Has Robotic Surgery Caught Up With Thoracoscopic Surgery?

Larry Hand

November 13, 2013

The number of robotic pulmonary resections appears to be increasing significantly, and robotic-assisted lung surgery may be an appropriate alternative to video-assisted thoracic surgery (VATS), according to an article published online October 3 in the Annals of Thoracic Surgery.

Experts interviewed about the study agreed that the study was important and provided new information on this developing technology, but they had other observations about how robotic surgery fits into the clinic today.

Michael Kent, MD, from the Division of Thoracic Surgery and Interventional Pulmonology, Beth Israel Deaconness Medical Center and Harvard Medical School, Boston, Massachusetts, and colleagues analyzed data from the State Inpatient Databases from 2008 through 2010.

The State Inpatient Databases are a set of databases maintained by the Agency for Healthcare Research and Quality and contain data contributed by 44 states, regardless of payer or insurance status. The databases contain considerable data on 90% of discharges within a state. For this study, the researchers confined their analysis to 8 states for 2008 to 2009 and 6 states for 2010, with 74% of the robotic surgeries performed in Florida.

The researchers identified 33,095 patients who had a lobectomy during the study period: 20,238 open procedures, 12,427 VATS procedures, and 430 robotic procedures. In 2008, robotic procedures accounted for 0.2% of all of the procedures. That proportion grew to 3.4% in 2010.

Using propensity-matched analysis, the researchers found that robotic procedures were associated with significant reductions in mortality (0.2% vs 2.0%; = 0.016), length of stay (5.9 vs 8.2 days; P < .0001), and overall complication rates (43.8% vs 54.1%; P = .003) compared with open thoracotomy. They also found nonsignificant reductions when compared with VATS. Variables covered during the analysis included age, sex, hospital setting, and a number of comorbidities.

Mean age of patients ranged from 65.9 years for open-surgery patients to 66.3 for VATS patients to 67.2 for robotic patients. Baseline characteristics were similar for sex and comorbidities.

Some Limitations

The researchers acknowledge several limitations of the study in the article, including limited conclusions based on potential database coding errors and selection of robotic cases based on a specific code for the procedure introduced in 2007. Another limitation may be the exclusion from analysis of patients who were coded with both robotic and open surgeries.

Excluding those patients does limit conclusion, according to Taine T.V. Pechet, MD, a thoracic surgeon and vice chief of surgery at Penn Presbyterian Medical Center and associate professor of clinical surgery at the University of Pennsylvania in Philadelphia.

"If you have a major complication while you're doing a surgery robotically, what you do is you open," Dr. Pechet told Medscape Medical News. "Those that were excluded may, in fact, be where the complications were, and we don't know because they were excluded. That, to me, is a big problem."

Subject to Coding

Relying on the coding for robotic surgery is also risky, he said. "It turns out to be very hard to pull out what cases are robotic, not just cases in thoracic surgery, because the codes were not universally applied. But that doesn't negate the study, which still provides us with information that is one more piece of the puzzle."

Overall, Dr. Pechet said, the study "needs to be taken with a very large grain of salt because this is a technology in evolution and development. [T]he time period they were looking at was in the earliest phases of adoption in the United States, and there were a scattered few people doing it, and nobody really knew the details of how to do the procedure."

He continued, "I started doing it in 2009, and when I started, nobody from the company or its representatives could suggest to me what the optimal approach should be, such as where you position the robot relative to the patient. It's a very different story now. If you wanted to adopt this technology now as a surgeon, you can go to a center and watch somebody who does lots of these and see the whole system and understand how to do it."

One aspect the study does not address deals with costs, according to Shanda H. Blackmon, MD, MPH, chief of the Division of Thoracic Surgery at Houston Methodist Hospital in Texas and associate professor of thoracic surgery for Weill Cornell Medical College of Cornell University in New York City. She performed the first robotic thoracic resection in Houston during this study period.

More Expensive, But...

"It's always going to be more expensive than a VATS lobectomy," she told Medscape Medical News. "However, when you start to potentially save money with robotic surgery is when you do a minimally invasive surgery. Whether it's robotic or VATS, we know that it results in less blood loss, shorter hospital stays, less pain, and overall better outcomes. If you take someone who otherwise would have been doing open surgery, there's definitely a benefit."

In reference to recent reports of adverse events during robotic surgeries, Dr. Blackmon said, "I think the adverse events happen in all types of new technology. The learning curve is steep."

She continued, "My opinion is if everyone could learn VATS surgery, it might be a less-expensive and best-of-both-worlds situation. However, for reasons unknown to our specialty, many thoracic surgeons have not adopted VATS lobectomy, and many of those who did adopt VATS lobectomy have successfully adopted robotics lobectomy."

Martin A. Makary, MD, MPH, associate professor of surgery and public health at Johns Hopkins University School of Medicine in Baltimore, Maryland, who was senior author of an article published in August in the Journal of Healthcare Quality about underreporting of robotic surgery complications, thinks similarly.

"From what I'm reading, there's no difference in patient outcomes between thoracoscopic [VATS] and robotic surgery, and the claims of superiority are with reference to the comparison group of open surgery. It affirms what we've known for a while, and that is that any type of minimally invasive surgery is superior to open surgery for certain operations, and this is one of them," he told Medscape Medical News.

He said robotic surgery is an expensive way to deliver minimally invasive surgery in a community setting where physicians have good skills in performing thoracoscopic surgery, but it can be an enabling tool in communities where physicians may lack those skills.

Robot or Orange Hat

"I applaud the authors for having demonstrated the safety and efficacy of robotic surgery in this setting, for chest surgery," he continued, but he disagrees with one aspect of the conclusions: "They're incorrectly attributing the benefits of minimally invasive surgery to the robot, whereas the real conclusion is that the minimally invasive approach is better," he explained. "That would be like me wearing an orange hat when I do minimally invasive surgery and saying the orange hat results in better patient outcomes. The driver is the minimally invasive approach, and that's what gives these better outcomes."

The authors, Dr. Pechet, and Dr. Makary have disclosed no relevant financial relationships. Dr. Blackmon has reported that she is an unpaid teacher and speaker on VATS.

Ann Thorac Surg. Published online October 3, 2013. Abstract

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