Hiran C. Fernando¹, Jin Ye Yeo²

¹Allegheny General Hospital, Department of Thoracic Surgery, South Tower, Pittsburgh, PA, USA; ²JOVS Editorial Office, AME Publishing Company

Correspondence to: Jin Ye Yeo. JOVS Editorial Office, AME Publishing Company. Email: jovs@amepc.org

Editor’s Note

The Journal of Visualized Surgery (JOVS) has published a number of special series in recent years, receiving overwhelming responses from academic readers around the world. Our success cannot be achieved without the contribution of our distinguished guest editors. This year, JOVS launched a new column, “Interviews with Guest Editors”, to better present our guest editors and to further promote the special series. We also hope to express our heartfelt gratitude for their tremendous effort and to further uncover the stories behind the special series.

The special series “Innovations in Robotic VATS and Bronchoscopic Procedures”(1) led by Dr. Hiran C. Fernando (Figure 1) from Allegheny General Hospital and Dr. John F. Lazar from Georgetown University Hospital has attracted many readers since its publication. This special series discussed the recent innovations in robotic video-assisted thoracoscopic surgery (VATS) and bronchoscopic procedures. At this moment, we are honored to have an interview with Dr. Fernando to share his scientific career experience and insights on this special series.

Figure 1 Dr. Hiran C. Fernando

Expert Introduction

Dr. Fernando is the Director of Thoracic Surgery at Forbes Regional Hospital, Allegheny Health Network, and Professor of Surgery at Drexel University College of Medicine. He has expertise in treating patients with lung cancer, esophageal cancer, gastroesophageal reflux, achalasia, mediastinal tumors, and myasthenia gravis. He is also skilled in video-assisted thoracoscopic surgery (VATS) and robotic procedures for the lung, esophagus, and mediastinum. His clinical interests include minimally invasive approaches for lung, esophageal, and mediastinal disease. He is a member of the American Association of Thoracic Surgery, the Society of Thoracic Surgeons, and the American Surgical Association.

Interview

JOVS: What drove you into the field of thoracic surgery?

Dr. Fernando: I became interested in the specialty of cardiothoracic surgery as a medical student, but was initially unsure whether to focus on cardiac surgery or general thoracic surgery. That changed after I had the chance to work with Peter Goldstraw as a senior house officer at the Royal Brompton Hospital. Not only was this a fantastic experience, but I also co-authored my first two research papers with him. I then continued training in the United States, completing a residency in thoracic surgery at UC Davis Medical Center, with Dr. John Benfield who was the Chair and Program Director at that time. Peter Goldstaw and John Benfield were wonderful mentors, and training with them cemented my interest in a career in academic thoracic surgery.

JOVS: Could you provide an overview of the innovations in robotic video-assisted thoracic surgery (VATS) and bronchoscopic procedures?

Dr. Fernando: In the United States, most minimally invasive thoracic operations have been performed with a VATS approach. However, for many years, VATS was only undertaken in a relatively small number of institutions, with most centers using open approaches. When the earlier robotic systems first became available, they were larger, a little clunkier to set up, and required an experienced bedside assistant to divide pulmonary vessels using a non-robotic stapler. For many experienced VATS surgeons, it was hard to justify the switch to a robotic system and undertake a new learning curve. However, as robotic systems improved, with added functionality such as better energy devices and robotic stapling, more and more VATS surgeons are converting to a robotic platform. Additionally, with features such as dual console systems and simulation for training, open surgeons are also finding it easier to adopt a robotic minimally invasive approach, rather than a VATS approach. Residents also seem to migrate towards a robotic approach, as they prefer the ergonomics of sitting at a robot console, having improved visualization, and not needing to mirror-image movement of instruments withing the pleural space, which is often needed with VATS.

JOVS: What are some specific advancements or technological breakthroughs in robotic VATS and bronchoscopic procedures that you find particularly promising or impactful?

Dr. Fernando: One of the most important advancements has been the addition of robotic staplers, which has been a game changer. Robotic staplers allow surgeons to control the most critical part of the operation, namely the vascular and bronchial divisions. Suturing is also better with a robot compared to a VATS approach. Robot bronchoscopy has also been a significant advancement. The legacy (non-robotic) navigation systems were a great advance when initially introduced to clinical practice. The robotic systems are more stable in comparison, allow for accurate navigation, and have opened the door to therapeutics such as bronchoscopy-guided ablation of lung cancers. This is an area that I believe will see further development and research over the coming years. Bronchoscopy-guided ablation will challenge current treatment paradigms, particularly for high-risk surgical patients.

JOVS: How do these advancements address challenges or limitations encountered in traditional VATS or bronchoscopic techniques?

Dr. Fernando: One of the challenges when performing VATS lung resections is operating in patients who are morbidly obese. The pivot point for VATS instruments occurs at the chest wall. In morbidly obese patients, there are almost two pivot points, because the chest wall and the skin/soft tissue can be several centimeters apart. With the robot, instruments articulate inside the chest, and so there is less restriction of movement of the instruments. Another advantage of robotic approaches is that insufflation is a very helpful adjunct to help visualization, particularly when there is poor collapse of the lung. Insufflation is not feasible when using VATS instruments such as those made by Scanlon, as these will not fit or work through a standard laparoscopic-insufflation port.

JOVS: Is the topic of this special series associated with any of your recent research projects? Could you share more about some significant projects you are working on?

Dr. Fernando: Our group has been looking at a number of different issues related to VATS, robotics, and bronchoscopy. One is a randomized study on the use of cryoablation of intercostal nerves, to see if this will help with pain control and improve respiratory function after VATS or robotic operations. This data will be presented at the AATS meeting in Toronto. We are also interested in the use of endobronchial valves in patients who have prolonged or large air leaks after lung resection. Our group has had some success with endobronchial valve placement for post-resection patients. The challenge is figuring out which patients to use these in, and the optimal timing of valve placement. For instance, should a valve be placed for any patient with a large air leak above a defined threshold on the 2nd or 3rd post-operative day, or should we wait until after the 5th post-operative day, when by definition the patient has a prolonged air leak?

JOVS: If given the opportunity to update this special series, what would you like to moderate, add, or emphasize to provide a more comprehensive series?

Dr. Fernando: When this series is next updated, it will be good to see how the experience with robotic bronchoscopy-guided ablation has progressed. A few centers are now reporting on uniportal robotic operations. I suspect that many surgeons will be interested in learning about this technique and the outcomes from sites that are performing these operations.

Reference

1. Innovations in Robotic VATS and Bronchoscopic Procedures. Available online: https://jovs.amegroups.org/post/view/innovations-in-robotic-vats-and-bronchoscopic-procedures