Robotic Lung Transplantation Explained

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Dr. Kenneth McCurry:

Thank you for joining us today on our podcast. We're very happy to have you here today. I'm Dr. Kenneth McCurry. I'm the Surgical Director of the Lung and Heart-Lung transplant program here at Cleveland Clinic and also the Enterprise Director of Transplantation. I'm here with Dr. Greg Jones today. Dr. Jones is one of our thoracic surgical faculty and a member of our lung transplant program. What we're going to talk about today is lung transplantation and specifically robotic lung transplantation, using a robot to assist doing lung transplantation. First, maybe we'll talk just a little bit about lung transplantation in general. Greg, maybe you could just outline sort of who might need a lung transplant, what the indications are and what the disease states are for which a lung transplantation could be considered.

Dr. Gregory Jones:

Currently, there are a couple different disease states that would cause someone to approach end-stage lung disease and enter into what we call the transplant window. Some of the more common ones, COPD (chronic obstructive pulmonary disease) is one that everyone seems to know and hear about. A lot of those patients have a smoking history. Those patients have lungs that are essentially overinflated and air is trapped within and not able to be used for gas exchange. One of the more common ones that we're seeing now recently is interstitial lung disease, which is basically a problem with the lung parenchyma, or the inner linings of the lung. It causes the lungs to get stiff and really not function properly.

Dr. Kenneth McCurry:

So, pulmonary fibrosis may be the name that many of you might recognize that have that disease. It's a form of interstitial lung disease.

Dr. Gregory Jones:

Basically, when we see these patients that are "in the transplant window", we've essentially exhausted all medical therapies that we can. We know that the outcome without intervention is probably not a favorable one. At that point, they usually see many different members of our transplant team, and we basically discuss them to determine whether or not they're appropriate candidates for transplant.

Dr. Kenneth McCurry:

Yeah. All that's good information, Greg, I think. Just to be clear, in the United States now, about 70% of the lung transplants that we're doing are for interstitial lung disease or what is commonly termed idiopathic pulmonary fibrosis. In that disease, unfortunately, despite some medical therapy available for it, that disease is typically progressive. Most of the patients that end up being referred for lung transplantation for that disease or another disease have progressive symptoms of shortness of breath. I think as Dr. Jones articulated, usually their oxygen requirements are increasing. Usually when we evaluate patients and decide to list them for a transplant, we generally think that without a transplant, their chances of dying of progressive lung disease over the next two years is quite high. So, lung transplantation can offer a longer life and a much better quality of life as well.

Dr. Gregory Jones:

It's very impressive how quickly some of these patients can progress. I mean, it's an interesting disease process, but it always surprises me how much oxygen requirement a patient can increase to have over just a short period of time.

Dr. Kenneth McCurry:

Just to talk a little bit about the procedure itself and get to robotic lung transplantation. There are a variety of different ways of doing lung transplants. Sometimes we do them through incisions on the side, sometimes an incision all the way across the front, sometimes one down the middle. We have explored different ways of doing it minimally invasively as well through smaller incisions to try to help recovery, decrease pain, those sorts of things. Some patients need those approaches that I've just described due to their complexity or their anatomy. But we are exploring different ways of doing it with a robot, and Dr. Jones has been leading that effort for our program. Maybe you can tell us a little bit about sort of the burgeoning area of robotic lung transplantation and how you think it might benefit patients, Greg?

Dr. Gregory Jones:

In the traditional approach to transplant, as Dr. McCurry mentioned, we usually will use larger incisions that occasionally will go through the breastbone or through the ribs. We do have some element of spreading of the ribs or the sternum, and that can cause pain. We want to limit that for patients in their recovery. The beauty of robotics, in addition to surgical factors, is that the incisions are much smaller. Sometimes they're called keyhole incisions, but usually we have five or six small incisions for our robotic instruments and a small camera with some assistant ports. The operation is done basically looking into a 3D camera, high-definition camera to be able to basically provide a minimally invasive approach to an otherwise more invasive operation.

For patients, the advantages really revolve around recovery. Smaller incisions, usually less pain, not having to go through ribs or sternum in order to access the chest. The patients like smaller incisions from a cosmetic standpoint as well, but it also helps with postoperative chest wall mechanics, breathing, and less pain certainly will get patients breathing more and hopefully enhance their recovery. That's really where we see kind of the advantage in lung transplant.

Dr. Kenneth McCurry:

Yeah. To be clear, Greg, so this is not some robot from “Lost in Space” who's doing the transplant or something else, right? Or the humanoid robots that we're seeing on Twitter or X now, I guess, right?

Dr. Gregory Jones:

It's true. It's a common question I get actually. There is a common misconception that the robot is doing the surgery and we're off in the coffee shop somewhere, but that is not true. Basically, what happens is there's what's called a console in kind of the corner of the room where I would be, and all of my movements with my hands are replicated at the bedside using robotic instruments inside the patient. That can dispel that rumor, if we can.

Dr. Kenneth McCurry:

Yeah. To be clear, I think this is only being performed at a handful of centers around the world, a few centers in the United States and one or two abroad. Indeed, part of the Cleveland Clinic Enterprise and Cleveland Clinic Abu Dhabi has done, I believe, a couple of robotic lung transplants as well.

But it's really done at high-volume experienced centers. In general, the way that we think about deploying this new sort of technology is to be sure that we're very facile and very experienced doing it through open techniques. Then once we're able to do that, begin to explore this advanced technology that allows us to deploy this sort of robotic technology in patients and to hopefully help them recover. Just to be clear, it's not appropriate for everyone, as Dr. Jones, I'm sure, would agree with me.

Dr. Gregory Jones:

Yes, definitely.

Dr. Kenneth McCurry:

There are some patients where it's just better to do it through a larger incision due to their complexity, their anatomy. But I think it's very important when you're considering lung transplantation and you have a sort of disease where lung transplantation might benefit, that seeking out an experienced center is really important, both on the surgical side and on the medical side. You have other thoughts here, Greg?

Dr. Gregory Jones:

Yeah, it's a very good point because the conduct of the operation is the exact same as an open transplant. Making sure that everything, the flow goes the exact same. As you said, centers that have experience doing this every day, it's usually going to be a little bit more facile and more appropriate to start up a protocol in a center like that. You're absolutely right. I wish it was appropriate for all patients, but right now it's a select population. Mainly with the robotic platform that we have, we need to be able to work inside the patient's chest. Some of our smaller patients, especially those with interstitial lung disease with kind of a contracted or smaller chest wall, in some of those patients, we will basically not have enough room to work. Anatomically, we're not offering it to those patients at the moment.

Another patient population that sometimes we will see listed for transplant are those that had chest surgeries previously. Sometimes that can be as simple as a chest tube with medication put inside that tube to stop an air leak or something from previous. Those patients usually have a significant amount of scar tissue that would prevent us from using the robot safely. So that's another group of patients that unfortunately we can't offer this to and will be recommended for traditional transplant.

Dr. Kenneth McCurry:

At Cleveland Clinic here in Ohio, we're one of the busiest lung transplant programs in the country. We hope to continue to grow this option for our patients. We're involved in a variety of other cutting-edge technologies as well as medical therapies as well. If you have any questions, please reach out to our program. We'd be happy to answer them for you.

As we're closing up, Greg, what sort of message would you want to say for patients who might be in need of a lung transplant in the future?

Dr. Gregory Jones:

Well, I'm really excited to be at an institution that really fosters innovation and supports taking the next step to advancing the field. While right now the indications are fairly small, I am excited to see what possibilities are offered to our patients down the road in terms of a robotic approach, innovations in the robotic instruments and in the technique. I'm just very privileged to be at a place that supports that. I'm excited to see what comes down the road and be able to offer these patients something a little different.

Dr. Kenneth McCurry:

If we can answer any questions, please feel free to reach out to our program. Thank you for listening to Love Your Heart today.

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