|
 
 |
| ORIGINAL ARTICLE |
|
| Year : 2022 | Volume
: 8
| Issue : 1 | Page : 21 |
|
A rehabilitation comparison of thoracoscopic and robotic lobectomy
Xia Mo, Lei Shen, Min Wang, Jiahao Yang
Department of Cardiothoracic Surgery, Changzhou First People's Hospital, Changzhou, Jiangsu, China
| Date of Submission | 21-Mar-2022 |
| Date of Decision | 27-Jun-2022 |
| Date of Acceptance | 28-Jun-2022 |
| Date of Web Publication | 27-Sep-2022 |
Correspondence Address:
Lei Shen
Cardio-Thoracic Surgery Changzhou First People's Hospital, Changzhou, 213003, Jiangsu
China
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/digm.digm_9_22
Objective: This study aimed to compare rehabilitation after lobectomy performed with a Da Vinci robot versus thoracoscopy. Materials and Methods: Patients who underwent lobectomy at the Changzhou First People's Hospital from November 2020 to May 2021 were analyzed retrospectively, including 182 patients in the Da Vinci robot group and 280 patients in the thoracoscopy group. Postoperative hospital stay and postoperative pain were compared between groups. Results: The hospitalization cost of the Da Vinci robot group was $ 10874.06 ± 1757.07, which was higher than that of the thoracoscopy group ($ 7500.96 ± 1704.83). The postoperative hospital stay was significantly shorter in the Da Vinci robot group (4.74 ± 2.104 days) than that in the thoracoscopy group (5.55 ± 2.669 days; t = −3.664, P < 0.001). No significant differences between groups were observed in postoperative intensive care unit admission time and postoperative chest tube indwelling time. The proportion of patients with no pain 2 h after the operation was significantly higher in the Da Vinci robot group than in the thoracoscopy group (26.9% vs. 11.8%; χ2 = 17.639, P < 0.001). The proportion of patients with no pain during the first activity was significantly higher in the Da Vinci robot group than in the thoracoscopy group (54.9% vs. 39.6%; χ2 = 12.109, P = 0.004). Conclusion: The total cost of Da Vinci robotic surgery was higher than that of thoracoscopy for lobectomy, but the postoperative recovery was better, and the pain was less severe.
Keywords: Da Vinci robot, Lobectomy, Pain, Thoracoscopy
How to cite this article:
Mo X, Shen L, Wang M, Yang J. A rehabilitation comparison of thoracoscopic and robotic lobectomy. Digit Med 2022;8:21 |
| Introduction | |  |
Rapid economic development, lifestyle changes, and environmental pollution have rapidly increased the incidence of, and mortality due to, pulmonary nodules. The Corona Virus Disease 2019 (COVID-19) pandemic has increased the computed tomography screening performed in major hospitals, thus increasing the early detection of lung cancer. In China, lung cancer has the highest incidence and mortality rate among malignant tumors. Surgical resection is the main treatment for lung cancer.[1] At present, the guidelines of the National Comprehensive Cancer Network strongly recommend minimally invasive surgery,[2] including traditional video-assisted thoracic surgery (VATS) and robot-assisted thoracoscopic surgery. The Da Vinci robot provides a similar three-dimensional field of vision, flexible joint movement, and surgical accuracy to those in thoracotomy, but it provides substantial advantages in suturing and fine control. Therefore, the Da Vinci robot is favorable in diagnosis and complex surgical treatment.[3] Herein, we retrospectively analyzed data for 182 patients receiving RATS and 280 patients receiving VATS, compared the postoperative indexes and rehabilitation differences between groups, and analyzed the advantages and disadvantages of each surgical modality.
| Materials and Methods | | |
Clinical data
The clinical data of patients who underwent RATS or VATS in our hospital from November 2020 to May 2021 were retrospectively analyzed. The inclusion criteria were as follows: (1) preoperative cardiopulmonary function able to tolerate the operation; (2) the absence of distant metastasis; and (3) use of RATS or VATS. The exclusion criteria were as follows: (1) conversion to thoracotomy and (2) serious postoperative complications, including empyema, chylothorax, bronchopleural fistula, pulmonary embolism, or even secondary thoracotomy. The RATS group comprised 182 patients, and the VATS group comprised 280 patients. No significant differences were observed in the body mass index, operation time, age, sex, or pathological type between groups [P > 0.05; [Table 1]]. | Table 1: Comparison of general data between the Da Vinci robot and thoracoscopic surgery groups
Click here to view |
Methods
Operation method
The operating procedures in the Da Vinci robot and thoracoscopy groups were the same as those of routine operation. An F28 thoracic drainage tube and a negative pressure drainage ball were routinely retained for closed thoracic drainage.
Nursing methods
Pain management
Before the operation, patients and their families received multimedia education regarding postoperative pain management, including the causes of postoperative pain, the difference between active and resting pain, and the importance of evaluation and management of active pain for postoperative recovery. We informed patients that pain is a subjective symptom, and all types of pain control require active patient participation. We taught patients how to use an analgesic pump with proper precautions, and to correctly use the numeric rating scale (NRS) for pain assessment. After the operation, the patients were returned to the intensive care unit (ICU). Two hours after the operation, the NRS score was determined when the patients got out of bed for the first time. If pain was present, the NRS score was determined in a timely manner. A multimodal analgesia scheme primarily using nonsteroidal analgesics[4],[5] was followed, with preventive or timely on-demand analgesia.
Respiratory tract management
All patients were prepared preoperatively for respiratory tract management, including strict smoking cessation, teaching of the proper method for cough and sputum excretion, lung function training, and maintenance of oral hygiene. No complications were observed at 2 and 6 h after the operation. Encourage and help the patient to sat up in bed at least four times a day to facilitate coughing and expectoration. Oxygen-driven atomization inhalation was administered twice daily. Nurses evaluated the patients' sputum, and patients with viscous mucus followed the physicians' advice for the use of mucolytic agents to promote the discharge of viscous secretions into the respiratory tract, decrease mucus retention, and improve respiratory function.[6] Chest X-ray examination was performed on day 1 postoperatively. Coughing, expectoration, and deep breathing were encouraged to promote lung recruitment. Patients had 24 h thoracic drainage volumes ≤ 200 mL without air leakage and chylothorax. If the X-ray findings indicated that the lungs were well inflated, the thoracic drainage tube was removed.
Thrombus risk assessment and early activities
According to the risk score for pulmonary embolism, when patients returned to the ICU after the operation, their limbs were treated with a pneumatic pump twice daily. We monitored coagulation function and administered low-molecular-weight heparin anticoagulation according to the coagulation and drainage findings. After leaving the ICU, the patients were transferred from the bed or wheelchair to the door of the ward. Nurses assisted patients in entering the ward and encouraged patients to get out of bed as soon as possible.
Liquid management
We determined the fluid demand by monitoring patients' hemodynamic indicators, then administered personalized rehydration methods.[7] Excessive fluid during the perioperative period can lead to acute lung injury, a serious complication after lobectomy. We controlled the amount of fluid to the greatest extent possible and encouraged patients to eat orally, to reduce the incidence of postoperative complications.
Discharge guidance
The patients were discharged in the afternoon or the second day after extubation. The discharge time was 3–5 days. We informed patients about precautions for respiratory function exercise, limb function exercise, diet and activities, suture removal time, and outpatient reexamination time after discharge. Within 1 week after discharge, a junior nurse conducted a telephone follow-up to answer patients' questions, and remind them of the review time and precautions, to improve their postoperative rehabilitation compliance.
Evaluation indexes
The postoperative ICU stay, postoperative hospital stay, chest tube insertion time, and operation cost were compared between groups. The presence of extensive pain was assessed after 2 h, during the first activity, and within 24 h after the operation. The pain was scored with a digital scoring method.
Statistical methods
SPSS 22.0 software (SPSS for Windows, version 22; SPSS, IL, USA) was used for statistical analysis. The normally distributed data are expressed as mean ± standard deviation, and independent sample t-test was used for intergroup comparisons. The Chi-squared test was used for numerical data. P < 0.05 indicated a statistically significant difference.
| Results | | |
Comparison of curative effects and hospitalization expenses between groups
The lobectomy proceeded smoothly in both groups. No serious complications were observed, and the patients recovered well. In the Da Vinci robot group, the patients' total postoperative hospital stay was significantly shorter than that in the thoracoscopic group, but the postoperative ICU stay and chest tube retention time were not significantly improved, and the total hospitalization cost was significantly higher [Table 2]. | Table 2: Postoperative recovery and hospitalization expenses of patients in the Da Vinci robot and thoracoscopy groups
Click here to view |
Comparison of postoperative pain between groups
The patients in both groups received routine postoperative care and a multimodal analgesic scheme using primarily nonsteroidal analgesics to relieve pain in a timely manner on demand. No significant differences in baseline diseases (diabetes and cerebral infarction) were observed between groups. The proportion of patients with perioperative bleeding and pain at 2 h after the operation and at the first activity in the Da Vinci robot group was significantly smaller than that in the thoracoscopic group. No significant difference was observed in the proportion of patients with sudden pain within 24 h after the operation [Table 3]. | Table 3: Postoperative pain among patients in the Da Vinci robot and thoracoscopy groups
Click here to view |
| Discussion | | |
Da Vinci robot-assisted surgery shortens overall postoperative hospital stay
We demonstrated that the postoperative hospital stay in the Da Vinci robot group was shorter than that in the thoracoscopy group, in agreement with previous research.[8],[9] This shorter stay may be associated with the more accurate operation of the Da Vinci robot, as well as the fewer adverse effects and postoperative complications, which were conducive to rapid postoperative recovery. Simultaneously, when RATS is used to dissect tissues, systemic lymph nodes, and adjacent blood vessels, it can be more precise than VATS in accomplishing complete resection and can prevent injury to the greatest extent possible,[10] thus shortening hospital stay. Traditional thoracoscopic surgery may damage healthy tissue, thus leading to slow postoperative recovery and a poor quality of life.[11] The hospitalization cost in the Da Vinci robot group was higher, because this surgical technology has high associated design, maintenance, and purchase costs, and it remains a relatively new technology.[12] These higher costs can place more psychological and economic pressure on patients and their families. Therefore, for patients undergoing robot-assisted surgery, nurses must provide adequate preoperative education to make patients fully aware of the efficacy, safety, and advantages of this method. Patients choose the operating method according to surgeons' suggestions, their own situation, and economic considerations, to reduce the psychological pressure.[13] Although the hospitalization cost of Da Vinci robotic surgery is high, this method effectively alleviates pain and decreases postoperative hospital stay, thus improving postoperative recovery and decreasing pain in lobectomy. Patients with more economic resources are advised to prioritize Da Vinci robotic surgery before lung surgery.
Da Vinci robot-assisted surgery can decrease perioperative bleeding and postoperative pain
The postoperative incidence of clinically relevant pain was 38% during the first 24 h after VATS.[14] Pain after VATS is both serious and common. This study indicated that the proportion of patients with > 200 mL intraoperative blood loss was significantly lower in the Da Vinci robot group than in the VATS group. Therefore, the robot system caused less trauma, thereby potentially contributing to the subsequent decrease in postoperative pain. The proportion of patients with pain at 2 h after the operation and during the first activity in the Da Vinci robot group was significantly lower than that in the thoracoscopy group. This diminished pain might have been due to the small incision required for the Da Vinci robot operation, which might have resulted in less pronounced stress and inflammatory responses than those in manual surgery, and decreased the release of pain-causing substances from tissues. However, our findings contrast with those of van der Ploeg et al.,[15] possibly due to the different time points at which postoperative pain scores were determined and the small number of samples. Continual pain stimulation can cause pathological remodeling of the central nervous system, and acute pain may develop into uncontrollable chronic pain. Postoperative pain substantially affects recovery.[16],[17] Many studies have shown that good postoperative analgesia can improve perioperative immune function.[18],[19] The effectiveness of postoperative pain management not only minimizes pain but also contributes to early activity and functional recovery, thus shortening hospitalization and improving patient satisfaction. More importantly, postoperative pain management can decrease the incidence of related complications, such as chronic pain, and improve patient satisfaction with care.[20],[21]
| Conclusion | | |
The Da Vinci robot system for lobectomy provides the advantages of a shorter postoperative hospital stay, less pain, and minimal invasiveness, all of which are conducive to earlier, less painful postoperative recovery. Robotic surgery provides surgeons with a minimally invasive and safe method, as well as favorable conditions for postoperative care, thus ultimately benefitting patients by decreasing pain and promoting early recovery.
Acknowledgments
We are grateful to Xiaoying Zhang for his guidance in this study.
Financial support and sponsorship
This work was supported by funding from the Young Talent Development Plan of the Changzhou Health Commission (CZQM2020034, CZQM2020004), Young Talents Science and Technology Project of Changzhou Health Commission (QN201913), and Social Development Projects of Changzhou Science and Technology Bureau (CE20205039).
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Siegel RL, Miller KD, Jemal A. Cancer statistics, 2020. CA Cancer J Clin 2020;70:7-30.  |
| 2. | |
| 3. | Veronesi G, Novellis P, Voulaz E, Alloisio M. Robot-assisted surgery for lung cancer: State of the art and perspectives. Lung Cancer 2016;101:28-34. |
| 4. | Nimmo SM, Foo IT, Paterson HM. Enhanced recovery after surgery: Pain management. J Surg Oncol 2017;116:583-91. |
| 5. | Mijatovic D, Bhalla T, Farid I. Post-thoracotomy analgesia. Saudi J Anaesth 2021;15:341-7. [Full text] |
| 6. | Utkin W, Ginters J, Balinja N. Prevention of complications after lung resection (author's transl). Zentralbl Chir 1977;102:629-63. |
| 7. | Kouritas VK, Zissis C, Bellenis I. Variation of the postoperative fluid drainage according to the type of lobectomy. Interact Cardiovasc Thorac Surg 2013;16:437-40. |
| 8. | Ding R, Tong X, Xu S, Zhang D, Gao X, Teng H, et al. A comparative study of Da Vinci robot system with video-assisted thoracoscopy in the surgical treatment of mediastinal lesions. Chinese Journal of Lung Cancer 2014;17:557-62. |
| 9. | Novellis P, Bottoni E, Voulaz E, Cariboni U, Testori A, Bertolaccini L, et al. Robotic surgery, video-assisted thoracic surgery, and open surgery for early stage lung cancer: Comparison of costs and outcomes at a single institute. J Thorac Dis 2018;10:790-8. |
| 10. | Nakamura H, Haruki T. Current status and future prospect of robot-assisted thoracoscopic surgery. Kyobu Geka 2018;71:55-66. |
| 11. | Suda T. Transition from video-assisted thoracic surgery to robotic pulmonary surgery. J Vis Surg 2017;3:55. |
| 12. | Kajiwara N, Patrick Barron J, Kato Y, Kakihana M, Ohira T, Kawate N, et al. Cost-benefit performance of robotic surgery compared with video-assisted thoracoscopic surgery under the Japanese national health insurance system. Ann Thorac Cardiovasc Surg 2015;21:95-101. |
| 13. | Wang J, Guo X, Wu Y, Ding Y. The application of Robocare nursing model in the whole nursing care of Da Vinci robot-assisted laparoscopic radical cancer surgery. Asian J Surg 2021;44:667-9. |
| 14. | Bendixen M, Jørgensen OD, Kronborg C, Andersen C, Licht PB. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: A randomised controlled trial. Lancet Oncol 2016;17:836-44. |
| 15. | van der Ploeg AP, Ayez N, Akkersdijk GP, van Rossem CC, de Rooij PD. Postoperative pain after lobectomy: Robot-assisted, video-assisted and open thoracic surgery. J Robot Surg 2020;14:131-6. |
| 16. | Kuner R, Flor H. Structural plasticity and reorganisation in chronic pain. Nat Rev Neurosci 2016;18:20-30. |
| 17. | Witt JK, Linkenauger SA, Bakdash JZ, Augustyn JS, Cook A, Proffitt DR. The long road of pain: Chronic pain increases perceived distance. Exp Brain Res 2009;192:145-8. |
| 18. | Peng Y, Yang J, Guo D, Zheng C, Sun H, Zhang Q, et al. Sufentanil postoperative analgesia reduce the increase of T helper 17 (Th17) cells and FoxP3 +regulatory T (Treg) cells in rat hepatocellular carcinoma surgical model: A randomised animal study. BMC Anesthesiol 2020;20:212. |
| 19. | Kim SY, Kim NK, Baik SH, Min BS, Hur H, Lee J, et al. Effects of postoperative pain management on immune function after laparoscopic resection of colorectal cancer: A randomized study. Medicine (Baltimore) 2016;95:e3602. |
| 20. | Marshall K, McLaughlin K. Pain management in thoracic surgery. Thorac Surg Clin 2020;30:339-46. |
| 21. | Aroke EN, McMullan SP, Woodfin KO, Richey R, Doss J, Wilbanks BA. A practical approach to acute postoperative pain management in chronic pain patients. J Perianesth Nurs 2020;35:564-73. |
[Table 1], [Table 2], [Table 3]
|
Search Pubmed for