Thoracic conditions, e.g. lung, respiratory diseases, and esophageal diseases have affected a large number of people worldwide. Among these conditions, serious diseases, for instance, lung cancer and thymus cancer (thymoma) often require surgery as a treatment of choice. Medical advances in thoracic surgery have accelerated the pace of changes, offering an amazing cooperation between cardiothoracic surgeons and technology, through which surgeries reach high levels of precision and efficiency. Cutting-edge robotic system, the da Vinci Xi is designed to accommodate and seamlessly integrate a range of current technologies in surgical areas, including intraoperative imaging, advanced instruments and anatomical access, enabling the surgeons to perform minimally invasive procedures in hard-to-reach surgical sites through small incisions. Indeed, the use of the da Vinci Xi is associated with less pain and a shorter operative time with an improved patient’s quality of life.  

Advances in thoracic surgery

Surgery remains a principal approach to treat a wide variety of thoracic diseases, such as lung cancer and thymus cancer, particularly those that the mass can potentially compress the adjacent organs and progress to life-threatening conditions. Conventional or open surgery involves splitting the breastbone and spreading the rib cage to access the chest cavity through a large cut made on the chest. Due to medical advancements, minimally invasive approach – thoracoscopic surgery can be performed through smaller incision (s) without having breastbone cutting or spreading the rib spaces. During the procedure, a thoracoscope – a long, thin tube with a light and a small video camera on the end is inserted through a small cut made between the ribs, enabling the surgeon to conduct the operation in the chest cavity with superior advantages of less pain, reduced postoperative complications and faster recovery. The da Vinci system is an advanced robotic technology designed to enable surgeons to perform robotic-assisted thoracoscopic surgery (RATS) with enhanced surgical precision and safety. Mounting evidence has suggested that RATS using the da Vinci Xi is considered a viable approach for certain cardiothoracic diseases as it yields advantages particularly in anatomically challenging areas.  

What is the da Vinci Xi?   

The da Vinci Xi is an advanced robotic surgical system using specialized technology that enhances the capabilities of surgeon’s hands. Controlled by computer system, four surgical arms consisting of tiny instruments with wrists at the tip allow surgeons to perform procedures in difficult-to-reach or complex areas with precise movements, better dexterity and enhanced magnification. A special high-definition camera attached provides magnified 3D views of the operating area, leading to high degree of surgical accuracy and patient’s safety. For every movement, the surgeon makes at the console standing next to the surgical arms and the da Vinci robot replicates every move inside patient’s body on a smaller scale. The surgeon has complete control during the entire procedure. 

Despite the fact that video-assisted thoracoscopic surgery (VATS) as a minimally invasive technique is an option to treat several thoracic conditions, the limitation might be seen when it comes to hard-to-reach area where deep-seated lymph node or nerve supplying to vocal cord or diaphragm in mid chest area (mediastinum) stay. Surgical instrument used in video-assisted thoracoscopic surgery might injure and cause damages to these nerves, causing hoarseness, malfunctioning diaphragm and other possible complications

In some cases, surgical instrument used during video-assisted thoracoscopic surgery might injure underneath the nerves underneath the rib cage locate (the intercostal nerves) causing postoperative pain and other possible complications. To overcome this boundary, the da Vinci Xi has designed in the way that the rotating point in the ribs remains static, resulting in minimal intercostal nerve trauma and less pain after surgery compared to video-assisted thoracoscopic surgery.   

What are thoracic conditions that can be treated with the da Vinci Xi? 

The da Vinci Xi has been effectively applied to the surgical treatment of thoracic diseases, such as: 

• Lung cancer: Lung cancer is one of the leading causes of cancer related deaths worldwide. It is often asymptomatic until the condition progresses to advanced stage. If caught in its early stage, surgery usually becomes a treatment of choice to increase the chance of being cured from the disease. During lung surgery to remove lung cancer, lymph node samples are typically removed during this procedure (lymph node dissection), enabling an accurate staging of the disease. If the quantity of removed lymph nodes is insufficient, it can potentially result in wrong staging, leading to improper treatment. Robotic-assisted thoracic surgery has shown advantages as it can accurately access lymph nodes located in difficult-to-reach areas. Moreover, clinical studies point out that by the quantity of excised lymph nodes retrieved by using robotic-assisted approach is more adequate for cancer staging. In addition, due to high degree of surgical precision, robotic-assisted approach poses the reduced rate of lymphatic leak as a possible complication after lymph node dissection. Surgical drains can be removed and the patients are able to be discharged quicker with an excellent surgical outcome. 
• Thymus cancer (Thymoma): Thymoma is a type of cancer that affects the thymus gland which is part of the lymphatic and immune systems. Thymus gland is located in between the lungs under the breastbone. It is often found in people aged 40-50. As thymoma usually produces no signs or symptoms, it is usually detected during chest X-ray or CT scan conducted for other investigations. As the tumor grows, it can result in local compressive effects on the adjacent structures, causing abnormal symptoms, e.g. feeling fatigue easily, cough, wheezing and arm or face swelling. Stages of thymus cancer range from completely encapsulated tumor to an extensive invasion to neighboring organs, such as pericardium, great vessel and lung as well as lymphatic system. Surgery is the most common treatment for early-stage thymoma. Whether or not radiation or chemotherapy is required as adjuvant therapy depends on the stage and disease severity. Since thymus gland sits between the lungs in a part of the mediastinum, it is considered an anatomically challenging area to reach for surgery. The robotic-assisted thoracic surgery to remove the thymus gland (robot-assisted thymectomy) using the da Vinci Xi system substantially improves surgical precision and safety, particularly for tumor located close to mediastinal great vessels in the upper part of the thymus gland, making surgical resection exceedingly challenging.    
• Myasthenia gravis (MG): Myasthenia gravis is a complex autoimmune disorder in which antibodies mistakenly destroy neuromuscular connections, causing weakness in the skeletal muscles. As it is characterized by fluctuating muscle weakness involving ocular, respiratory and limb muscles, symptoms of MG are, for example, drooping of the eyelids especially in the afternoon or evening, hoarseness, difficulty swallowing, arm and leg weakness as well as trouble breathing. Non-surgical treatment involves various kinds of immunosuppressive medications. However, long-term use of these medicines can potentially lead to undesired effects while disease severely progresses. After evaluated by the neurologist, surgery to remove the thymus gland might become a preferred treatment option, enabling some patients to be less dependent or completely independent on medicines. To achieve the best outcome, surgery must be conducted to fully remove thymus gland (thymectomy), To do so, the da Vinci Xi system helps the surgeon to precisely access the thymus gland for a complete resection around vascular area through minimally invasive technique. 

What are advantages of the da Vinci Xi for minimally invasive thoracic surgery? 

The fourth generation of the da Vinci system yields benefits, including: 

• Better access: Robotic arms are capable of free movements of nearly 360° on seven axes, thereby improving access to anatomically challenging or hard-to-reach areas  
• More precise surgery: Surgery can be carried out efficiently since the robotic arm’s movements are highly precise with greater range of motion, ensuring that the maneuvers made by the surgeon are safe and precise in all angles.
• Improved visualization: A sophisticated camera provides magnified, high-definition views of the surgical area with a better visualization of vessels, nerves and muscles nearby, resulting in less complications caused by damages to the surrounding areas. 
• Faster recovery: Due to small incisions, patients often experience less pain, shorter hospital with a quick return to daily life.