Exploring Robotic-assisted Thoracic Surgery for Lung Cancer: Does Robotic-assisted Thoracic Surgery Result in Improved Functional Outcomes Compared to Thoracotomy and How do Patients Appraise the Experience of Undergoing RATS

Lung cancer is the second most common cause of cancer in the UK and the most common cause of cancer death. Surgery is currently the most effective treatment for curing lung cancer and it can be performed using open (thoracotomy) or minimally invasive techniques (Video Assisted Thoracic Surgery (VATS)). Despite VATS being associated with fewer postoperative complications (PPCs), faster recovery and better survival at 4 years compared to thoracotomy it is only used by 20-44% of thoracic surgeons in the UK and just 5% of surgeons in Europe report using minimally invasive techniques for lung resection. Rigid, restrictive instruments and suboptimal vision means a steep learning curve is necessary to conduct VATS successfully. RATS maybe a more attractive minimally invasive approach as it offers 3DHD vision, a 360 degree view of the chest, and a fully articulated arm. JCUH and the Barts Hospital are two of the few centers in the UK performing RATS.

Research on RATS has been largely limited to single retrospective case series reports focusing on safety (PPCs and mortality) and cost effectiveness outcomes. Little research has been conducted exploring the effect of RATS on patient-centered outcomes that are also important quality measures.

To date, no studies have explored the impact of RATS on exercise capacity, yet investigators know that individuals who undergo a thoracotomy have a 16% reduction in exercise capacity at 6 months follow up. Exercise capacity has been shown to be an important predictor for long-term prognosis and length of stay following thoracic surgery, which can have substantial implications for cost. Furthermore, percentage VO2 max has been shown to be the best predictor of PPCs within 30 days of undergoing a lung resection (predictive value 85.5%), which is an important indicator of patient safety.

Two studies have looked at HRQOL post-RATS and compared it to an open technique. Balduyck and colleagues reported that whilst significant reductions from baseline were seen 1 month post-surgery in those who underwent an open procedure (sternotomy), HRQOL had returned to baseline values by 1 month post-surgery in those who underwent RATS. However, indicators of whether individuals received RATS or an open procedure were not controlled for which is likely to be important as individuals who have large tumors are not eligible to receive RATS. Instead RATS is usually assigned to older, frailer individuals. The second study did conduct between-groups comparisons between those who underwent a robotic lobectomy V those who received an open rib and nerve sparing lobectomy. The mental-component of the SF-12 was significantly higher in the robot group at 3 weeks post-surgery, indicating better mental quality of life, although there were no significant between-group differences detected for the physical-component. By 4 months follow up neither the mental nor the physical HRQOL scores differed between the two groups. The SF-12 in a general measure of health status and to date the impact of open surgery V RATS on disease-specific HRQOL has not been explored.

Physical activity is associated with improved HRQOL in patients with lung cancer and increased survival post-diagnosis of cancer. However, 2 months following a lung resection, performed via a thoracotomy or VATS, physical activity levels were still reduced. Unfortunately comparisons between surgical groups were not possible in this study due to the small number of patients who underwent VATS (14), therefore postoperative physical activity in those who have undergone thoracotomy compared to minimally invasive surgery is still unknown.