From Scopes to Bots: The Clinical Journey from VATS to RATS
Year: 2025
Type: article
Abstract: Minimally invasive procedures originated with the development of specialized scopes, enabling targeted access to body cavities. The foundation of these procedures was the use of specialized scopes, such as laparoscopes, thoracoscopes, arthroscopes, hysteroscopes, and endoscopes. Video-assisted thoracic surgery (VATS) emerged in the 1990s as a transformative alternative to open thoracotomies. VATS reduced surgical trauma by offering magnified visualization through the use of small incisions, a thoracoscope, and specialized instruments. This approach decreased postoperative pain, shortened hospital stays from weeks to days, and minimized complications like chronic neuralgia. By the 2000s, VATS became the gold standard for procedures such as lobectomies, pleural biopsies, and sympathectomies. Limitations, however, persisted, including restricted instrument articulation, two-dimensional visualization in early systems, a steep learning curve, and surgeon fatigue during complex dissections.[1] Over the last two decades, robot-assisted techniques have built upon video-assisted surgery in most surgical procedures. This trend is driven by advancements in robotic technology, which offers surgeons enhanced dexterity, vision, and precision, ultimately leading to improved patient outcomes. Melfi et al.[2] published the first paper describing the use of a surgical robot for lobectomy, noting how the robotic wrist facilitated dissection in remote areas of the chest. The integration of robotic systems addressed the constraints of VATS through key innovations offered by robotic vision and control. Enhanced dexterity with multiple degrees of freedom enabled precise suturing in confined spaces, such as the mediastinum. Three-dimensional high-definition imaging provided better depth perception and magnification, which is critical for identifying vascular structures. Tremor elimination and motion scaling filtered out tremors, allowing for micro-adjustments that were not feasible to make manually. The outcome and procedural benefits offered by robotic thoracic surgery (RATS) have led to a significant increase in its adoption worldwide. Thoracic centers are increasingly adding robotic-assisted thoracoscopic surgery (RATS) to their portfolios, performing a wide range of procedures, including lung resections, esophageal resections, and mediastinal tumor resections. In this issue, Granell Gil et al.[3] present their recent experience with RATS using lung-protective ventilation during one-lung anesthesia and multimodal analgesia, including locoregional techniques. Their series included surgeries for the lung, mediastinum, thoracic wall, and pleura. They report lower complication rates, better outcomes, and shorter hospital stays with the use of RATS. RATS also confers a statistically significant advantage over VATS in terms of persistent air leak, intraoperative blood loss, and chest tube duration.[4] Others have also reported similar benefits [Table 1]. Although the mean operative time was higher for RATS,[5] the mean conversion rate of RATS is currently lower than that of VATS.Table 1: RATS vs. VATS in terms of complications and clinical outcomesIn terms of operative metrics, RATS extends surgery by 30–60 minutes due to docking complexity, though proficiency reduces this gap. A retrospective analysis indicated that RATS reduces intraoperative bleeding by more than 50% in pulmonary resections.[12] RATS offers an oncological benefit, enabling more precise tumor resection with improved lymph node clearance. RATS yields 30% more lymph nodes for lung cancer staging due to superior access.[11] RATS faces criticism for higher upfront costs, but shorter hospitalization significantly reduces healthcare costs. Studies comparing the cost of RATS with VATS and assessing their relative benefits and resource implications are currently being conducted. It is expected that the initial increased expenses associated with RATS lung resection may be gradually offset as the program progresses.[13] Long-term savings are achieved through lower reoperation rates for complications.[14] A significant limitation cited for RATS is the steep learning curve for surgeons and the requirement for dedicated training programs. However, the learning curve for RATS is 45 procedures for proficiency, as compared to a longer requirement of 53 procedures for proficiency for VATS.[15] The trainee also has the opportunity to engage in a wide range of virtual reality simulation modules provided by the manufacturer. Such high-fidelity simulation is not available for VATS or open surgery training. The faster surgeon adaptation and improved ergonomics have made the learning curve less steep. There are certain hurdles in the advancement of RATS. There is a need for dedicated operating room space and preparation time, which impairs the efficiency of robotic procedures. Many surgeons believe that RATS compromises haptic sensation, necessitating the use of visual cues for tissue tension. Many insurers still classify RATS as “investigational” and deny reimbursement, thereby increasing the financial burden on patients. There is a growing adoption of RATS in complex procedures (e.g., sleeve resections and segmentectomies) due to 3D visualization and better surgical access to remote sites. The development of new robotic instruments and technologies continues to advance the field of RATS. Research is ongoing to refine RATS techniques further and evaluate their effectiveness in various thoracic procedures. Artificial intelligence is being integrated into robotic systems to automate tasks such as suturing and tissue dissection, thereby further enhancing precision and efficiency. The integration of AI into robotic systems is expected further to improve the accuracy and automation of surgical tasks. RATS is evolving toward autonomous functionality, utilizing machine learning algorithms to identify anatomy and predict bleeding risks. Fluorescence Imaging using Firefly technology is emerging as a tool to visualize tumor margins and perfusion in real-time. Robotic systems will soon be utilized in more complex and challenging cases, potentially expanding the range of procedures that can be performed with RATS. The transition from VATS to RATS represents a paradigm shift beyond mere technical upgrades. The development of more affordable and accessible robotic platforms may facilitate broader adoption of RATS in the future. It embodies the evolution of thoracic surgery from minimizing trauma to maximizing precision. RATS offers demonstrable benefits in oncologic efficacy, ergonomics, and recovery metrics. As robotic platforms become more accessible and intelligent, this technology promises to democratize high-quality thoracic care globally. Currently, most thoracic units in low- and middle-income countries do not own robotic systems. 5 G-based tele-robotics may enable remote operations, thereby enhancing access to underserved regions.
Source: Annals of Cardiac Anaesthesia
Author: Mukul Chandra Kapoor
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: diamond
OpenAlex ID: W4412112996