Advances In Thoracic Robotic Surgery: When Technology Changes Technique
Gaetano Romano1, Carmelina C. Zirafa1, Elena Marrama2, Vittorio Aprile2, Federico Davini1, Franca Melfi1.
1Minimally Invasive and Robotic Thoracic Surgery, Robotic Multispecialty Center for Surgery, University Hospital of Pisa, Pisa, Italy, 2Department of Surgical, Medical, Molecular pathology and Critical Care, University Hospital of Pisa, Pisa, Italy.
Background: The introduction of the robotic system in thoracic surgery has revolutionizedthe treatment of pulmonary and mediastinal pathologies.Over the years, different technological upgrades have allowed the surgeons to change the technique.The aim of this study is to illustrate the impact of three upgrades in robotic thoracic surgery: the use of robotic staplers for lung resections, the green indocyanine infusion associated with intraoperative infrared vision for identification of pulmonary nodules and phrenic nerve during thymectomies and the technical improvements between third and fourth generations of robotic system. Methods: Stapler: We retrospectively analyzed 20 patients who underwent anatomic pulmonary resection for NSCLC from January 2015 to January 2016. Patients were divided into two groups: Group I: 10 patients, resections performed with robotic staplers and Group II: 10 patients, resections performed with endoscopic staplers. We evaluated the effectiveness in terms of postoperative complications and postoperative pain. Green indocyanine infusion: We evaluated 20 patients in which the indocyanine green infusion was used for the visualization of suspicious nodules for NSCLC (5 patients) and visualization of the phrenic nerve during thymectomies (15 patients). Technical improvements: We retrospectively evaluated 52 patients who underwent robotic thymectomy (Group I: 23 patients treated using the III robotic generation, Group II 29 patients treated with the IV generation). We evaluated effectiveness in terms of postoperative pain and analgesic request. Results: Stapler: No postoperative complication in both groups. Lower NRS mean scoreand analgesic request in group I. Green indocyanine: The use of indocyanine green has proved to be useful in the identification of invisible pulmonary nodules and in the execution of thymectomy in case of thymomas adjacent to the phrenic nerve. Technical improvements: We found a statistically significant difference in the mean value of the NRS 24 hours after surgery (p<0.05). Group I 4.07 (SD 2.51), Group II 1.72 (SD 1.15) and a statistically significant difference in the administration of analgesics. Group I 2.62 administrations (SD 0.94), Group II 1.52 administrations (SD 1.12) one day after surgery. Conclusions: The evolution of technology has improved the execution of robotic surgical procedures with a positive impact on postoperative outcomes. 
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