The superiority of robot in surgery of mediastinal diseases

Since 2001, when robotic technology was first approved by the US Food and Drug Administration (FDA) (1) and then introduced in clinical practice, the best targets for cardio-thoracic surgery were considered all those procedures requiring operating in tiny and/or difficult to reach spaces, where an extreme dexterity an precision of instruments are required (2). In the last two decades a progressive and exponential increase in utilization and acceptance of robotic approach was observed, leading to successfully perform the majority of thoracic surgical procedures by using the robotic technology (3). These procedures include anatomical lung resections (4,5), excision of benign and malignant mediastinal masses (6-8), diaphragmatic plication or resection (9), oesophagectomy for malignant tumours and treatment of benign oesophageal diseases (10). It is undoubted that the diseases of mediastinum represent the best application of robotic technology in thoracic surgery such as underlined by several authors (11,12).

The success and the widespread acceptance and utilization of robotic technology stems from several reasons: (I) technical with the easy manoeuvrability and dexterity of instruments with 7 degrees of freedom, that allow difficult dissections in narrow fields, the 3-dimensional view with high-quality and magnification of operative field, the tremor filtering system (6-Hz motion filter) able to avoid any physiological instability in the instrument manipulation, and the easy standardization and reproducibility; (II) oncological with comparable if not superior results obtained both in the field of lung and mediastinal tumours; (III) anatomical with the mediastinum representing a surgical area with tiny spaces, sometimes difficult to reach, with major vessels and nerves where the manipulation may be at risk, thus requiring a very precise dissection; (IV) learning curve and teaching facilities, in fact the enhanced technology, with better visualization, the intuitive system and the recently introduced dual consoles make training in robotic surgery an excellent tool with an easier and faster learning curve (13).

The major limitation is still represented by the high fixed cost of the robotic system and the availability of only one system (da Vinci robotic platform, Intuitive Surgical, Inc., Sunnyvale, CA, USA); however, on the wave of success of robotic technology in the last years, several Companies are working on new and maybe more complex systems that could be introduced in the clinical practice in the next future.

This special issue on “Robotic Mediastinal Surgery” aims to give us an overview of the state of the art, the most innovative applications of robotic technology and the tips and tricks in the majority of operations for mediastinal diseases. The high qualification and experience of contributing authors, certainly will add a significant improvement in the field of robotic thoracic surgery stimulating the readers to increase their skill.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Shanghai Chest for the series “Robotic Mediastinal Surgery”. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/shc.2019.01.01). The series “Robotic Mediastinal Surgery” was commissioned by the editorial office without any funding or sponsorship. GM served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Shanghai Chest from Dec 2017 to Nov 2019. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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Giuseppe Marulli