European Journal of Cardiovascular Medicine

The integration of robotic technologies into modern surgical practice has revolutionized many fields, including thoracic surgery. Robotic surgical systems, originally conceived to extend the capabilities of the surgeon’s hands and enable precise remote-controlled procedures, have demonstrated significant advancements in enhancing operative dexterity, precision, and visualization. The da Vinci surgical platform , developed by Intuitive Surgical, remains the most widely adopted system globally. Since receiving FDA approval in 2000, the da Vinci system has been successfully applied across various surgical specialties, particularly in urology and more recently in thoracic surgery (1). Over the past decade, Robotic-Assisted Thoracic Surgery (RATS) has emerged as an important modality for performing complex thoracic procedures, including lung resections, mediastinal mass excisions, and esophageal surgeries. Compared to conventional Video-Assisted Thoracoscopic Surgery (VATS), robotic systems offer three-dimensional (3D) imaging and articulated instruments, enabling superior maneuverability and improved access to intricate anatomical regions. Furthermore, advancements such as the Versius system, developed by CMR Surgical, are expanding the spectrum of available robotic platforms. However, most published data on RATS outcomes currently pertain to procedures performed using the da Vinci system (2). Despite its considerable practical advantages—such as reduced patient trauma, lower postoperative pain, shorter hospital stays, and improved lymphadenectomy yield—the widespread adoption of RATS has been limited by cost constraints and resource availability (3). Nonetheless, many thoracic surgical teams have enthusiastically embraced this technology, and a growing body of evidence highlights its clinical benefits (2,3).  RATS has gained particular acceptance for mediastinal procedures, where its enhanced precision is especially advantageous, although its role in pulmonary resections continues to evolve (3). In parallel, robotic platforms have also become invaluable educational tools. Dual-console systems and integrated recording features provide surgical trainees with enhanced exposure to thoracic anatomy and procedural techniques, making RATS an essential component of contemporary thoracic surgical education (4,5). Structured training curricula increasingly recognize the importance of robotic competencies in preparing the next generation of thoracic surgeons for minimally invasive practice (4,5). While global data on RATS outcomes are accumulating (2,3), there remains a relative paucity of evidence from Indian academic and public healthcare settings. However, to date, no comprehensive institutional analysis has been undertaken to evaluate the clinical outcomes, and implementation challenges of RATS in this context. The primary objectives of this retrospective review are to characterize the adoption of RATS at VMMC-SJH over a defined time period.

This retrospective study was conducted in the Department of Cardiothoracic and Vascular Surgery at Vardhman Mahavir Medical College & Safdarjung Hospital (VMMC-SJH), New Delhi. The medical records of all patients who underwent Robotic-Assisted Thoracic Surgery (RATS) using the da Vinci surgical platform. Patients of all age groups and both sexes who underwent RATS for various thoracic pathologies, including lung resections (lobectomy, segmentectomy), mediastinal mass excisions, and esophageal procedures, were included. Exclusion criteria comprised incomplete medical records, patients converted to open thoracotomy prior to significant dissection, and those undergoing hybrid or combined procedures with other specialties.

Data were collected from operative records, anesthesia charts, perioperative notes, and follow-up documentation maintained in the department. The following variables were recorded: demographic characteristics, type of procedure performed, operative time (skin incision to closure), estimated blood loss, intraoperative complications, need for conversion to open surgery, and postoperative parameters including chest tube duration, length of hospital stay, and postoperative complications

All procedures were performed by a team of surgeons trained in robotic thoracic surgery using the da Vinci Xi system. The surgical approach included placement of robotic ports and assistant ports based on standard RATS lobectomy or mediastinal mass excision techniques described in the literature.

Statistical analysis:

Descriptive statistics were used to summarize patient demographics, surgical details, and perioperative outcomes. Continuous variables were expressed as mean ± standard deviation (SD), while categorical variables were presented as frequencies and percentages. Statistical analysis was performed using SPSS software (version 25).

A total of 21 patients who underwent Robotic-Assisted Thoracic Surgery (RATS) at VMMC-SJH between 2018 and 2024 were included in the study. The mean age of the patients was 39.4 ± 16.8 years. The study consisted of 8 males (38%) and 13 females (62%). The mean body surface area (BSA) was 1.6 ± 0.2 m², with a mean height of 160 ± 10.9 cm and a mean weight of 56.8 ± 12.2 kg  (Table 1).

Regarding the types of surgeries performed, thymectomy constituted the most common procedure, accounting for 7 cases (33%), followed by lobectomy in 5 patients (24%). Both bullectomy and excision of tumor were performed in 4 patients each (19%), while pneumonectomy was performed in 1 patient (5%). The mean incision size used for port placement was 11.5 ± 1.2 mm. The number of robotic ports used varied among patients: 2 ports in 2 cases (9%), 4 ports in 10 cases (48%), 5 ports in 8 cases (38%), and 6 ports in 1 case (5%). Most patients (91%) had a single chest drain placed postoperatively, while 2 drains were used in 2 cases (9%). The mean duration of ICU stay was 1.6 ± 0.6 days (Table 2).

Conversion to open thoracotomy was required in 4 patients (19%). Postoperative complications were observed in 5 patients (24%). The most frequent complication was a prolonged air leak from the intercostal drain (ICD), reported in 1 patient (5%). Atelectasis occurred in 1 patient (5%), while 1 patient (5%) required delayed drain removal on day 6 due to high output. Additionally, 1 patient (5%) developed fever with purulent discharge, necessitating drain removal on day 10. The remaining 16 patients (76%) had an uneventful postoperative course without complications.

Table 1: Characteristics of the study participants

Table 2: Surgery details

In this single-centre retrospective analysis of 21 Robotic-Assisted Thoracic Surgery (RATS) procedures conducted between 2018 and 2024, our experience demonstrated that RATS is a feasible and safe approach in a public tertiary-care setting. The study  comprised a relatively young population (mean age 39.4 years), with a predominance of female patients. The distribution of surgical procedures—primarily thymectomies and lobectomies—underscores the versatility of RATS in managing both mediastinal and pulmonary pathologies. These findings align with the growing global trend where RATS is increasingly used not only for lung cancer resections but also for complex mediastinal operations, where its superior dexterity and visualization offer better advantages (6,7).

The conversion rate of 19% in our cohort reflects the early phase of program adoption and falls within the broader range reported in the literature. Large multicenter series have documented conversion rates as low as 6% for RATS (compared to 11% for VATS), while single-institution experiences have reported rates of 8%. Taken collectively, these findings indicate that institutional RATS conversion rates generally lie between approximately 6% and 9% (8,9). This may reflect the early phase of the institutional learning curve. Other studies have highlighted that initial experiences with robotic surgery tend to show higher conversion rates, which decline with greater surgical team experience and procedural standardization (10). Conversions in our series were due to standard intraoperative challenges such as dense adhesions and anatomical complexities—factors similarly identified in the literature as common reasons for conversion (11-13).

The postoperative complication rate of 24% in our study was relatively low, with most events being minor and self-limiting. Prolonged air leak and atelectasis were each observed in 5% of patients, aligning with or improving upon rates reported in recent meta-analyses of robotic lobectomy outcomes, where prolonged air leak rates of approximately 15% have been observed (10). Moreover, the efficient postoperative recovery in our series, reflected by a short ICU stay and rapid chest drain removal in the majority of patients, is consistent with findings from larger studys demonstrating that RATS is associated with shorter hospital stays and reduced postoperative morbidity compared to both open surgery and VATS (8,9).

Current evidence supports that RATS provides comparable, if not superior, outcomes to VATS in several aspects. Robotic platforms offer enhanced precision and visualization, which are particularly advantageous for performing high-quality lymphadenectomy and complex manoeuvres, such as those required in sleeve resections or diaphragmatic plication (7). Several studies comparisons suggest that RATS may be associated with lower blood loss, shorter hospital stays, and improved lymphadenectomy yield (14-17). Notably, the application of RATS in mediastinal and thymic surgery has been met with greater enthusiasm compared to lung resections, as its manoeuvrability and superior visualization offer key advantages in this anatomically constrained region (18). While some authors reported benefits of RATS over VATS in terms of reduced blood loss and length of stay during thymectomy, these findings are not yet consistently demonstrated across all studies (19-21).

Technical aspects of RATS continue to evolve. Both portal and assisted robotic lobectomy approaches yield satisfactory results (23). Many surgeons have adopted four-arm approaches with the da Vinci Xi platform, enhancing operative independence and precision. The use of CO2 insufflation can improve visualization, though its benefit may vary with surgical approach. Additionally, interest in robotic sleeve lobectomy has increased, with several studies highlighting improved suturing capability and satisfactory outcomes using the robotic platform (17,22,24).

While RATS may achieve a better lymphadenectomy compared to VATS in some studies, particularly regarding oncological radicality and nodal staging (14,15,17,22), evidence regarding nodal upstaging remains mixed (17,22,24). Nonetheless, thorough lymph node dissection is crucial, as missed nodal disease is associated with a higher risk of recurrence.

Cost remains a major consideration. Although robotic platforms entail high initial investment and maintenance costs, potential reductions in complications and shorter hospitalizations may offset these expenses over time. Future efforts should focus on reducing overall costs to facilitate wider adoption of this technology (25,26).

The learning curve for RATS appears less steep than that for VATS, particularly for complex procedures. Operative time and docking efficiency typically improve after 15–20 procedures (27), and literature suggests that proficiency in robotic lobectomy may be achieved after approximately 20–30 cases (28,29). Additionally, the absence of tactile feedback in RATS can be partially mitigated by its high-definition 3D vision, with ongoing development of tactile feedback technologies promising further improvements.In comparison with open surgery, RATS offers the potential to combine the precision of open techniques with the minimally invasive advantages of VATS. If future studies continue to validate these benefits while addressing cost concerns, RATS may well become the preferred modality for many thoracic procedures. Furthermore, emerging uniportal and biportal RATS approaches could enhance adoption among surgeons transitioning from open to minimally invasive techniques.Our study has limitations, including its retrospective design, small sample size, and absence of a direct VATS or open comparison group. We also did not assess oncologic outcomes such as lymph node yield or long-term survival. However, the existing literature indicates that RATS offers oncologic outcomes comparable to VATS and open surgery (14,15,17,22).

This retrospective study demonstrates that Robotic-Assisted Thoracic Surgery (RATS) is a feasible and safe minimally invasive option for thoracic procedures in a public tertiary-care setting. Our initial experience shows acceptable conversion rates, low postoperative morbidity, and rapid recovery. The robotic platform proved versatile across both mediastinal and pulmonary surgeries. While cost and learning curve remain important considerations, RATS holds promise as an integral component of thoracic surgical practice. Further prospective studies and larger series are needed to validate its long-term clinical and oncologic outcomes.

Limitations

This study is limited by its retrospective design and small sample size, which may affect the generalizability of the findings. The lack of a direct comparison with Video-Assisted Thoracoscopic Surgery (VATS) or open thoracotomy prevents definitive conclusions regarding the relative advantages of RATS. Additionally, long-term oncologic outcomes were not assessed. Larger prospective studies are needed to validate these initial findings and further define the role of RATS in thoracic surgery.

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