IntroductionWe report the results of the first prospective international randomized control trial to compare the perioperative outcome and surgical radicality of the robotic approach with those of traditional video-assisted surgery in the treatment of early-stage lung cancer.MethodsPatients with clinical stage T1–T2, N0–N1 non-small cell lung cancer (NSCLC) were randomly assigned to robotic-assisted thoracoscopic surgery (RATS) or video-assisted thoracic surgery (VATS) resection arms. The primary objective was the incidence of adverse events including complications and conversion to thoracotomy. The secondary objectives included extent of lymph node (LN) dissection and other indicators.ResultsThis trial was closed at 83 cases as the probability of concluding in favor of the robot arm for the primary outcome was null according to the observed trend. In this study, we report the results of the analysis conducted on the patients enrolled until trial suspension. Thirty-nine cases were randomized in the VATS arm and 38 in the robotic arm. Six patients were excluded from analysis. Despite finding no difference between the two arms in perioperative complications, conversions, duration of surgery, or duration of postoperative stay, a significantly greater degree of LN assessment by the robotic technique was observed in regards to the median number of sampled LN stations [6, interquartile range (IQR) 4–6 vs. 4, IQR 3–5; p = 0.0002], hilar LNs (7, IQR 5–10 vs. 4, IQR 2–7; p = 0.0003), and mediastinal LNs (7, IQR 5–10 vs. 5, IQR 3–7; p = 0.0001).ConclusionsThe results of this trial demonstrated that RATS was not superior to VATS considering the perioperative outcome for early-stage NSCLC, but the robotic approach allowed an improvement of LN dissection. Further studies are suggested to validate the results of this trial.Clinical Trial Registrationclinicaltrials.gov, identifier NCT02804893.

Background: More than ten years ago we started a program of video-assisted thoracic surgery (VATS) lung metastasectomy in non-intubated local anesthesia. In this study we investigated the effectiveness and long term results of this combined surgical-anesthesiological technique. Methods: Between 2005 and 2014, 48 patients (25 men and 23 women) with pulmonary oligometastases from colorectal cancer, at the first episode, underwent VATS metastasectomy under non-intubated local anesthesia. Three patients required intubation for intolerance. In the same period 13 patients scheduled for non-intubated metastasectomy refused awake surgery and were used as a control group. Results: The two groups were homogeneous for both demographic and pathological features. Mean number of lesions resected per patient were 1.51 (non-intubated) vs. 1.77 (control), respectively (P=0.1). The oxygenation was significantly lower in the non-intubated group especially at the end of the procedure, but the values inverted from the first postoperative hour. There was no mortality in any groups. The non-intubated group demonstrated a significant shorter overall operating time (P=0.04), better quality of recovery after both 24 (P=0.04) and 48 hours (P=0.04), shorter median hospital stay (P=0.03) and lower estimated costs (P=0.03), even excluding the hospital stay. Major morbidity rate was lower (6% vs. 23%) yet not significant (P=0.1). Both disease free survival and overall survival were similar between groups. Conclusions: VATS lung metastasectomy in non-intubated local anesthesia was safely performed in selected patients with oligometastases with significant advantages in overall operative time, hospital stay and economical costs. Morbidity rate was lower yet not significant. Long term results were similar.

In the early 2000s, the 'Awake Thoracic Surgery Research Group' at Tor Vergata University began a program of thoracic operations in awake nonintubated patients. To our knowledge this was the first program created with this specific purpose. Since then over 1000 tubeless operations have been carried out successfully, making this series one of the widest in the world. Both nononcologic and oncologic conditions were successively approached and major operations for lung cancer are now being performed. Uniportal access was progressively adopted with significant positive outcomes in postoperative recovery, patient acceptance and economical costs. Failure rates due to patient's intolerance and open surgery conversion are progressively reducing. Tubeless thoracic surgery can be accomplished in a safe manner with effective results.

Use of low-dose CT scan allows detection of lung cancer at early stages, enabling a more conservative surgery and a better long-term survival in those patients. In this scenario, intentional anatomical segmentectomy is gaining consent over standard lobectomy among surgeons. A minimally invasive approach such as VATS reduced invasiveness and complication rate compared to open surgery, but this technique comes also with some disadvantages in terms of dexterity and intuitiveness. Robotic surgery allows to overcome those limitations, making segmentectomies easier and safer to perform. In addition, it offers the possibility to utilize intravenous indocyanine green to define the intersegmental plane, allowing a more precise surgery. We reviewed the literature and describe the technique of the robot assisted segmentectomy with a focus on the new technologies available nowadays.