Human versus (human directed) robotic keyhole surgery

When we talk about robotic surgery, to the patient it conjures up futuristic images of a technologically sophisticated robot doing the operation instead of a (human) surgeon.

For lung cancer surgery, the reality is that a surgeon is either doing the operation using keyhole surgery directly, or through “remote control” using smaller and internal articulating “robotic” instruments and camera visualisation. I think there are a number of comparable similarities and differences.

For non-robotic keyhole surgery, both surgeons are scrubbed with the patient, if anything goes wrong (usually bleeding complication), they are directly there and can attend to any major bleeding. In addition they have tactile feedback so they know how hard to push (or more importantly not to!) and switching instruments are much faster at a second or two. The comparable disadvantage is the lack of moving articulation as conventional instrumentation only has one (fixed) angle of articulation.

For robotic keyhole surgery, the surgeon is unscrubbed at a console without tactile feedback and needs to spend a few minutes scrubbing up to convert when required for a major bleeding complication that cannot be controlled. He or she would be able to have a greater control of angle of approaches for dissection during the procedure but will be slowed by any requirement for instrument changes in addition to the fixed costs of the robotic equipment (over £1.5 million) and consumables for the procedure (the NHS is considering withdrawing funding support for robotic surgery in the UK).

So which is better?

The honest answer is that we don’t know, and as usual it depends on what you mean by “better”? Will robotic keyhole surgery carry advantages over non-robotic surgery in terms of cancer outcomes or recovery to justify any increase in cost? Currently the UK is undertaking VIOLET a randomised trial of keyhole versus (conventional) open surgery, and we hope to have an answer by 2020 as our first priority. I know that NCT02804893 is a prospective multicentre randomised trial being undertaken to compare complications and conversion rates between robotic and VATS approaches to stage I and II lung cancer, but that doesn’t really answer the question.

My personal view is that future clinical trials in lung cancer are likely to demonstrate similar “efficacy” between the two methods as Yaxley et al have found with robotic versus conventional prostatectomy. My view would be that cost are unlikely to be justifiable unless the costs of robotics are drastically reduced and eventually the likely outcome would be a hybrid approach using a combination of human keyhole surgeons augmented by robotic enhanced instruments as the best balance between efficacy and cost.