Conversion to thoracotomy 0 (0%) 0 (0%) NA Resection margin (mm) (range) 15 (2–65) 22.5 (1–35) 0.837 Dissected lymph node (range) 5 (1–15) 6 (3–18) 0.451 R0 resection 20 (100.0%) 20 (100.0%) NA Chest tube time (range) 3 (2–23) 3 (2–10) 0.828 Hospital stay (range) 7.5 (4–24) 7.5 (5–13) 0.906 30-day mortality 0 (0%) 0 (0%) NA 90-day mortality 0 (0%) 0 (0%) NA Complications 0.168  No 15 (75.0%) 16 (80.0%)  Yes 5 (25.0%) 4 (20.0%)  Grade IIIb or severe 0 (0%) 0 (0%) 0.311 Variables . RATS . Hybrid VATS . P value . Total number of patients 20 20 Age (range) 68 (42–86) 67 (45–85) 0.327 Sex 0.489  Male 5 (25.0%) 7 (35.0%)  Female 15 (75.0%) 13 (65.0%) Smoking history 6 (30.0%) 9 (45.0%) 0.225 Respiratory function  %Vital capacity (range) 101 (82.6–131.5) 105.9 (80.8–143.0) 0.158  %DLCO (range) 85.0 (50.4–107.9) 78.5 (45.5–135.1) 0.452 Comorbidities  Emphysema 2 (10.0%) 3 (15.0%) 0.632  Interstitial pneumonia 1 (5.0%) 2 (10.0%) 0.548 Total tumor size (mm) (range) 16 (8–35) 15 (8–42.7) 0.685 Solid component size (mm) (range) 7.8 (0–23) 6.9 (0–24) 0.153 GGO ratio (%) (range) 50 (0–100) 66.5 (0–100) 0.239 Clinical stage 0.889  0 3 (15.0%) 3 (15.0%)  IA1 9 (45.0%) 11 (55.0%)  IA2 6 (30.0%) 5 (25.0%)  IA3 2 (10.0%) 1 (5.0%) Operation time (min) 163.5 (114–314) 147 (75–259) 0.447 Console time (min) 104 (60–246) Blood loss (ml) 26.5 (5–247) 33.5 (10–263) 0.330 Surgical procedure 0.677  Simple segmentectomy 16 (75.0%) 17 (85.0%)  Complex segmentectomy 4 (25.0%) 3 (15.0%) Conversion to thoracotomy 0 (0%) 0 (0%) NA Resection margin (mm) (range) 15 (2–65) 22.5 (1–35) 0.837 Dissected lymph node (range) 5 (1–15) 6 (3–18) 0.451 R0 resection 20 (100.0%) 20 (100.0%) NA Chest tube time (range) 3 (2–23) 3 (2–10) 0.828 Hospital stay (range) 7.5 (4–24) 7.5 (5–13) 0.906 30-day mortality 0 (0%) 0 (0%) NA 90-day mortality 0 (0%) 0 (0%) NA Complications 0.168  No 15 (75.0%) 16 (80.0%)  Yes 5 (25.0%) 4 (20.0%)  Grade IIIb or severe 0 (0%) 0 (0%) 0.311 RATS; robot-assisted surgery and VATS; video-assisted thoracoscopic surgery. Open in new tab Discussion This is the first study to report findings about robotic anatomical segmentectomy from Japan. We showed that robotic anatomical segmentectomy is feasible and safe. Our study’s complication rate was comparable with those of a previous report (11). There were no perioperative deaths. We performed all procedures without conversion to thoracotomy, in an acceptable surgical time and blood loss. Compared with VATS segmentectomy, there are no significant disadvantages in robotic anatomical segmentectomy. As a minimally invasive surgery, VATS has spread widely due to advantages in length of incisions, post-operative pain and complications when compared with thoracotomy surgery (19, 20). However, VATS also has limitations, including a two-dimensional visual field, and restriction of instruments. These handicaps could be overcome by the three-dimensional visual field and polyarticular instruments of a robotic surgery system. Importantly, a three-dimensional view is needed for segmentectomy to create the intersegmental line. Therefore, robotic surgery has the potential to expand its indications. Despite the short follow up duration, 19 patients (95.0%) survived without recurrences. In the present study, one patient with pleomorphic carcinoma experienced recurrence and death from lung cancer in the early period from surgery. Although we must consider the indication of segmentectomy itself in the case of high malignancy lung cancer, such as solid predominant large tumor, preoperatively diagnosed pleomorphic carcinoma or small cell lung cancer, robotic anatomical segmentectomy seems to provide sufficient oncological outcome when compared with VATS or open segmentectomy, as previously reported (15). There are several limitations to this study. First, this study includes a small sample size from a single institution. Second, this study includes patients with low-risk characteristics, including female, non-smoker, early clinical stage and no comorbidities. On the other hand, this study includes four patients who underwent complex segmentectomy that required dissection of several intersegmental planes, which demonstrates that robotic surgery can be performed for complex procedures. In addition, due to Japanese public insurance coverage, most of our robotic anatomical segmentectomy cases were in the introduction period of robotic surgery at our institute. Notably, we used the da Vinci Surgical system Si® during the period of this study. However, we now use the da Vinci Surgical system Xi® (Intuitive Surgical, Sunnyvale, USA), which has fine arms that make it possible for surgeon to perform operations comfortably. A recent study that analyzed the learning curve of robotic anatomical segmentectomy reports that ~40 surgeries are needed to achieve technical competency (21). Better outcomes are possible if we perform robotic anatomical segmentectomy often. Therefore, to confirm the feasibility and safety of this procedure, it is important to perform robotic anatomical segmentectomy on more patients. Additionally, these results may contribute to the expansion of indications for robotic surgery. Conclusion Complication and prognosis of robotic segmentectomy for early stage NSCLC were feasible. To confirm these initial results, further analysis with more patients is needed. Acknowledgement None. Funding statement The authors declare that this study was not funded externally. Conflict of interest statement The authors have no conflicts of interest to declare. References (1) Goya T , Asamura H , Yoshimura H , et al. Prognosis of 6644 resected non-small cell lung cancers in Japan: a Japanese lung cancer registry study . Lung Cancer 2005 ; 50 : 227 – 34 . Google Scholar Crossref Search ADS PubMed WorldCat (2) Ginsberg RJ , Rubinstein LV . Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung cancer study group . Ann Thorac Surg 1995 ; 60 : 615 – 22 . Discussion 622 . Google Scholar Crossref Search ADS PubMed WorldCat (3) Okada M , Koike T , Higashiyama M , et al. Radical sublobar resection for small-sized non-small cell lung cancer: a multicenter study . J Thorac Cardiovasc Surg 2006 ; 132 : 769 – 75 . Google Scholar Crossref Search ADS PubMed WorldCat (4) El-Serif A , Gooding WE , Santos R , et al. Outcomes of sublobar resection versus lobectomy for stage I non-small cell lung cancer: a 13-year analysis . Ann Thorac Surg 2006 ; 82 : 408 – 15 . Discussion 415 . Google Scholar Crossref Search ADS PubMed WorldCat (5) Tsutani Y , Miyata Y , Nakayama H , et al. Appropriate sublobar resection choice for ground glass opacity-dominant clinical stage IA lung adenocarcinoma: wedge resection or segmentectomy . Chest 2014 ; 145 : 66 – 71 . Google Scholar Crossref Search ADS PubMed WorldCat (6) Harada H , Okada M , Sakamoto T , et al. Functional advantage after radical segmentectomy versus lobectomy for lung cancer . Ann Thorac Surg 2005 ; 80 : 2041 – 5 . Google Scholar Crossref Search ADS PubMed WorldCat (7) Balduyck B , Hendriks J , Lauwers P , Van Schil P . Quality of life evolution after lung cancer surgery: a prospective study in 100 patients . Lung Cancer 2007 ; 56 : 423 – 31 . Google Scholar Crossref Search ADS PubMed WorldCat (8) Handa Y , Tsutani Y , Mimae T , et al. Complex segmentectomy in the treatment of stage IA non-small-cell lung cancer . Eur J Cardiothorac Surg 2019 ; doi: 10.1093/ejcts/ezz185 . OpenURL Placeholder Text WorldCat Crossref (9) Suzuki K , Saji H , Aokage K , et al. Comparison of pulmonary segmentectomy and lobectomy: safety results of a randomized trial . J Thorac Cardiovasc Surg 2019 ; 158 : 895 – 907 . Google Scholar Crossref Search ADS PubMed WorldCat (10) Nakamura K , Saji H , Nakajima R , et al. A phase III randomized trial of lobectomy versus limited resection for small-sized peripheral non-small cell lung cancer (JCOG0802/WJOG4607L) . Jpn J Clin Oncol 2010 ; 40 : 271 – 4 . Google Scholar Crossref Search ADS PubMed WorldCat (11) Park BJ , Flores RM , Rusch VW . Robotic assistance for video-assisted thoracic surgical lobectomy: technique and initial results . J Thorac Cardiovasc Surg 2006 ; 131 : 54 – 9 . Google Scholar Crossref Search ADS PubMed WorldCat (12) Dylewski MR , Ohaeto AC , Pereira JF . Pulmonary resection using a total endoscopic robotic video-assisted approach . Semin Thorac Cardiovasc Surg 2011 ; 23 : 36 – 42 . Google Scholar Crossref Search ADS PubMed WorldCat (13) Rajaram R , Mohanty S , Bentrem DJ , et al. Nationwide assessment of robotic lobectomy for non-small cell lung cancer . Ann Thorac Surg 2017 ; 103 : 1092 – 100 . Google Scholar Crossref Search ADS PubMed WorldCat (14) Pardolesi A , Park B , Petrella F , et al. Robotic anatomic segmentectomy of the lung: technical aspects and initial results . Ann Thorac Surg 2012 ; 94 : 929 – 34 . Google Scholar Crossref Search ADS PubMed WorldCat (15) Nguyen D , Gharagozloo F , Tempesta B , et al. Long-term results of robotic anatomical segmentectomy for early-stage non-small-cell lung cancer . Eur J Cardiothorac Surg 2019 ; 55 : 427 – 33 . Google Scholar Crossref Search ADS PubMed WorldCat (16) Goldstraw P , Chansky K , Crowley J , et al. The IASLC lung cancer staging project: proposals for revision of the TNM stage groupings in the forthcoming (eighth) edition of the TNM classification for lung cancer . J Thorac Oncol 2016 ; 11 : 39 – 51 . Google Scholar Crossref Search ADS PubMed WorldCat (17) Clavien PA , Barkun J , de Oliveira ML , et al. The Clavien-Dindo classification of surgical complications: five-year experience . Ann Surg 2009 ; 250 : 187 – 96 . Google Scholar Crossref Search ADS PubMed WorldCat (18) Okada M , Sakamoto T , Yuki T , et al. Hybrid surgical approach of video-assisted minithoracotomy for lung cancer: significance of direct visualization on quality of surgery . Chest 2005 ; 128 : 2696 – 701 . Google Scholar Crossref Search ADS PubMed WorldCat (19) Laursen LØ , Petersen RH , Hansen HJ , et al. Video-assisted thoracoscopic surgery lobectomy for lung cancer is associated with a lower 30-day morbidity compared with lobectomy by thoracotomy . Eur J Cardiothorac Surg 2016 ; 49 : 870 – 5 . Google Scholar Crossref Search ADS PubMed WorldCat (20) Bendixen M , Jørgensen OD , Kronborg C , et al. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial . Lancet Oncol 2016 ; 17 : 836 – 44 . Google Scholar Crossref Search ADS PubMed WorldCat (21) Zhang Y , Liu S , Han Y , et al. Robotic anatomical segmentectomy: an analysis of the learning curve . Ann Thorac Surg 2019 ; 107 : 1515 – 22 . Google Scholar Crossref Search ADS PubMed WorldCat © The Author(s) 2020. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permission@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)
TI - Initial experience of robotic anatomical segmentectomy for non-small cell lung cancer
JF - Japanese Journal of Clinical Oncology
DO - 10.1093/jjco/hyz199
DA - 2020-04-07
UR - https://www.deepdyve.com/lp/oxford-university-press/initial-experience-of-robotic-anatomical-segmentectomy-for-non-small-C0z2AdV6pT
DP - DeepDyve
ER -