Why Consider Robotic Surgery for Lung, Esophageal, and Other Chest Cancers?

Thoracic surgeon Bernard Park.

Thoracic surgeon Bernard Park.

For most people, surgery is still the best option to cure cancers of the chest such as lung cancer, esophageal cancer, and mediastinal tumors (located in the area of the chest between the lungs). For a long time the only method was to make a large incision and spread the ribs apart or saw open the breastbone to get access to the chest cavity and the tumor. In fact, this is still the most common technique used in operating rooms around the globe. Thanks to new technology and surgical innovations, however, an increasing number of patients at Memorial Sloan Kettering and other hospitals have the option to undergo removal of thoracic tumors through minimally invasive robotic surgery.

The use of video-assisted thoracic surgery (VATS, or thoracoscopy) to perform more complex procedures was first described in the mid-1990s. With the aid of a telescopic camera, light source, and specialized instruments, a surgeon operates through small incisions in the chest that do not require spreading of the ribs.

A decade later, thoracic surgeons at MSK pioneered the use of telerobotic technology consisting of a three-dimensional, high-definition visual system and precise robotic arms to further enhance the minimally invasive approach.

We asked Bernard Park, attending thoracic surgeon and Deputy Chief of Clinical Affairs, to explain why he feels robotic assistance is “the highest technological form of minimally invasive surgery” and, in many ways, the optimal choice for removing lung and other chest cancers.

Less Trauma, Faster Recovery

“We need to be able to offer people curative surgery without resorting to making large, rib spreading cuts,” says Dr. Park, “and if robotic surgery enables us to accomplish that, it’s well worth it. Patients get all the benefits of minimally invasive surgery — less damage from incisions, faster recovery, fewer complications — and a more rapid ability to either return to their pre-surgical condition or move on with additional treatment if necessary.” By using robotic technology, surgeons can retain the advantages of open surgery, such as full exposure and depth perception. Because these advantages are particularly heightened in tight spaces, it makes sense that robotics initially became widely adopted for operations such as radical prostatectomy and hysterectomy, performed in the small and narrow confines of the pelvis.

Within the chest cavity, heightened visualization and dexterity are crucial as well.

“With conventional minimally invasive surgery, such as VATS, the surgeon currently must use straight instruments with a two-dimensional image,” says Dr. Park. “While many skilled surgeons can overcome this limitation, if there is a platform that levels the playing field, why not take advantage of it?” When Dr. Park performs robotic surgery, he sits next to the patient at a console that allows him to see the surgical field and control all of the instruments. “The beauty of the system is the ability of the surgeon to control nearly all elements of the procedure at the touch of a finger,” he says. “My movements at the console are simply and elegantly translated to movements of the instruments.”

With robotics, the instruments are also “wristed,” meaning “they have seven degrees of freedom that approximates the human hand,” Dr. Park explains. “This means you can work in a very confined space. You can have precise movements and depth perception that allows for more precise ability to execute the necessary steps of the operation.”

Dr. Park also notes that a major issue when operating in the chest is the danger of working around the lung vessels, which are very delicate and where injuries can cause life-threatening bleeding. “With robotics, you’re able to better see and dissect around these vessels and to prevent those kinds of injuries.”

He adds that “because of this overall level of control, if there are patients with more complicated tumors that would traditionally only be offered open surgery, we are able to offer the benefits of a minimally invasive approach while still achieving optimal surgical treatment.”

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Why Experience Still Matters

While robotics is a powerful technology and can confer benefits to patients and surgeons, it’s ultimately just a tool. A person’s outcome hinges more on the skill and experience of the surgeon and knowing when it’s appropriate to use the technology than on the tool itself, says Dr. Park.

“If you have superior technology without superior judgment and experience, then it’s never going to make up for the lack of skill or poor decision-making,” he says. “That said, I think that the robotic technology can make surgeons who understand the strengths and limitations better. In the end, the responsibility is on the surgeon to use the technology appropriately.”

To find a chest surgeon who is skilled in robotics, Dr. Park recommends carefully evaluating the quality of the institution at which the doctor works, whether he or she has an established track record with robotic surgery, and how many cases he or she performs in a year using the technology. For lung cancer, one of the most common cancers in men and women, look for someone who performs at least 50 major lung resections a year, he explains. For less common diseases, such as thymoma, the number will be lower.

Even more reason, he notes, to schedule your operation at a place such as MSK, where robotic surgeries such as this are done all the time.

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Commenting is disabled for this blog post.

A friend of mine has esophageal cancer stage IV, with limphenodes around the stomach and throat. He did radiation and is now doing chemo. The doctor say it's inoperable. Do you think there may be another option?

Isabel, we are unable to answer personal medical questions on our blog. If your friend would like to make an appointment to speak with an MSK doctor, he can call 800-525-2225 or go to http://www.mskcc.org/cancer-care/appointment for more information. Thank you for your comment.

General question an I understand that many factors are accounted for while trying to answer this question. Factors include the patients health before an after surgery pathology report to be completed an assessment of the patient to determine when follow up radiation chemo or both should be performed after having a localized tumor which was diagnosed as metastatic lung cancer, believe to be stage 2 or 3 due to size of the tumor an it being localized, the bone & brain scan all came back good, pet scan only showed the infected area which was the tumor. What I understand for treatment, by reading other patients stories is that treatment whether it was radiation chemo or both varied, some was a week, others where as long as 2-3 weeks, some patients said they started radiation first then had surgery to remove a tumor. I also understand it's based on the dr's an what "game plan" they come up with. My question is. how long can we expect treatment to start after having the surgery? looking for a general time frame. What I got out of it would be within 1-2 weeks an if there going to attack this aggressively or just go with light treatment to try to kill off any cancer cells that may have not been detected during tests or left from the surgery. What's the time frame you look to get treatment?

Mark, you are correct that it depends on a number of factors including how long it takes for the patient to recover from surgery. If you’d like to make an appointment for a consultation at MSK, you can call 800-525-2225 or go to http://www.mskcc.org/cancer-care/appointment for more information. Thank you for your comment.

2years ago on August 30th 2012 Dr. Downey removed my right lung
Which saved my life. It wasn't easy due to subsequent infections
And I visited the operating room at least 24 times for cleaning
My chest cavity. Today I work full time run after and with my 9 yr old daughter
And visit my friend Dr.Robert Downey twice a year!
I also never received chemo or radiation
I never look in the rear view mirror but I must admit
I am truly blessed and lucky!

Patrick, thank you for sharing your story!

Recently noted on cats can a small tumor on bottom middle lobe and a small area also on lower lobe. Pulmonary did a Biopsy came back non malignant. Pulmonary oncologist and thoraic oncologist state it looks very suspicious and needs to come out. Hopefully using Vatts procedure. Wondering if I should get a second opinion.live in Clinton Ct being seen at Smilow.

While this surgery is indeed wonderful, I would add the caveat that not every patient will be a candidate for it. A surgeon will not know what he is getting into before the first incisions are made. Indeed it is rare, but sometimes not even a conventional gastric pull up can be used as there is not adequate vascular flow to support it. Then one moves on to plan B or. C, using the colon or small bowel.

With no complications or surprises, what is the general recovery time for robotic wedge biopsy, for robotic lobectomy or robotic 2 lobectomy? I realize everyone is different, but just a general idea of recovery time and when most patients can resume normal activity and work.

Barbara, thank you for your comment.

We sent your questions to Dr. Park, who responded that It is uncommon to utilize the robotic system for a simple wedge resection (biopsy) unless there is an additional component, like systematic removal of the lymph nodes. In that case, recovery is generally overnight in the hospital and patients are back to most normal activity in 1-2 weeks.

For lobectomy or biolobectomy, he said the length of stay is typically 2-3 days average, and again, back to normal activity in 2 weeks. This is of course keeping in mind that not everyone recovers within the same time frame.

He added that after any minimally invasive surgery, there will be some discomfort and fatigue that is worse the first week. Most patients are off strong pain medications after 1 week and thus they can drive and do most light activities. If they do not have a heavy physical labor occupation, most can return to work in 2-3 weeks.

Just had a ct scan & it showed 2 modules on r lung, 1 over an inch. Going for a pet scan this week at NY Cornell. Should I be worried?

If a worrisome spiculated lung nodule is in the lower lobe of the lung and difficult to access by needle aspiration, would robotics provide a better opportunity to access this for testing? I see they don't do regular biopsies by robotics typically, but a needle biopsy has been attempted and they were unable to access it. The goal would be to avoid an open lung biopsy in an elderly man.

Deborah, thank you for reaching out. We suggest you discuss the biopsy options with the treating physician. If you would like to make an appointment to seek a second opinion with a Memorial Sloan Kettering physician, please call our Physician Referral Service at 800-525-2225 or go to http://www.mskcc.org/cancer-care/appointment. Thanks for your comment.

I have been diagnosed with lung adenocarcinoma with 3 lymph nodes and a 2 inch mass cancerous. I have systemic lupus which is currently very quiet in me. Course of treatment 6 to 6 1/2 weeks of radiation 60 to 66 grey 5 days a week and mild chemotherapy once a week at the same time. No surgery to remove. All to begin May 16th. Can you please tell me if you would agree with this course of treatment. I am 63 years old and aside from these cancerous lymph nodes and the mass, my lungs are clear and in good condition. Thank you.
Pat Neglia

Dear Pat, we are sorry to hear about your diagnosis. Unfortunately, we cannot offer specific medical advice about your care on our blog. You are welcome to make an appointment for a second opinion with one of our specialists who can review your current course of treatment and discuss possible next steps. If you would like to arrange for a consultation, please call our Physician Referral Service at 800-525-2225. Thank you for reaching out to us.

Hi I just had a pet scan and it showed some activity I have a nodule 1.7 cm upper right lobe. I'm not sure which way to go vats or robotic. I'm part of emblem and they are trying to keep in network but I want to go Sloan

A routine chest X-Ray at my Doctor's office showed a shadow, so a CT Scan was scheduled for a week later - March 22nd. The CT shows a solid, well-formed node, a little less than an inch. A full-body PET scan shows only the node - no lymph or secondary tumors.

A biopsy was attempted a week or so later - the position of the node prevented a successful biopsy. Next step will be the use of a robotic surgical system to perform the biopsy, determine if the node is malignant or not, and based on the result, remove the node or the whole upper lobe of my right lung.

For scheduling reasons, the robotic procedure can't be scheduled until the first or second week in May.

I'm worried if this 7 or 8 week time span, from first detection to finding out whether the node is malignant or not, might be considered acceptable?

Had CT scan a few days ago due to a growth near my lungs that was picked up on routine chest X-ray for fractured ribs. CT reveals solid mass (9.2 x 0.6 x 7.6 cm). Thymoma is suspected pending biopsy. If it's thymoma, can this large tumor be removed via robotic surgery. I am terrified of a sternotomy and possible complications to go after an asymptomatic tumor that's not affecting any other organs.

Are there alternatives to a lobectomy for a typical carcinoid tumors on the right lower lobe airway? I will lose my pilot's license if I get a lobectomy. I've read about laser cutting this mass in the airway but don't know if that is even possible in the US.

I have been diagnosed with Stage 1 lung cancer. No lymph node involvement. The mass is on my left inner part of my lunch. Could robotic surgery be an option for me?

Dear Sherry, robotic surgery is often an option for people in your situation, but it’s difficult to say without a full review of your medical history and records. If you would like to speak with someone at MSK about this, you can call 800-525-2225. You can go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment and best wishes to you.

i want to send a cd of a ct scan and one of a pet scan to evaluate if needle biopsy would be satisfactory. i will pay for the consult of course

Allan, thank you for reaching out.

We suggest that you call 800-525-2225 to speak with someone at MSK who can address these questions.