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Dr Albert Jauregui on the value and future of robotic lung transplantation

The opportunity to transform patient care using robotic techniques for lung transplantation is being championed and embraced at Vall d’Hebron University Hospital, spearheaded by Dr Albert Jauregui. Here, with an introduction from Helena Beer, Dr Jauregui discusses robotics within the context of complex lung surgeries, his increasing experience with this technique as well as the benefits and challenges he’s identifying and addressing, and the promising future of this enhanced surgery.

For many clinicians, the opportunity to support patients through a difficult time in their lives and have a profound and enduring impact on their health and wellbeing is a key reason for joining the profession, and transplantation is arguably one of the fields in which this can be achieved most acutely.

This was certainly among the determining factors in Dr Albert Jauregui’s career choice. ‘I decided to dedicate myself to thoracic surgery because it is a very attractive specialty within the field of surgery [as] you have many possibilities to help patients,’ he says.

As chief of the department of thoracic surgery and lung transplantation at the Vall d’Hebron University Hospital in Barcelona, Spain, Dr Jauregui is the driving force behind the adoption of medical technologies that have been making significant advances in the field so that his team can make an even bigger impact on clinical care and patient outcomes.

Robotically assisted, minimally invasive surgeries for lung cancer have been undertaken at the hospital for several years, but lung transplantation has still required aggressive surgery, which is something that Dr Jauregui is keen to change.

In 2023, his team performed Spain’s first two robotically assisted single-lung transplants, with both patients showing good improvement in the postoperative period and needing only mild pain medication after surgery – an outcome that the team is very happy with.

Bilateral lung transplants are next on the agenda, and Dr Jauregui and his team plan to perform five of these robotically assisted procedures this year and 10 in 2025 to build up the bank of evidence and continue working towards offering this type of innovative surgery to more patients.

What are the main difficulties, risks and complications in lung transplantation?

Although the pool of lung donors has increased in recent years, thanks partly to relaxing the acceptance criteria and allowing new types of donors, the number still needs to be improved. The most important thing is to ensure a correct match between donor and recipient based on blood typing and immune characteristics to avoid organ rejection.

It is also essential to consider the graft size because large lungs can cause spatial problems in small thoracic cavities, and small grafts can be related to chronic dysfunction in the recipient. Therefore, it is crucial for lung transplant teams to try to find the best recipients for each donor.

Lung transplantation itself is considered one of the most complicated transplantation procedures due to the unique characteristics of the lungs – they are the only solid organs that have contact with the ‘outside world’ through breathing. Technically, it is a challenging surgery requiring collaboration with a large, experienced, multidisciplinary team to ensure the best results.

Lung transplant recipients are also particularly susceptible to infections and require high doses of immunosuppressive medications under strict control to avoid graft rejection and boost their immunity.

How have robotic technological innovations been incorporated into lung surgeries, including transplants, over the last decade and positively impacted patient care?

Thoracic robotic surgery has had a great impact on patients, especially in lung cancer where we see that its progress is unstoppable. The technical improvements offered by robotic surgery provide the patient with benefits in terms of recovery after surgery that are much better than traditional surgery.

Furthermore, the accompanying surgical precision makes the robotic technique extremely useful in lung cancer and transplantation and, thanks to the great experience of our transplantation team, we felt it had to be a logical evolution towards less aggressive and more precise surgeries.

Patients awaiting a lung transplant are usually significantly weakened and are traditionally offered a very aggressive open technique.

Our team performed robotically assisted surgeries with synthetic lungs in the lab before moving to large animal models. It was found that by deflating the lung and relying on the skin’s flexibility, we could use a smaller incision below the sternum to remove and insert the lungs.

Now, with the incorporation of robotic surgery for this type of patient, we have been able to reduce surgical aggression with preliminary results showing a substantial improvement in their recovery after a lung transplant.

The technique is still in its infancy and it’s at too early a stage to be able to operate on all the patients who are on the waiting list for a lung transplant using robotic surgery. Recipients tend to be a very heterogeneous patient group, but we are sure that in the very near future, it will become the surgical technique of choice.

Tell us more about the outcomes of the first robotically assisted transplants you performed and how these compared with traditional procedures

As it is a surgery performed with small incisions and minimal invasion, the healing process will, of course, be quicker and less painful. This is especially beneficial because, as already said, these patients are usually frail due to the nature of their disease. Providing care in the least invasive way possible can only bring better results.

Robotic procedures account for 3% of all lung transplants performed at our centre. The technique is already defined, but greater patient numbers are needed to demonstrate its differences compared with traditional methods.

Our team will perform more robotic lung transplants each year, but it will take time to reach definitive conclusions. For now, the results regarding recovery and postoperative pain are encouraging. Patients who undergo robotic surgery need less analgesia and recover faster, but we still cannot reach absolute conclusions.

What are the barriers and challenges in utilising these newer technologies, and how are these being addressed?

The most significant limitation is the widespread differences seen in terms of disease and degree of severity for patients on lung transplant waiting lists. As robotic lung transplantation is a very new technique, it requires performing a larger number of procedures and greater experience to generalise its use in more patients.

Another area for improvement is the surgeons’ experience with robotic surgery procedures themselves. Robotic surgery is increasingly being used, but it is still not widespread in general thoracic surgery programmes, and even less so in lung transplant programmes.

However, the worldwide interest in our findings in Barcelona makes the future promising, and we hope that more thoracic surgeons will join the movement.

This technology will undoubtedly improve in the future with the advent of more precise and even less invasive platforms. We are sure that organ transplants will become increasingly robotic in the future.