Commentary: Robotic lobectomy: Changing times, unchanging principles

Central MessageSurgery will continue to evolve, to change, but the more things change, the more they need to stay the same.See Article page 473. Surgery will continue to evolve, to change, but the more things change, the more they need to stay the same. See Article page 473. Evarts Graham performed the first successful pneumonectomy for lung cancer on April 5, 1933, establishing pneumonectomy as the operative treatment of choice for the management of lung cancer at that time.1Horn L. Johnson D.H. Evarts A. Graham and the first pneumonectomy for lung cancer.J Clin Oncol. 2008; 26: 3268-3275Crossref PubMed Scopus (32) Google Scholar,2Graham E.A. Singer J.J. Landmark article Oct 28, 1933. Successful removal of an entire lung for carcinoma of the bronchus. By Evarts A. Graham and J. J. Singer.JAMA. 1984; 251: 257-260Crossref PubMed Scopus (26) Google Scholar In 1942, Kent and Blades from the Chest Service of the Barnes hospital published their clinical experience of the technique of individual ligation for 27 patients undergoing pulmonary lobectomy, which had previously been read at the 24th Annual Meeting of the American Association for Thoracic Surgery in Toronto.3Kent E.M. Bladen B. The surgical anatomy of the pulmonary lobes.J Thorac Surg. 1942; 12: 18-30Abstract Full Text PDF Google Scholar,4Faber L.P. Individual ligation technique for lower lobe lobectomy.Ann Thorac Surg. 1990; 49: 1016-1018Abstract Full Text PDF PubMed Scopus (9) Google Scholar Core principles of preoperative bronchoscopy and operative ligation of the artery followed by ligation of the vein and then bronchus were established.3Kent E.M. Bladen B. The surgical anatomy of the pulmonary lobes.J Thorac Surg. 1942; 12: 18-30Abstract Full Text PDF Google Scholar,4Faber L.P. Individual ligation technique for lower lobe lobectomy.Ann Thorac Surg. 1990; 49: 1016-1018Abstract Full Text PDF PubMed Scopus (9) Google Scholar Several decades later, in 1962, Shimkin and colleagues compared case series of pneumonectomy and lobectomy performed by Dr Overholt and Dr Ochsne and demonstrated that “survival after lobectomy was equivalent to pneumonectomy with fewer complications.”5Shimkin M.B. Connelly R.R. Marcus S.C. Cutler S.J. Pneumonectomy and lobectomy in bronchogenic carcinoma. A comparison of end results of the Overholt and Ochsner clinics.J Thorac Cardiovasc Surg. 1962; 44: 503-519Abstract Full Text PDF PubMed Google Scholar,6Abbas A.E. Surgical management of lung cancer: history, evolution, and modern advances.Curr Oncol Rep. 2018; 20: 98Crossref PubMed Scopus (23) Google Scholar CALGB 39802 established the feasibility of a standardized approach to video-assisted thoracoscopic surgery lobectomy while preserving core principles of individual ligation technique for the lobectomy with standard node sampling or dissection.7Swanson S.J. Herndon 2nd, J.E. D'Amico T.A. Demmy T.L. McKenna Jr., R.J. Green M.R. et al.Video-assisted thoracic surgery lobectomy: report of CALGB 39802—a prospective, multi-institution feasibility study.J Clin Oncol. 2007; 25: 4993-4997Crossref PubMed Scopus (431) Google Scholar Cerfolio and colleagues8Cerfolio R.J. Ghanim A.F. Dylewski M. Veronesi G. Spaggiari L. Park B.J. The long-term survival of robotic lobectomy for non-small cell lung cancer: a multi-institutional study.J Thorac Cardiovasc Surg. 2018; 155: 778-786Abstract Full Text Full Text PDF PubMed Scopus (65) Google Scholar performed a multi-institutional retrospective review of a consecutive series of 1339 patients from 4 institutions, which demonstrated “an impressive stage-specific survival of patients with completely resected NSCLC.” In this month's issue of JTCVS Techniques, Servais9Servais E. Robotic-assisted left lower-lobe pulmonary lobectomy: eleven steps..J Thorac Cardiovasc Surg Tech. 2021; 10: 473-479Scopus (2) Google Scholar describes a robotic-assisted left lower lobe pulmonary lobectomy in 11 steps. This “how-to” paper provides a safe and reproducible approach for left lower lobectomy that may enhance surgeon adoption, furthering the use of a minimally invasive approach to anatomic pulmonary resection for lung carcinoma. Our group has adopted the robotic-assisted video assisted approach to thoracic surgery with the mandate that surgical principles such as individual ligation technique and optimal nodal evaluation (sampling and/or dissection) be maintained without compromise. Consequently, we concur with Upham and Onaitis, who have stated that “everyone would support less-invasive surgery via any approach if it were able to provide the expected decrease in morbidity and allow for at least equivalent if not improved oncologic outcomes,”10Upham T.C. Onaitis M.W. Video-assisted thoracoscopic surgery versus robot-assisted thoracoscopic surgery versus thoracotomy for early-stage lung cancer.J Thorac Cardiovasc Surg. 2018; 156: 365-368Abstract Full Text Full Text PDF PubMed Scopus (10) Google Scholar and D'Amico,11D'Amico T.A. The best that surgery has to offer.J Thorac Cardiovasc Surg. 2013; 145: 699-701Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar who has stated that “patients may not be receiving the ideal therapy in the future if surgeons do not recognize and practice the best that surgery has to offer in optimizing oncologic efficacy while minimizing invasiveness and complications.” Thoracic surgical treatment for lung cancer has evolved from total organ resection to lobectomy and to anatomic sublobar resection for the appropriate indications and patients. At the current time, the application of a minimally invasive approach to pulmonary lobectomy must maintain the core principles of individual ligation with appropriate nodal evaluation to accomplish a pathologic complete resection. Surgery will continue to evolve, to change, but the more things change, the more they need to stay the same. As Jimmy Carter said, “We must adjust to changing times and still hold to unchanging principles.” This is also the way. Robotic-assisted left lower-lobe pulmonary lobectomy: Eleven stepsJTCVS TechniquesVol. 10PreviewFeature Editor's Introduction—In the following Video Atlas Article, you will find some of the clearest and most comprehensive video-based instruction for robotic lobectomy. Herein, the author distills a robotic left upper lobectomy procedure into a logical and discrete series of steps, each peer-reviewed and each demonstrated with high-quality video and short-format text. Included are instructions for lean instrumentation with printable a case card and illustration of a highly nuanced surgical technique that optimizes economy of motion and that thinks several steps ahead to improve overall case efficiency. Full-Text PDF Open Access

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