Professor Gregor Kocher, M.D., is a leading expert in the field of thoracic surgery and enjoys an excellent reputation both nationally and internationally. His broad range of therapeutic approaches and his innovative, minimally invasive surgical techniques make him a leading authority in his field. As Head of Thoracic Surgery at the Hirslanden Clinic in Bern and as Chief of Thoracic Surgery at Clara Hospital in Basel, Prof. Dr. Kocher works as an independent thoracic surgeon at various medical institutions.
His expertise spans the entire spectrum of thoracic surgery, from conservative treatment methods to highly complex surgical procedures. He has specialized in particular in minimally invasive procedures, including robot-assisted surgery. A particular focus of his work is the treatment of lung tumors. Prof. Dr. Kocher is known for his groundbreaking minimally invasive surgeries, in which he achieves precise tumor removal while minimizing damage to the surrounding tissue. These innovative surgical techniques have already helped numerous patients improve their quality of life and recover more quickly.
Another highlight in Prof. Dr. Kocher’s career was the world’s first minimally invasive, robot-assisted removal of a Pancoast tumor in November 2023. This groundbreaking surgical technique could represent a paradigm shift in the treatment of such complex tumors and opens up new possibilities for patients around the world.
In addition to his clinical work, Prof. Dr. Kocher is also active in medical research and teaching. As a member of several renowned medical societies, he contributes to the continuous expansion of expertise in the field of thoracic surgery and drives new developments forward.
What particularly sets Prof. Dr. Kocher apart is his personal commitment to his patients. He places great emphasis on individualized and comprehensive care, from the initial consultation through to follow-up care. His patients benefit from an interdisciplinary network and a wide range of treatment options designed to meet their needs and achieve optimal treatment outcomes.
The editorial team at Leading Medicine Guide wanted to learn more specifically about robot-assisted minimally invasive treatment of lung tumors and was able to speak with the expert, Prof. Dr. Kocher, on this topic.
.png "Prof. Dr. med. Gregor Kocher")
Lung cancer is one of the most common and deadliest forms of cancer worldwide. This disease affects not only smokers but also nonsmokers, and can take various forms, including non-small cell lung cancer and small cell lung cancer. Despite significant advances in diagnosis and treatment, lung cancer remains a major challenge for the medical community and affected patients.
Minimally invasive surgery has taken on an important role in the treatment of lung cancer and offers potential advantages for patients’ recovery and postoperative well-being compared to traditional open surgery.
These modern surgical techniques, such as thoracoscopic or robot-assisted surgery, typically involve smaller incisions and less tissue trauma, leading to a faster recovery time. Reduced postoperative pain is also a common benefit, which can improve patients’ overall well-being after the procedure. Another potential benefit is the shorter hospital stay following minimally invasive surgery compared to open procedures. This can both reduce costs and lessen the burden on patients. Furthermore, research suggests that minimally invasive procedures may carry a lower risk of certain postoperative complications, which further enhances the safety of the surgery.
“In a thoracotomy—open surgery on the lung—the surgeon opens the chest using a rib spreader through a longer incision of 15–20 cm between the ribs. This naturally causes pain. In a minimally invasive procedure, the incision is no longer than 2–3 cm, and the chest does not need to be spread open very wide, since the procedure can be performed using a camera. Consequently, the smaller surgical incision alone results in less collateral damage, less blood loss, no injury to muscles, fewer complications, and less pain. The risk of pneumonia is also reduced. For the patient, another advantage of minimally invasive surgery is that the hospital stay is limited to 3–4 days, whereas patients who have undergone open surgery typically remain in the hospital for about 7–8 days. Mobility is also regained more quickly with minimally invasive surgery—the patient is back on their feet on the day of the surgery and is ready to resume daily activities after about 1–2 weeks, whereas this takes about a month after open surgery,” explains Prof. Dr. Kocher at the start of our conversation, going on to outline the criteria for making this decision:
“Basically, the open procedure is the traditional method, and for a long time, the technology and instruments for a minimally invasive procedure were not available. In Europe, half of all lung surgeries are still performed using the open approach. In Switzerland, we’re a bit further along in this regard, and approximately 90% are performed using minimally invasive techniques. We actually only perform open surgery if the tumor is central and very large, taking up a lot of space in the chest cavity—space that is needed for the procedure, since the lung must be collapsed to make the operation feasible; otherwise, the tumor cannot be removed. “Even if the tumor has invaded several ribs, a minimally invasive procedure doesn’t make sense.”
At the Hirslanden Beau Site Clinic in Bern and the Lindenhof Hospital in Bern, where Prof. Dr. Kocher works as an independent thoracic surgeon, 90–95% of surgeries are performed using minimally invasive techniques. The robot is used whenever it offers an advantage.
Robot-assisted surgery, particularly in the treatment of lung cancer, offers a number of specific advantages that distinguish it from other minimally invasive procedures.
A key element is the precision and accuracy enabled by the robotic system. The robotic arms translate the surgeon’s movements into precise movements inside the body, allowing for finer and more accurate incisions. This is crucial when removing lung cancer tumors, as precise incisions are necessary to spare the surrounding healthy tissue. “Robot-assisted surgery is also part of minimally invasive surgery. Typically, three to four robotic arms are used, which are inserted into the patient through small skin incisions. Here at our hospital, we’ve developed a technique that requires only two skin incisions, through which we insert all the instruments. The robot has the major advantage of providing a three-dimensional view via two cameras. This naturally allows for more precise work, and the robot executes commands with a 2.5x magnification,” said Prof. Dr. Kocher.
The robotic instruments also offer greater dexterity and range of motion than human hands. Their flexibility enables finer manipulations in tight and hard-to-reach areas of the lung that might be difficult or impossible with conventional instruments. This contributes to a less invasive procedure, as it results in less tissue trauma, which in turn can lead to faster recovery and a reduced risk of postoperative complications.
The choice of surgical procedure for treating lung cancer—whether minimally invasive or robot-assisted—is an important factor that can influence patients’ long-term survival.
Studies suggest that patients who undergo minimally invasive or robot-assisted surgery may have better long-term survival rates than patients who undergo traditional open surgery. “The data in this area are not yet very robust. However, they clearly indicate so far that minimally invasive surgery offers significant advantages for long-term survival. And with the help of the robot, we can also perform more difficult procedures much more safely, for example, in patients with large lung metastases. The duration of the surgery must also be taken into account. Here, we distinguish between minimally invasive surgery, open surgery, and robot-assisted surgery. With open surgery, time must be factored in for the incision and suturing, which is why minimally invasive surgery is faster by comparison. With robot-assisted surgery, the preparation time must be factored in, as the patient also needs to be prepared. Therefore, these steps can be combined, and no time is lost. Docking the robot to the patient then takes an additional 10–15 minutes. Changing instruments takes a bit longer with a robot—so you could say that you need to plan for about 20 minutes more time with a robot than without one,” explains Prof. Dr. Kocher.
Lymph node metastases occur when cancer cells spread through the lymphatic or blood vessels in the body and settle in the lymph nodes or other organs. The term “lymph node metastases” stems from the fact that these metastases are frequently found in lymph nodes, where they can cause hardening and swelling.
The choice between minimally invasive and robot-assisted surgical procedures for the treatment of lung cancer depends heavily on various factors, including the size, location, and type of tumor.
“Tumor size plays a significant role. When it comes to small tumors in the lung, minimally invasive surgery can be performed successfully without a robot. It’s also important to consider that the trocars (instruments) used with the robotic arms have a diameter of 8–12 mm, whereas the instruments used without a robot are somewhat thinner. This is something that needs to be weighed carefully. Work is currently underway to develop thinner trocars, so there will certainly be further improvements in this area. Often, minimally invasive surgery is only possible with the aid of a robot. So it varies from case to case,” explains Prof. Dr. Kocher.
The type of lung cancer also plays a role. Non-small cell lung cancer (NSCLC) and small cell lung cancer (SCLC) have different characteristics and require different treatment approaches. NSCLC, the most common type, is often a candidate for minimally invasive or robot-assisted procedures, especially if the tumor is detected early and is located in a favorable position. SCLC is generally more aggressive and may require more extensive surgical treatment, possibly in combination with other therapies such as chemotherapy and radiation therapy.
The purchase and maintenance of a robotic surgery system, as well as the training of medical staff, are costly, and extensive training is required to operate the robot.
“There are two societies here that have so-called ‘task forces.’ I am a member of the European Society for Thoracic Surgery, and one of my main focuses is ensuring that a training curriculum is defined and completed so that robot-assisted surgery can be performed safely. This begins with simulations, followed by surgeries on ‘dummies’ (using small plastic models). Only then do surgeons perform their first simple procedures on patients, with a surgeon experienced in robot-assisted surgery present. It takes approximately 1–2 years of training before one can safely operate the robot independently. Experience with minimally invasive techniques is required. Opinions differ regarding the number of surgeries needed to gain the necessary expertise. “Currently, it’s estimated to be 20–50 surgeries. Of course, the caseload must then be maintained to ensure a good ‘case flow,’” explains Prof. Dr. Kocher regarding robot-assisted training.
The world’s first minimally invasive robot-assisted removal of a Pancoast tumor in November 2023 opens up new avenues for treating such complex tumors and marks a milestone in modern surgery.
The treatment of Pancoast tumors can be revolutionized by robot-assisted surgery. “Surgery for a Pancoast tumor is very challenging. This tumor originates in the upper lobe of the lung and invades the upper ribs of the chest. Patients with this type of tumor present with pain, radiating pain in the arms, and sensory disturbances in the arms, because the tumor also compresses the nerves and can invade blood vessels. For this reason, patients are also pretreated with chemotherapy and radiation therapy, which leads to scarring in the area of the tumor. For the surgeon, this means dealing with a tumor plus scar tissue, which is what makes the surgery so challenging. Until now, such tumors have been treated with open surgery. The sternum had to be cut through, the scapula detached, and all muscle layers severed in order to gain access to the chest cavity. A few years ago, so-called hybrid procedures were described. The upper lobe resection was performed thoracoscopically using a robot. The vessels leading to the lung lobe were removed, the lung was detached, and the procedure was then completed via open surgery. The ribs had to be removed for this in order to be able to excise the tumor,” said Prof. Dr. Kocher regarding the previous approach, adding regarding the current status:
“At the end of 2023, we performed the first robot-assisted surgery for a Pancoast tumor described in the literature here in Bern. For this procedure, we severed the lung lobe and detached it from the pulmonary hilum (the inner side of the lung), and then used the robot to perform the rib resection and detach the tumor from the blood vessels. This was only possible thanks to a high level of expertise. The patient spent only four days in the hospital, and all follow-up examinations were normal. To date, there have been no recurrences, and the patient is mobile.”
A characteristic feature of the Pancoast tumor is that it is often diagnosed at an advanced stage, as it frequently causes symptoms only after it has already invaded surrounding tissues or structures. Symptoms include pain in the shoulder, arm, or neck, which may result from the tumor spreading to nerves or muscles. This is often referred to as “shoulder pain syndrome.” Another typical feature of Pancoast syndrome is its effect on the Horner’s nerve, which leads to what is known as Horner’s syndrome. This manifests as symptoms such as a sunken eye socket, a constricted pupil, and a drooping eyelid on the affected side of the face.
Future Prospects
“Surgical techniques using robots are constantly evolving. It would be great if the robotic arms could become smaller. In China, the first new models are already available that still offer the same precision and excellent visibility. As for AI (artificial intelligence), there are several algorithms that can assist us in surgery. For example, a 3D projection of blood vessel pathways can be overlaid on the patient’s image to even more effectively prevent unintended injuries. Surgeries could be simulated. This involves using a patient’s CT scan to practice the procedure before performing it on the patient. This is a development that will definitely take place in the near future. It has even been tested to program a robot so that surgery can be performed independently of location—the robot is in India, but the surgeon is in the U.S. and can control it remotely. Of course, a team must always be present at the patient’s side to intervene, because the more technology is involved, the more potential sources of error there are. So while this approach is certainly possible, it should not be the goal. “However, the latest platform of the daVinci robot sensibly allows experts to log in remotely for extremely difficult cases to see exactly what the surgeon is currently seeing on the screen and to provide advice and assistance,” says Prof. Dr. Kocher, summarizing the current state of affairs and future options, and thus concluding our conversation.
Thank you very much, Professor Dr. Kocher, for this in-depth look into the complex world of thoracic surgery!
