ORIGINAL ARTICLE Robotic-Assisted Lung Resection for Malignant Disease Casandra A. Anderson,* Minia Hellan,* Andres Falebella,† Clayton S. Lau,‡ Fredric W. Grannis, Jr,§ and Kemp H. Kernstine§ Objective: There have been few reports of the use of robotic surgery to resect lung malignancies. Feasibility and safety of robotic lung resection for malignant lung lesions will be assessed by performing a retrospective analysis. Methods: Between September 2004 and November 2006, 21 pa- tients (11 male and 10 female patients) underwent robotic lung resection. Twenty resections were performed for primary nonsmall cell lung cancer and two for metastatic lesions. One patient had bilateral resections for two primary tumors. Fourteen lobectomies, five segementectomies, one wedge resection, and two bilobectomies were performed. Seventy-two percent of operative procedures included mediastinoscopy and/or bronchoscopy at the time of resection. Results: Thirty-day mortality and conversion rate was 0%. The median operating room time and estimated blood loss was 3.6 hours and 100 mL, respectively. The median intensive care unit and total length of hospital stays were 2 and 4 days, respectively. Chest tubes were removed after a median of 2.0 days. The complication rate was 27%, which included atrial fibrillation, need for postoperative bron- choscopy, and pneumonia. The median tumor size and number of lymph nodes harvested was 2.3 cm and 16, respectively. All resec- tion margins were negative. Median follow-up time was 9.8 months, with no local recurrences at this time. Conclusion: Robotic lung resection appears safe and feasible and allows for significant lymph node retrieval, offers short hospital stays and low morbidity for patients undergoing surgical resection of lung malignancies. Future studies are needed to define the role of robotic surgery in lung cancer treatment. Key Words: Robotic lobectomy, Minimally invasive lung resection, Lung cancer, Robotic technology. (Innovations 2007;2: 254 –258) M inimally invasive video-assisted thoracic surgery (VATS) anatomic lung resection was first described for the treat- ment of lung cancer in the early 1990s. 1–3 Since that time, many authors have accumulated evidence to suggest that VATS may have several advantages over conventional open resections for early stage lung cancer. Such advantages in- clude shorter length of hospital stay, 4,5 decreased pain, 6–9 decreased postoperative morbidity, 8,10 and quicker return to activity. 5 Even though these advantages have been elicited, VATS lobectomy has not gained wide acceptance. The lim- itations of VATS, in difficult to access and visualize spaces such as the pleural cavity, include the lack of three-dimen- sional vision, compromised dexterity with limited range of motion, poor ergonomics, and amplification of physiologic tremor. 11 The da Vinci robotic system (Intuitive Surgical Inc., Sunnyvale, CA) attempts to overcome these limitations im- proving the surgeon’s vision, dexterity, and comfort. It offers the possibility of performing very precise surgery in confined spaces such as the chest. There is limited literature suggesting the safety and feasibility of robotic-assisted lung resection, particularly for lung cancer. 12,13 The current literature predominately focuses on early postoperative outcomes. In this report, we describe our technique and present our 2-year results for robotic- assisted lung resections with lymphadenectomy for lung can- cer using the da Vinci system addressing preoperative patient assessment, postoperative morbidity, and oncologic out- comes. METHODS Between September 2004 and November 2006, 21 patients underwent robotic lung resections for suspected ma- lignancy. Charts of these patients were retrospectively re- viewed with institutional investigational review board ap- proval. Patient characteristics are displayed in Table 1. Overall, 33% of patients were older than 70 years of age, 18% had predicted FEV1 less than 60%, and 23% had predicted DLCO (diffusion capacity of the lung for carbon monoxide) less than 60%. Forty-eight percent of patients had COPD (chronic obstructive pulmonary disease), all of which had a smoking history, although none were active smokers at the time of the procedure. Twenty resections were performed for primary non- small cell lung cancers and two for metastatic lesions. One patient had bilateral resections for two primary tumors. Of the patients with primary nonsmall cell lung cancers, 10 had been treated for a previous malignancy. Fourteen lobectomies, 5 segementectomies, 1 wedge resection, and 2 bilobectomies were performed. Tumor location is listed in Table 1. Sixteen (72%) of operative procedures included cervical, left medi- astinoscopy, and/or bronchoscopy with frozen section review of the pathology specimens at the time of resection. One From the Departments of *Surgical Oncology, †Anesthesia, ‡Urologic On- cology, and §Thoracic Surgery, City of Hope, Duarte, California. Address correspondence and reprint requests to Kemp H. Kernstine, Depart- ment of Thoracic Surgery, City of Hope and Beckman Research Institute, 1500 Duarte Road, Duarte, CA 91010; E-mail: kkernstine@coh.org. Copyright © 2007 by the International Society for Minimally Invasive Cardiothoracic Surgery ISSN: 1556-9845/07/0205-0254 Innovations • Volume 2, Number 5, September 2007 254