Innovation
What the literature shows Single-anaesthetic robotic bronchoscopy and resection has moved over the past five years from proof of concept to a small but consistent body of comparative evidence. Wolf and colleagues reported the first matched comparison in stage I non-small cell lung cancer in 2023. Time from radiographic identification of a nodule to therapeutic intervention fell from 116 days in a staged pathway to 65 days in a single- anaesthetic cohort, with fewer complications and shorter hospital stay.7
In 2024, Akhmerov’s
group reported the SABR (this is a confusing term with radiation treatment….) series. Time from biopsy to resection collapsed from 17 days to zero, with no increase in immediate postoperative morbidity and a measurable reduction in cost of care.3 A 2025 analysis by Perez and Soukiasian formalised the single-anaesthesia protocol. The pathway was restricted to patients with a Mayo Clinic solitary pulmonary nodule malignancy risk score of 90% or greater, with intra-operative pathology confirmation before definitive anatomical resection. In this cohort the benign resection rate fell from 21.9% with diagnostic wedge resection to 7.6% with single-anaesthetic robotic bronchoscopic biopsy, with no difference in postoperative complications.4
Ramsuchit and
colleagues reported 73 patients undergoing single-anaesthetic bronchoscopy and resection with shape-sensing robotic bronchoscopy. Intra-operative localisation succeeded in 100% of cases and average variable cost was approximately $4,000 lower than for two staged procedures.5 European data are now also emerging.
The Fast Track pathway from Milan, reported by Guarize and Spaggiari, combines Ion bronchoscopy, technetium-99m marker placement, and next-day robotic resection in a three-day protocol. In their first ten cases, localisation succeeded in 100%, diagnostic yield was 90%, and there were no procedural complications.6 Beyond the single-anaesthetic indication,
robotic bronchoscopy has more broadly streamlined the lung cancer patient pathway. It allows histological diagnosis to be combined with EBUS staging in patients who may benefit from neoadjuvant treatment, shortening the time to definitive management decisions. Marking of the lesion at the time of bronchoscopy also helps to identify lesions that would otherwise be impalpable at surgery, avoiding the need to convert to open surgery and maximising margin clearance. What is novel about the index case described
here is the combination of features within the UK independent sector. A sub-centimetre, non-
Mr Andrea Bille and Professor Santis performing the ION procedure, in the ION theatre, at HCA Healthcare UK’s London Bridge Hospital.
solid target lesion was managed by Ion-guided fiducial coil localisation rather than dye marking. A synchronous solid nodule in the contralateral lung was managed in the same operating session, immediately after resection of the first side. Da Vinci Xi anatomical resection followed in one continuous anaesthetic. To our knowledge it is the first such case performed outside a clinical trial in UK private healthcare.
The HCA Healthcare UK Ion programme HCA Healthcare UK introduced the Ion Endoluminal System at London Bridge Hospital in 2023, becoming the first independent provider in Europe to offer shape-sensing robotic-assisted bronchoscopy outside a clinical trial. Over the subsequent two years, the programme has supported the diagnostic evaluation of patients with small or otherwise inaccessible pulmonary nodules. The clinical service has been built around a multidisciplinary thoracic oncology team of respiratory physicians, thoracic surgeons, radiologists, and pathologists meeting in a single MDT to plan each Ion case prospectively. Two strands of internal research have informed our current practice. The first is a prospective evaluation of diagnostic yield and complication rates for Ion-guided biopsy of small nodules in our independent-sector population, presented at the 24th BTOG Annual Conference.8
Among nodules with a median
diameter of 7 mm, 31% were malignant on biopsy and 20% were early-stage lung cancers, substantially higher than predicted by the Brock model (median Brock score 5.4%). The finding is consistent with wider reports that current risk- stratification tools may under-call malignancy
in the smallest nodules. Some nodules currently allocated to imaging surveillance may benefit from earlier histological assessment. The second strand is the integration of Ion
bronchoscopy with our existing robotic thoracic surgery service. The case described here is the operational expression of that integration. A respiratory physician and thoracic surgeon working as a single team can move from diagnostic uncertainty to definitive treatment within one operating session, without two admissions, two anaesthetics, or weeks of waiting.
Operational considerations For services considering a similar pathway, several practical points stand out from the published literature and from our own experience. Theatre time and scheduling need to be modelled on programme throughput, not on individual case length. A combined case occupies a longer single operating session than either procedure alone, but it eliminates a second case slot, a second admission, and an inter-procedural wait. The business case is built on aggregate efficiency rather than on time per case. Intra-operative pathology can be the rate- limiting step. In our current practice we rely on ROSE of fine needle aspirates and imprints from cryo-biopsies during the bronchoscopic phase wherever possible, reserving formal frozen- section analysis for samples that will directly determine the extent of resection. A reliable cytopathology presence in theatre, with a pre-agreed workflow for specimen handling and direct surgeon-to-pathologist communication, is more important than
October 2026 I
www.clinicalservicesjournal.com 27
Photo courtesy of London Bridge Hospital.
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