Overview
Lung cancer has been the number one killer of all cancers in the past decades in Singapore; it is the second most common cancer in males and third in females. It is highly associated with smoking and over 1,000 patients are newly diagnosed with lung cancer yearly in Singapore.
Surgical Resection for lung cancer
Depending on the stage of lung cancer and the general status of patients, the treatment may consist of surgery, chemotherapy and/or radiotherapy. This may occur in single or combined treatment modality. For early stage cancer, the aim is to radically resect the tumour and prevent future recurrence. Surgical resection is routinely offered to patients with stage 1 and 2 lung cancer, provided that the patients’ condition permits. For advanced stage cancer, the aim would then be to prolong the patients’ survival and alleviate their symptoms.
Surgical resection of lung cancer involves lobectomy, segmentectomy or pneumonectomy. Traditionally, this is achieved via posterolateral thoracotomy with incision of about 10-15cm. Thoracotomy is considered the gold standard by most thoracic surgeons in the world. While it offers an excellent surgical exposure and safety, thoracotomy carries some disadvantages. Due to larger incision and rib spreading, the patients commonly suffer from more pain after operation. There is also an increased risk of bleeding and infection. This leads to longer hospital stay and slower recovery.
Video Assisted Thoracoscopic Surgery
Over the past 10 to 15 years, like most surgical specialties, minimally-invasive surgical approach has been developed in thoracic surgery by means of video-assisted thoracoscopic surgery (VATS). VATS has a wide application, extending from pleurodesis, lung biopsy, to lobectomy and mediastinal tumour resection. Through smaller incision of about 1cm and non-rib spreading, patients benefit from reduced post-operative pain, shorter hospital stay and faster recovery. In addition, the functional and aesthetic outcomes are also much more favourable.
VATS lobectomy, through the years of experience, has established its role in lung cancer surgery. Its efficacy, safety and oncological results have been proven by time. However, this technique has a steep learning curve. The limited manoeuvrability and poor ergonomic characteristics of the VATS instruments pose a real technical challenge to surgeons. Furthermore, the limited two-dimensional view of the operating field provided by a normal computer screen eliminates the perception of depth. This may further compromise the precision and safety of the operation.
Robotic Assisted Lobectomy
NHCS uses the da Vinci Surgical System to perform robotic assisted lobectomy. The robotic system serves as an excellent dissecting tool and is truly an adjunct to VATS lobectomy. Being a type of minimally invasive surgery, it simply requires three to four small incisions to complete lobectomy. Each incision measures about 10-12mm with the largest incision being less than 4cm. Through these small ports, the endocamera and Endowrist instruments are inserted. Endowrist instruments are designed to mimic the human wrists, hands and fingers. The system allows the Endowrist instruments a much superior range of motion and improved ergonomic characteristics than a human hand. The surgeon will manipulate the Endowrist instruments through a master control at the console a few feet away from the patient. This will then translate the surgeon’s natural wrist and hand movements into corresponding precise and scaled movements. The Insight Vision System also enables a high resolution three-dimensional view of the operating field which includes depth of field and magnification. All these features offer a surgical precision that is not available in a standard minimally invasive procedure.
To this date, robotic-assisted lobectomy is only performed in a few thoracic surgery centres in the world and NHCS is the first in South east Asia to perform this procedure. It requires a high scale of learning and good teamwork to overcome the steep learning curve. Currently, as in VATS lobectomy, it is only offered to patients with stage I or II lung cancer with reasonable cardiopulmonary fitness. Early studies reveal promising results due to the improved precision in surgical techniques. It enhances the safety of the operation and potentially provides a higher probability of oncologic radicality.
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