Robotic versus thoracoscopic lung resection A systematic review and meta-analysis Alexander Emmert, MD a, ∗ , Carmen Straube, MD b , Judith Buentzel, MD b , Christian Roever, PhD c Abstract Background: Robotic video-assisted surgery (RVATS) has been reported to be equally effective to video-assisted surgery (VATS) in lung resection (pneumonectomy, lobectomy, and segmentectomy). Operation time, mortality, drainage duration, and length of hospitalization of patients undergoing either RVATS or VATS are compared in this meta-analysis. Methods: A systematic research for articles meeting our inclusion criteria was performed using the PubMed database. Articles published from January 2011 to January 2016 were included. We used results of reported mortality, operation time, drainage duration, and hospitalization length for performing this meta-analysis. Mean difference and logarithmic odds ratio were used as summary statistics. Results: Ten studies eligible were included into this analysis (5 studies for operation time, 3 studies for chest in tube days, 4 studies for length of hospitalization, and 6 studies for mortality). We were able to include 3375 subjects for RVATS and 58,683 subjects for VATS. Patients were mainly treated for lung cancer, metastatic foci, and benign lesions. We could not detect any difference between operation time; however, we found 2 trends showing that drainage duration and length of hospitalization are shorter for following RVATS than for following VATS. Mortality also is lower in patients undergoing RVATS. Conclusions: Therefore, we conclude that RVATS is a suitable minimal-invasive procedure for lung resection and suitable alternative to VATS. RVATS is as time-ef fi cient as VATS and shows a trend to reduced hospital stay and drainage duration. More and better studies are required to provide reliable, unbiased evidence regarding the relative bene fi ts of both methods. Abbreviations: RVATS = robot-assisted minimally invasive surgery, VATS = video- assisted minimally invasive surgery. Keywords: lung cancer, robot-assisted minimally invasive surgery, video-assisted minimally invasive surgery 1. Introduction Surgery is a pre-requisite for successful cancer management, both for diagnostics and treatment. [1,2] During the last years, minimal- invasive surgery procedures such as video-assisted thoracic surgery (VATS) or robot video-assisted thoracic surgery (RVATS) have become increasingly re fi ned and are meanwhile commonly used for lung resection instead of an open thoracotomy approach. [3] Patients undergoing VATS suffer from fewer complications, have less pain and blood loss, and recover faster than patients subjected to open thoracotomy. [4,5] Furthermore, VATS lobec- tomy is associated with shorter chest tube duration, hospitaliza- tion, lower morbidity, and improved survival. [6] The da Vinci robotic surgical (RVATS-system) has been established in several different disciplines and has found applica- tion in urologic, gynecologic, and rectal surgery. It appears to be especially advantageous of surgery of deep and narrow spaces such as the pelvis or the mediastinum. [7] The da Vinci system was introduced to thoracic surgery as RVATS. [8] It offers several technical advantages such as 3-dimensional high-de fi nition fi eld of view, tremor fi ltration, augmented dexterity, or the capability of tele-surgery. [9] The application of RVATS underwent various improvements and upgrades since the fi rst case-series report in 2002, whereas different techniques have been described and developed for performing robotic lobectomy. [10 – 12] Patients treated with a robotic approach show a lower morbidity and mortality than patients undergoing open thoracotomy. [13] Both VATS and RVATS are superior to open thoracotomy in terms of survival, morbidity, and mortality. [2,4,6,13] Both approaches were recently compared by Ye et al [14] , whose meta-analysis mainly focuses on morbidity and mortality. We additionally included parameters such as operating time, hospitalization, and drainage duration. Since Ye et al published their meta-analysis, 2 more comparative studies have been published, showing the issue to be topical. [15,16] We included several new studies [17 – 19] in addition to those by Ye et al. 2. Methods 2.1. Literature review and data extraction A systematic literature reviewwas performed by searching PubMed on 26 January 2016, using the search terms ([ “ surgery ” OR Editor: Monica Casiraghi. JB and CR contributed equally to this study. Funding: The authors acknowledge support by the German Research Foundation and the Open Access Publicsation Funds of Göttingen University. The authors have no con fl icts of interest to disclose. a Department of Thoracic and Cardiovascular Surgery, b Department of Haematology and Oncology, c Department of Medical Statistics, University Medical Center, Georg-August University, Göttingen, Germany. ∗ Correspondence: Alexander Emmert, Department of Thoracic and Cardiovascular Surgery, University Medical Center, Georg-August University, Göttingen, Germany (e-mail:
[email protected] ). Copyright © 2017 the Author(s). Published by Wolters Kluwer Health, Inc. This is an open access article distributed under the Creative Commons Attribution-NoDerivatives License 4.0, which allows for redistribution, commercial and non-commercial, as long as it is passed along unchanged and in whole, with credit to the author. Medicine (2017) 96:35(e7633) Received: 22 April 2017 / Received in fi nal form: 6 July 2017 / Accepted: 11 July 2017 http://dx.doi.org/10.1097/MD.0000000000007633 Systematic Review and Meta-Analysis ® OPEN 1 MAY 2018 | The Surgical Technologist | 207