Michael R. Gooseman,¹ Michael E. Cowen¹
¹Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Hull, UK
DOI: 10.5281/zenodo.19237231
Robotic thoracic surgery continues to progress rapidly with the volume of operations undertaken robotically continuing to increase and the range and complexity of surgery also increasing. There is a growing body of literature related to the good clinical outcomes that can be achieved by robotic assisted thoracic surgery (RATS). Alongside RATS as a minimally invasive surgical approach, avoiding rib spreading and utilising smaller incisions, is video assisted thoracoscopic surgery (VATS). VATS has been firmly established with RCT evidence of benefits in areas such as surgery for early stage lung cancer when compared to open surgery, but where VATS continues to be undertaken, there is a progressive increase in surgery being done robotically. Following on from the robotic programme being established in our unit in 2019, we have undertaken hundreds of robotic thoracic cases with excellent clinical outcomes and, having also recently undertaken emergency robotic thoracic surgery with both a good surgical experience and most importantly a good clinical outcome for our patient, it is from this perspective that we ask if there is a time when the robotic surgeon should limit or potentially even stop their VATS practice.
The answers to these questions are complex and will likely trigger debate, especially in a surgical landscape that is potentially more varied and complex than ever. There is a very reasonable view that being confident and competent to utilise various approaches can be beneficial. There are different skills and attributes required to perform these procedures, making a more versatile and adaptable surgeon. With current training in thoracic surgery, it is likely that training will be received in VATS prior to or alongside RATS. In addition, in the reality of complex healthcare systems, it is likely that both will continue to have a role depending on the operation type and complexity, being mindful of maximising patient benefit in terms of quality and quantity of life but also acknowledging the healthcare costs and striking an appropriate balance. Insight, reflection and assessment of one's own work and results are clearly very important for any surgeon. This will ensure they keep providing the highest standards of patient care, adapting if needed, looking for areas for progression and improvement, and consolidating best practice. It is from this perspective that we raise the question regarding the approach for a major component of a thoracic surgeon's workload: lobectomy for lung cancer. We have a robotic lobectomy experience that is now extensive with patient outcomes that are very favourable, which can be monitored through the National Consultant Information Programme. More recently we have undertaken robotic lobectomy exclusively with little VATS lobectomy.
Our outcomes show this has been delivered safely and efficiently and in our hands, with the experience and practice we have, a robotic approach is now favourable to a VATS. We are deliberately careful with the wording here and recognise that we are unable to point to large randomised control trials and long term outcome data to support a personal viewpoint. That said, there are other operations, such as segmentectomy or diaphragm plication, for which our opinion is perhaps even stronger that robotic surgery offers benefit over VATS. The reasons for this are explained by the technical benefits brought about by utilising the robotic technology, such as through CO₂ insufflation to aid vision or indocyanine green to help delineate segmental anatomy. It is not unreasonable to think that this viewpoint will strengthen as technology continues to progress.
High quality surgery can take many and numerous forms and there is no single way of delivering this, but how would the surgeon who feels they should be doing an operation robotically proceed if asked to cover a non-robotic list? This is a question we feel relevant when a robotic practice is established and flourishing. The most straightforward solution would be to see if there is the opportunity to utilise the robot. Beyond this it may present more of a dilemma: should surgery, to avoid delay, proceed VATS, or should it be deferred? Of course, no one wishes to unnecessarily delay cancer surgery, but if the surgeon believes they can offer surgery more effectively using a different approach, it is a potentially difficult position to be in when the overall aim is to achieve the best outcome for the individual patient. Similarly, there are other factors to consider, such as surgical experience. Whilst we would continue to proceed VATS at this stage, what happens as time and years progress with fewer operations done in this manner? Should a surgeon be taking on an approach when they are doing it in increasingly small numbers? Hopefully, future high quality randomised control trials will give answers but in the meantime, it remains a point for individual thought and reflection.
Conflicts of interest: Nil
Funding: No funding was provided for this study
Corresponding author: Mr M R Gooseman, Department of Thoracic Surgery, Castle Hill Hospital, Hull University Teaching Hospitals NHS Trust, Hull, UK. Email: Michael.gooseman@nhs.net
Previously published as: Gooseman, M., & Cowen, M. (2025). Is there a time when the robotic thoracic surgeon should limit or stop video assisted thoracoscopic surgery? Impact Surgery, 2(7), 236–237. https://doi.org/10.62463/surgery.272
References
- Patel YS, Baste JM, Shargall Y, et al. Robotic lobectomy is cost-effective and provides comparable health utility scores to video-assisted lobectomy: early results of the RAVAL trial. Ann Surg. 2023;278(6):841–9. doi:10.1097/SLA.0000000000006073
- Jin R, Zheng Y, Yuan Y, et al. Robotic-assisted versus video-assisted thoracoscopic lobectomy: short-term results of a randomised clinical trial (RVlob trial). Ann Surg. 2022;275(2):295–302.
- Lim E, Batchelor TJP, Dunning J, et al. Video-assisted thoracoscopic or open lobectomy in early-stage lung cancer. NEJM Evid. 2022. doi:10.1056/EVIDoa2100016
- Getting It Right First Time (GIRFT). National Consultant Information Programme (NCIP). 2025.