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Vijayakumar A, Abdel-Rasoul M, Hekmat R, Merritt RE, D'Souza DM, Jackson GP, Kneuertz PJ. National learning curves among robotic thoracic surgeons in the United States: Quantifying the impact of procedural experience on efficiency and productivity gains. J Thorac Cardiovasc Surg 2024; 167:869-879.e2. [PMID: 37562675 DOI: 10.1016/j.jtcvs.2023.07.051] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/12/2023] [Accepted: 07/29/2023] [Indexed: 08/12/2023]
Abstract
OBJECTIVE This study aims to characterize the aggregate learning curves of US surgeons for robotic thoracic procedures and to quantify the impact on productivity. METHODS National average console times relative to cumulative case number were extracted from the My Intuitive application (Version 1.7.0). Intuitive da Vinci robotic system data for 56,668 lung resections performed by 870 individual surgeons between 2021 and 2022 were reviewed. Console time and hourly productivity (work relative value units/hour) were analyzed using linear regression models. RESULTS Average console times improved for all robotic procedures with cumulative case experience (P = .003). Segmentectomy and thymectomy had the steepest initial learning curves with a 33% and 34% reduction of the average console time for proficient (51-100 cases) relative to novice surgeons (1-10 cases), respectively. The hourly productivity increase for proficient surgeons ranged from 11.4 work relative value units/hour (+26%) for lobectomy to 17.0 work relative value units/hour (+50%) for segmentectomy. At the expert level (101+ cases), average console times continued to decrease significantly for esophagectomy (-18%) and lobectomy (-23%), but only minimally for wedge resections (-1%) (P = .003). The work relative value units/hour increase at the expert level reached 50% for lobectomy and 40% for esophagectomy. Surgeon experience level, dual console use, system model, and robotic stapler use were factors independently associated with console time for robotic lobectomy. CONCLUSIONS The aggregate learning curve for robotic thoracic surgeons in the United States varies significantly by procedure type and demonstrate continued improvements in efficiency beyond 100 cases for lobectomy and esophagectomy. Improvements in efficiency with growing experiences translate to substantial productivity gains.
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Affiliation(s)
- Ammu Vijayakumar
- Thoracic Surgery Division, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | | | - Robert E Merritt
- Thoracic Surgery Division, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Desmond M D'Souza
- Thoracic Surgery Division, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Gretchen P Jackson
- Digital, Intuitive Surgical, Sunnyvale, Calif; Department of Pediatric Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Peter J Kneuertz
- Thoracic Surgery Division, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio.
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Xu H, Zhang L. Assessment of Quality Outcomes and the Learning Curve for Robot-Assisted Anatomical Lung Resections. J Laparoendosc Adv Surg Tech A 2024; 34:67-76. [PMID: 38126882 DOI: 10.1089/lap.2023.0171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023] Open
Abstract
Background: To determine the perioperative quality assessment results and learning curves for robot-assisted anatomical lung resection. Methods: We analyzed the data of the initial 400 patients who underwent lobectomies or segmentectomies by 1 surgeon from January 2020 to November 2021. The learning curve was analyzed using cumulative sum analysis. Results: The surgical experience was divided into an initial phase (1st-40th procedures), a transition phase (41st-131st procedures), and a proficient phase (132nd procedure onward). The operative time showed a conspicuously continuous improvement over the 400 consecutive patients. After the 120th procedure, there were significant improvements in the rate of persistent air leakage (11.7% versus 3.9%; P = .003), chest tube duration (3.92 ± 1.91 versus 2.99 ± 1.31, P = .00), and postoperative hospital stay (6.22 ± 2.02 versus 4.93 ± 1.44, P = .00). Conclusions: In conclusion, 40 patients were necessary to pass the learning curve, and technical proficiency with favorable perioperative outcomes was achieved after 120-130 patients.
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Affiliation(s)
- Hao Xu
- Department of Thoracic Surgery, The Second Hospital Affiliated to Harbin Medical University, Harbin, China
| | - Linyou Zhang
- Department of Thoracic Surgery, The Second Hospital Affiliated to Harbin Medical University, Harbin, China
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Igai H, Numajiri K, Ohsawa F, Nii K, Kamiyoshihara M. Comparison of the Learning Curve between Uniportal and Robotic Thoracoscopic Approaches in Pulmonary Segmentectomy during the Implementation Period Using Cumulative Sum Analysis. Cancers (Basel) 2023; 16:184. [PMID: 38201611 PMCID: PMC10778519 DOI: 10.3390/cancers16010184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 12/26/2023] [Accepted: 12/27/2023] [Indexed: 01/12/2024] Open
Abstract
BACKGROUND The aim of this retrospective study was to compare the learning curve and perioperative outcomes between the two approaches uVATS and RATS during their implementation periods. METHODS The uVATS group included 77 consecutive uVATS segmentectomies performed by HI between February 2019 and June 2022, while the RATS group included 30 between July 2022 and September 2023. The patient characteristics, perioperative outcomes, and learning curves were compared between the two groups. The learning curve was evaluated using operative time and cumulative sum (CUSUMOT) analysis. RESULTS Most patient characteristics and perioperative outcomes were equivalent between the two groups. In the uVATS group, after a positive slope was observed until the 14th case (initial period), a plateau was observed until the 38th case (stable period). Finally, a negative slope was observed after the 38th case (proficiency period). In the RATS group, after a positive slope was observed until the 16th case (initial period), a plateau was observed until the 22nd case (stable period). Finally, a negative slope was observed after the 22nd case (proficiency period). CONCLUSIONS In segmentectomy, a surgeon reached the proficiency period earlier in RATS than in uVATS, although the trends to the stable period were similar.
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Affiliation(s)
- Hitoshi Igai
- Department of General Thoracic Surgery, Japanese Red Cross Maebashi Hospital, 389-1 Asakura-cho, Maebashi 371-0811, Gunma, Japan
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Paglialunga PL, Molins L, Guzmán R, Guirao A, Grando L, Sanchez-Lorente D, Guerrero C, Bello I, Quiroga N, Boada M. Starting a robotic thoracic surgery program: From wedge resection to sleeve lobectomy in six months. Initial conclusions. Cir Esp 2023; 101:833-840. [PMID: 37544607 DOI: 10.1016/j.cireng.2023.04.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 04/08/2023] [Indexed: 08/08/2023]
Abstract
INTRODUCTION Robot-assisted thoracic surgery (RATS) is a rapidly expanding technique. In our study, we aimed to analyze the results of the process to adopt robotic surgery in our Department of Thoracic Surgery. METHODS This is an intention-to-treat analysis of a series of consecutive patients operated on using the RATS approach in our hospital from January 2021 to March 2022. Data were registered for patient characteristics, type of surgery, operative times, conversion rate, chest tube duration, length of hospital stay and complications. The IBM SPSS® statistical software was used for the statistical analysis. A cumulative sum analysis of the operating time was performed to define the learning curve. RESULTS During the study period, 51 patients underwent robotic surgery, including pulmonary and non-pulmonary interventions. In addition, 15 patients (29.4%) underwent non-pulmonary interventions: one pleural (2%), 2 diaphragmatic (3.9%), and 12 mediastinal (23.5%). Among the mediastinal surgeries, one conversion was necessary (8.3%) for a complex vascular malformation, and 11 were completed by RATS, including 7 (58.3%) thymomas, 3 (25%) pleuro-pericardial cysts, and one (8.3%) neurogenic tumor. Mean operative time was 141 min (104-178), mean chest tube duration was 0.9 days (0-2), and mean length of stay was 1.45 days (1-2). Thirty-six patients underwent lung surgery (70.6%). The complete RATS resections (34; 94.4%) included: 3 wedge resections (11.1%), 2 segmentectomies (3.7%), 28 lobectomies (81.5%), and one sleeve lobectomy (3.7%). Mean surgery time was 194.56 min (141-247), chest tube duration was 3.92 days (1-8), and length of stay was 4.6 days (1-8). Complications occurred in 4 patients (11.1%). No 90-day mortalities were registered. CONCLUSIONS The implementation of RATS was achieved with good clinical results and operative times for all indications. A rapid learning curve was accomplished in short time. Previous VATS experience, patient selection, team training and program continuity are fundamental to successfully develop a RATS program.
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Affiliation(s)
- Pablo Luis Paglialunga
- Department of Thoracic Surgery, Institut Clínic Respiratori (ICR), Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Catalonia, Spain.
| | - Laureano Molins
- Department of Thoracic Surgery, Institut Clínic Respiratori (ICR), Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Rudith Guzmán
- Department of Thoracic Surgery, Institut Clínic Respiratori (ICR), Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
| | - Angela Guirao
- Department of Thoracic Surgery, Institut Clínic Respiratori (ICR), Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Leandro Grando
- Department of Thoracic Surgery, Institut Clínic Respiratori (ICR), Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
| | - David Sanchez-Lorente
- Department of Thoracic Surgery, Institut Clínic Respiratori (ICR), Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
| | - Carlos Guerrero
- Department of Thoracic Surgery, Institut Clínic Respiratori (ICR), Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
| | - Irene Bello
- Department of Thoracic Surgery, Institut Clínic Respiratori (ICR), Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Catalonia, Spain
| | - Nestor Quiroga
- Department of Thoracic Surgery, Institut Clínic Respiratori (ICR), Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
| | - Marc Boada
- Department of Thoracic Surgery, Institut Clínic Respiratori (ICR), Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Catalonia, Spain
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Alvarado CE, Worrell SG, Sarode AL, Jiang B, Halloran SJ, Argote-Greene LM, Linden PA, Towe CW. Comparing Thoracoscopic and Robotic Lobectomy Using a Nationally Representative Database. Am Surg 2023; 89:5340-5348. [PMID: 36573595 DOI: 10.1177/00031348221148347] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
BACKGROUND Studies of robotic lobectomy (Robot-L) have been performed using data from high-volume, specialty centers which may not be generalizable. The purpose of this study was to compare mortality, length of stay (LOS), and cost between Robot-L and thoracoscopic lobectomy (VATS-L) using a nationally representative database hypothesizing they would be similar. METHODS The Premier Healthcare Database was used to identify patients receiving elective lobectomy for lung cancer from 2009 to 2019. Patients were categorized as receiving Robot-L or VATS-L using ICD-9/10 codes. Survey methodology and patient level weighting were used to correct for sampling error and estimation of a nationally representative sample. A propensity match analysis was performed to reduce bias between the groups. Primary outcome of interest was in-hospital mortality. Secondary outcomes were LOS and patient charges. RESULTS Among 62 698 patients, 19 506 (31.1%) underwent Robot-L and 43 192 (68.9%) underwent VATS-L. Differences between the groups included age, race, comorbidities, and insurance type. A propensity matched cohort demonstrated similar in-hospital mortality for Robot-L and VATS-L (.9% vs .9%, respectively, P = .91). Patients who underwent Robot-L had a shorter LOS (4 vs 5d, respectively, P < .001) but higher patient charges (90 593.0 vs 72 733.3 USD, respectively, P < .001). CONCLUSIONS In a nationally representative database, Robot-L and VATS-L had similar mortality. Although Robot-L was associated with shorter hospitalization, it was also associated with excess charges of almost $20,000. As Robot-L is now the most common approach for lobectomy in the U.S., further study into the cost and benefit of robotic surgery is warranted.
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Affiliation(s)
- Christine E Alvarado
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Stephanie G Worrell
- Section of Thoracic Surgery, Department of Surgery, University of Arizona, Tucson, AZ, USA
| | - Anuja L Sarode
- UH-RISES: Research in Surgical Outcomes and Effectiveness, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Boxiang Jiang
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Sean J Halloran
- Department of Surgery, University of Toledo School College of Medicine and Life Sciences, Toledo, OH, USA
| | - Luis M Argote-Greene
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Philip A Linden
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Christopher W Towe
- Division of Thoracic and Esophageal Surgery, Department of Surgery, Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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Berzenji L, Wen W, Verleden S, Claes E, Yogeswaran SK, Lauwers P, Van Schil P, Hendriks JMH. Minimally Invasive Surgery in Non-Small Cell Lung Cancer: Where Do We Stand? Cancers (Basel) 2023; 15:4281. [PMID: 37686557 PMCID: PMC10487098 DOI: 10.3390/cancers15174281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/16/2023] [Accepted: 08/21/2023] [Indexed: 09/10/2023] Open
Abstract
In the last two decades, robotic-assisted thoracoscopic surgery (RATS) has gained popularity as a minimally invasive surgical (MIS) alternative to multi- and uniportal video-assisted thoracoscopic surgery (VATS). With this approach, the surgeon obviates the known drawbacks of conventional MIS, such as the reduced in-depth perception, hand-eye coordination, and freedom of motion of the instruments. Previous studies have shown that a robotic approach for operable lung cancer has treatment outcomes comparable to other MIS techniques such as multi-and uniportal VATS, but with less blood loss, a lower conversion rate to open surgery, better lymph node dissection rates, and improved ergonomics for the surgeon. The thoracic surgeon of the future is expected to perform more complex procedures. More patients will enter a multimodal treatment scheme making surgery more difficult due to severe inflammation. Furthermore, due to lung cancer screening programs, the number of patients presenting with operable smaller lung nodules in the periphery of the lung will increase. This, combined with the fact that segmentectomy is becoming an increasingly popular treatment for small peripheral lung lesions, indicates that the future thoracic surgeons need to have profound knowledge of segmental resections. New imaging techniques will help them to locate these lesions and to achieve a complete oncologic resection. Current robotic techniques exist to help the thoracic surgeon overcome these challenges. In this review, an update of the latest MIS approaches and nodule detection techniques will be given.
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Affiliation(s)
- Lawek Berzenji
- Department of Thoracic and Vascular Surgery, University of Antwerp, 2610 Wilrijk, Belgium
- Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Laboratory of Thoracic and Vascular Surgery, 2650 Edegem, Belgium
| | - Wen Wen
- Department of Thoracic and Vascular Surgery, University of Antwerp, 2610 Wilrijk, Belgium
- Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Laboratory of Thoracic and Vascular Surgery, 2650 Edegem, Belgium
| | - Stijn Verleden
- Department of Thoracic and Vascular Surgery, University of Antwerp, 2610 Wilrijk, Belgium
- Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Laboratory of Thoracic and Vascular Surgery, 2650 Edegem, Belgium
| | - Erik Claes
- Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Laboratory of Thoracic and Vascular Surgery, 2650 Edegem, Belgium
| | - Suresh Krishan Yogeswaran
- Department of Thoracic and Vascular Surgery, University of Antwerp, 2610 Wilrijk, Belgium
- Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Laboratory of Thoracic and Vascular Surgery, 2650 Edegem, Belgium
| | - Patrick Lauwers
- Department of Thoracic and Vascular Surgery, University of Antwerp, 2610 Wilrijk, Belgium
- Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Laboratory of Thoracic and Vascular Surgery, 2650 Edegem, Belgium
| | - Paul Van Schil
- Department of Thoracic and Vascular Surgery, University of Antwerp, 2610 Wilrijk, Belgium
- Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Laboratory of Thoracic and Vascular Surgery, 2650 Edegem, Belgium
| | - Jeroen M. H. Hendriks
- Department of Thoracic and Vascular Surgery, University of Antwerp, 2610 Wilrijk, Belgium
- Antwerp Surgical Training, Anatomy and Research Centre (ASTARC), Laboratory of Thoracic and Vascular Surgery, 2650 Edegem, Belgium
- Department of Thoracic and Vascular Surgery, Antwerp University Hospital, Drie Eikenstraat 655, 2650 Edegem, Belgium
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Bedetti B, Zalepugas D, Arensmeyer JC, Feodorovici P, Schmidt J. [Robotics in thoracic surgery]. Pneumologie 2023; 77:374-385. [PMID: 37311471 DOI: 10.1055/a-1854-2770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
The increasing diffusion of the robotic-assisted technique in thoracic surgery (RATS) in Germany was initially delayed in comparison with other countries. Therefore, there is a large potential to implement the volume of the surgical procedures performed by RATS.The RATS-technique has many positive aspects. For example, the angulated instruments allow a full wristed dexterity like the human hand, but with a greater range of motion. The surgical Robot has a tremor filter and replicates perfectly the surgeon's movements. Furthermore, the 3D-scope enables an image magnification up to 10 times compared to the normal thoracoscopes. The RATS has also some disadvantages. For example, the operating surgeon sits far away from the patient and is not sterile while performing surgery. This is an important factor in in case of emergency situations, like major bleeding, which often require a conversion to thoracotomy.All robotic systems are built after the same master-slave technology, that allows the operating surgeon to have full control of the master system. The slave system consists of mechanical actuators that respond to the master system's inputs, so the surgical robot will translate every single movement of the surgeon at the console.The main surgical indications for RATS are: mediastinal tumors, diaphragm plication and anatomical lung resection like segment resections, lobectomies or sleeve resections.In the future, the implementation of virtual and augmented reality is expected in the training but also in the planning of RATS-operations.
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Pickering OJ, van Boxel GI, Carter NC, Mercer SJ, Knight BC, Pucher PH. Learning curve for adoption of robot-assisted minimally invasive esophagectomy: a systematic review of oncological, clinical, and efficiency outcomes. Dis Esophagus 2023; 36:6961031. [PMID: 36572404 DOI: 10.1093/dote/doac089] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 10/25/2022] [Indexed: 05/30/2023]
Abstract
BACKGROUND Robot-assisted minimally invasive esophagectomy (RAMIE) is gaining increasing popularity as an operative approach. Learning curves to achieve surgical competency in robotic-assisted techniques have shown significant variation in learning curve lengths and outcomes. This study aimed to summarize the current literature on learning curves for RAMIE. METHODS A systematic review was conducted in line with PRISMA guidelines. Electronic databases PubMed, MEDLINE, and Cochrane Library were searched, and articles reporting on learning curves in RAMIE were identified and scrutinized. Studies were eligible if they reported changes in operative outcomes over time, or learning curves, for surgeons newly adopting RAMIE. RESULTS Fifteen studies reporting on 1767 patients were included. Nine studies reported on surgeons with prior experience of robot-assisted surgery prior to adopting RAMIE, with only four studies outlining a specified RAMIE adoption pathway. Learning curves were most commonly analyzed using cumulative sum control chart (CUSUM) and were typically reported for lymph node yields and operative times, with significant variation in learning curve lengths (18-73 cases and 20-80 cases, respectively). Most studies reported adoption without significant impact on clinical outcomes such as anastomotic leak; significant learning curves were more likely in studies, which did not report a formal learning or adoption pathway. CONCLUSION Reported RAMIE adoption phases are variable, with some authors suggesting significant impact to patients. With robust training through formal programmes or proctorship, however, others report RAMIE adoption without impact on clinical outcomes. A formalized adoption curriculum appears critical to prevent adverse effects on operative efficiency and patient care.
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Affiliation(s)
- Oliver J Pickering
- School of Cancer Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Gijs I van Boxel
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK
| | - Nick C Carter
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK
| | - Stuart J Mercer
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK
| | - Benjamin C Knight
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK
| | - Philip H Pucher
- Department of General Surgery, Queen Alexandra Hospital, University Hospital Portsmouth NHS Trust, Portsmouth, UK
- Department of Pharmacology and Biosciences, University of Portsmouth, Portsmouth, UK
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de Rezende BB, Assumpção LR, Haddad R, Terra RM, Marques RG. Characteristics of the learning curve in robotic thoracic surgery in an emerging country. J Robot Surg 2023:10.1007/s11701-023-01590-2. [PMID: 37083992 DOI: 10.1007/s11701-023-01590-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 03/26/2023] [Indexed: 04/22/2023]
Abstract
It is not established which factors impact the learning curve (LC) in robotic thoracic surgery (RTS), especially in emerging countries. The aim of this study is to analyze LC in RTS in Brazil and identify factors that can accelerate LC. We selected the first cases of two Brazilian surgeons who started their LC. We used CUSUM and the Lowess technique to measure LC for each surgeon and Poisson regression to assess factors associated with shorter console time (CT). 58 patients were operated by each surgeon and included in the analysis. Surgeries performed were different: Surgeon I (SI) performed 54 lobectomies (93.11%), whereas Surgeon II (SII) had a varied mix of cases. SI was proctored in his first 10 cases (17.24%), while SII in his first 41 cases (70.68%). The mean interval between surgeries was 8 days for SI and 16 days for SII. There were differences in the LC phases of the two surgeons, mainly regarding complications and conversions. There was shorter CT by 30% in the presence of a proctor, and by 20% with the Da Vinci Xi. Mix of cases did not seem to contribute to faster LC. Higher frequency between surgeries seems to be associated with a faster curve. Presence of proctor and use of bolder technologies reduced console time. We wonder if in phase 3 it is necessary to keep a proctor on complex cases to avoid serious complications. More studies are necessary to understand which factors impact the LC.
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Affiliation(s)
- Bruna Brandão de Rezende
- Universidade do Estado do Rio de Janeiro, Pós Graduação em Fisiopatologia e Ciências Cirúrgicas, Rio de Janeiro, RJ, Brazil.
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Lia Roque Assumpção
- Universidade do Estado do Rio de Janeiro, Pós Graduação em Fisiopatologia e Ciências Cirúrgicas, Rio de Janeiro, RJ, Brazil
| | - Rui Haddad
- Departamento de Cirurgia, Pontifícia Universidade Católica - PUC-RIO, Rio de Janeiro, RJ, Brazil
| | - Ricardo Mingarini Terra
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
- Instituto do Coração, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - Ruy Garcia Marques
- Universidade do Estado do Rio de Janeiro, Pós Graduação em Fisiopatologia e Ciências Cirúrgicas, Rio de Janeiro, RJ, Brazil
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Svetanoff WJ, Bergus KC, Xia J, Diefenbach KA, Michalsky MP, Aldrink JH. Robotic-assisted resection of mediastinal tumors in pediatric patients. Semin Pediatr Surg 2023; 32:151262. [PMID: 36738480 DOI: 10.1016/j.sempedsurg.2023.151262] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Wendy Jo Svetanoff
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Katherine C Bergus
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States; Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Jason Xia
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States
| | - Karen A Diefenbach
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States; Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Marc P Michalsky
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States; Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Jennifer H Aldrink
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, OH, United States; Department of Surgery, The Ohio State University College of Medicine, Columbus, OH, United States.
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Learning Curve of Robotic Lobectomy for the Treatment of Lung Cancer: How Does It Impact on the Autonomic Nervous System of the Surgeon? J Pers Med 2023; 13:jpm13020193. [PMID: 36836426 PMCID: PMC9961561 DOI: 10.3390/jpm13020193] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/12/2023] [Accepted: 01/20/2023] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE Our purpose is to define the learning curve for robot-assisted thoracoscopic surgery lobectomy by reporting the experience of a single surgeon. MATERIAL AND METHODS We progressively collected the data concerning the surgical performance of a single male thoracic surgeon, from the beginning of his robotic activity as first operator from January 2021 to June 2022. We evaluated several pre-, intra- and postoperative parameters concerning patients and intraoperative cardiovascular and respiratory outcomes of the surgeon, recorded during surgical interventions, in order to evaluate his cardiovascular stress. We used cumulative sum control charts (CUSUM) to analyze the learning curve. RESULTS A total of 72 lung lobectomies were performed by a single surgeon in this period. Analyzing the CUSUM of several parameters, the inflection point identifying the transition beyond the surgeon learning phase was reached at cases 28, 22, 27 and 33 when considering operating time, mean heart rate, max heart rate and mean respiratory rate, respectively. CONCLUSIONS The learning curve for robotic lobectomy seems to be safe and feasible with a correct robotic training program. The analysis of a single surgeon from the beginning of his robotic activity demonstrates that confidence, competence, dexterity and security are achieved after about 20-30 procedures, without compromising efficiency and oncological radicality.
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12
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Educational assessment of intrathoracic and extrathoracic surgical stabilization of rib fractures. Injury 2023; 54:63-69. [PMID: 36283879 DOI: 10.1016/j.injury.2022.09.064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Revised: 09/21/2022] [Accepted: 09/30/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND Surgical stabilization of rib fractures (SSRF) is being done with increased frequency and new advances. Intrathoracic SSRF is a new less invasive approach compared to the traditional extrathoracic plating procedure. Educational assessment can be done through descriptive analysis of learning curves with operation time used as a proxy measurement for learning. The objective of this level 3 observational cohort study is to assess the learning curve of introducing the intrathoracic method of plating at a large academic medical institution. METHODS Intrathoracic surgical stabilization of rib fractures was introduced at a tertiary trauma center in March of 2019. All patients that received SSRF beginning 11/2017 were included. Patients with abbreviated injury scale score of the head, abdomen, extremity, or face greater than three and days from injury to SSRF greater than 4 were excluded. Operation time was determined from time of incision to completion of skin closure. Time per fracture and time per plate were calculated using total operation time. Learning curves and CUSUM graphs for individual surgeons that had completed in more than 3 SSRF cases were generated using and trended for statistical significance. RESULTS After exclusions, there were 38 patients with extrathoracic SSRF between November 2017-September 2021 and 24 patients with intrathoracic plating between March 2019-Sept. 2021. There were 5 fellows and 6 residents that performed extrathoracic SSRF. Four fellows and 2 residents performed intrathoracic SSRF. Graphs of time per fracture and time per plate over time produced learning curves without an inflection point for extrathoracic or intrathoracic SSRF in any of the following categories: all surgeries (Figs. 1 and 2), academic year (July to June), individual attending surgeons, fellows, or residents. CONCLUSION There was no discernible inflection point on the generated learning curves. Time per plate and time per fracture did not decrease as surgeons gained more experience. Introducing intrathoracic SSRF in a large academic hospital may not need to account for a learning curve adjustment period.
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13
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Lau J, Ioan Cvasciuc T, Simpson D, C de Jong M, Parameswaran R. Continuing challenges of primary neuroendocrine tumours of the thymus: A concisereview. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2022; 48:2360-2368. [PMID: 35922282 DOI: 10.1016/j.ejso.2022.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2022] [Revised: 07/13/2022] [Accepted: 07/18/2022] [Indexed: 12/14/2022]
Abstract
Primary neuroendocrine tumours of the thymus (NETTs) are exceedingly rare tumours, usually presenting around mid-life, which have a propensity towards males and smokers. They are seen more often in those with MEN-1, but multiple different genetic mutations have been found to be involved in the tumorigenesis of NETTs. Histologically, NETTs are classified according to number of mitoses, the presence of necrosis, and the presence or absence of small cell features. NETTs display a wide spectrum of behavior, and they can be incidentally found on chest imaging, on screening in MEN-1, or present with symptoms of local compression. Advanced disease and paraneoplastic syndromes are common. CT-, PET/CT-, MRI-scans, and somatostatin receptor scintigraphy are the imaging modalities of choice both for the initial assessment as well as for monitoring after treatment. For patients with localized disease, complete surgical resection with lymphadenectomy provides the best chance of long-term, disease-free survival, and can be achieved through either an open or thoracoscopic approach. While chemotherapy-regimens based on platinum, taxane, and temozolomide are used most often, the optimum chemotherapy regimen in the adjuvant and palliative settings remains unclear, as does the role of radiotherapy. Ongoing research on the most effective use of somatostatin analogues, peptide receptor radionuclide therapy (PPRT), kinase inhibitors and immunotherapy in patients with other types of advanced neuroendocrine tumours may lead to further treatment options for NETTs in the future.
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Affiliation(s)
- Joel Lau
- Division of Endocrine Surgery, National University Health System, 119074, Singapore
| | - Titus Ioan Cvasciuc
- Division of Endocrine Surgery, Royal Victoria Hospital, Grosvenor Road, Belfast, 274 Grosvenor Rd, Belfast, BT12 6BA, UK
| | - Duncan Simpson
- Division of Endocrine Surgery, Royal Victoria Hospital, Grosvenor Road, Belfast, 274 Grosvenor Rd, Belfast, BT12 6BA, UK
| | - Mechteld C de Jong
- Division of Endocrine Surgery, National University Health System, 119074, Singapore
| | - Rajeev Parameswaran
- Division of Endocrine Surgery, National University Health System, 119074, Singapore; Yong Loo Lin School of Medicine, 10 Medical Dr, 117597, Singapore.
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14
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Robotic Thymectomy: An Update. CURRENT SURGERY REPORTS 2022. [DOI: 10.1007/s40137-022-00323-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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15
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Impact of center volume on conversion to thoracotomy during minimally invasive pulmonary lobectomy. Surgery 2022; 172:1478-1483. [PMID: 36031450 DOI: 10.1016/j.surg.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 06/22/2022] [Accepted: 07/08/2022] [Indexed: 11/20/2022]
Abstract
BACKGROUND Conversion to open is a potentially serious intraoperative event associated with minimally invasive pulmonary lobectomy. However, the impact of institutional expertise on conversion to open has not been studied on a large scale. We used a nationally representative database to evaluate the association between hospital pulmonary lobectomy caseload and rates of conversion to open. METHODS All adults who underwent minimally invasive pulmonary lobectomy were identified from the 2017 to 2019 Nationwide Readmissions Database. Annual institutional caseloads of open and minimally invasive lobectomy were independently tabulated. Restricted cubic splines were used to parametrize the relationship between conversion to open and hospital volumes. Furthermore, multivariable regression was used to examine the association of conversion to open with in-hospital mortality, length of stay, and hospitalization costs. RESULTS Of an estimated 52,886 patients who met study criteria, 4.9% required conversion to open. Compared to others, conversion to open patients were slightly younger (66 vs 67 years) and more commonly male (52.2 vs 42.3%, P < .001). After adjustment, male sex (adjusted odds ratio 1.42), history of tobacco use (adjusted odds ratio 1.35), and prior radiation therapy (adjusted odds ratio 1.35, P < .001) were associated with increased odds of conversion to open. Increasing minimally invasive lobectomy volume was linked to lower risk-adjusted rates of conversion to open, whereas greater open lobectomy caseload was associated with higher rates. Despite no impact on mortality (adjusted odds ratio 1.11, P = .73), conversion to open was associated with a 1.2-day increment in length of stay and $5,600 in attributable costs. CONCLUSION The present study found institutional minimally invasive pulmonary lobectomy caseload to be associated with decreased rates of conversion to thoracotomy, emphasizing the relevance of minimally invasive training among surgeons and perioperative staff.
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Gómez-Hernández MT, Fuentes MG, Novoa NM, Rodríguez I, Varela G, Jiménez MF. Similar outcomes after newly implemented rats approach compared to standard vats for anatomical lung resection. A propensity-score matched analysis. Cir Esp 2022; 100:504-510. [PMID: 35842254 DOI: 10.1016/j.cireng.2022.06.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 04/06/2021] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Outcomes after the introduction of surgical innovations can be impaired by learning periods. The aim of this study is to compare the short-term outcomes of a recently implemented RATS approach to a standard VATS program for anatomical lung resections. METHODS Retrospective review of consecutive patients undergoing pulmonary anatomical resection through a minimally invasive approach since RATS approach was applied in our department (June 01, 2018, to November 30, 2019). Propensity score matching was performed according to patients' age, gender, ppoFEV1, cardiac comorbidity, type of malignancy, and type of resection. Outcome evaluation includes: overall morbidity, significant complications (cardiac arrhythmia, pneumonia, prolonged air leak, and reoperation), 30-day mortality, and length of hospital stay. Data were compared by two-sided chi-square or Fisher's exact test for categorical and Mann-Whitney U test for continuous variables. RESULTS A total of 273 patients (206 VATS, 67 RATS) were included in the study. After propensity score matching, data of 132 patients were analyzed. The thirty-days mortality was nil. Overall morbidity (RATS: 22.4%, VATS: 29.2%; p=0.369), major complications (RATS: 9% vs VATS: 9.2%; p=0.956) and the rates of specific major complications (cardiac arrhythmia RATS: 4.5%, VATS: 4.6%, p=1; pneumonia RATS:0%, VATS:4.6%, p=0.117; prolonged air leak RATS: 7.5%; VATS: 4.6%, p=0.718) and reoperation (RATS: 3%, VATS: 1.5%, p=1) were comparable between both groups. The median length of stay was 3 days in both groups (p=0.101). CONCLUSIONS A RATS program for anatomical lung resection can be implemented safely by experienced VATS surgeons without increasing morbidity rates.
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Affiliation(s)
| | - Marta G Fuentes
- Service of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain
| | - Nuria M Novoa
- Service of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain
| | - Israel Rodríguez
- Service of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain
| | | | - Marcelo F Jiménez
- Service of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain; Salamanca Institute of Biomedical Research, Spain
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17
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Merritt RE, D'Souza DM, Abdel-Rasoul M, Kneuertz PJ. Analysis of trends in perioperative outcomes in over 1000 robotic-assisted anatomic lung resections. J Robot Surg 2022; 17:435-445. [PMID: 35753009 DOI: 10.1007/s11701-022-01436-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 06/06/2022] [Indexed: 11/24/2022]
Abstract
Robotic-assisted surgery is gaining popularity as a minimally invasive approach for anatomic lung resection. We investigated the temporal changes in case volume, costs, and postoperative outcomes for robotic-assisted anatomic lung resection in over 1000 cases. We reviewed our institutional STS database for patients who had undergone robotic-assisted lobectomy, bi-lobectomy, or segmentectomy as the primary procedure between years 2009-2021. The patients were divided into two groups: first 500 cases (n = 501) and second 500 cases (n = 500). Temporal trends of case volume, surgical indications, hospital length of stay, costs, and perioperative outcomes were analyzed. A total of 1001 patients were analyzed, of which 968 (96.7%) patients underwent robotic-assisted lobectomy, 21 (2.1%) patients underwent bi-lobectomy, 10 (1.0%) patients underwent segmentectomy, and 3 (0.3%) patients underwent sleeve lobectomy. Primary lung cancer was the most common indication (87.7%), followed by metastatic lung tumors (7.1%), and benign diagnosis (5.2%). The overall postoperative complication rate decreased from 46.1% for the first 500 cases compared to 29.6% for the second 500 cases (p < 0.0001). The median hospital length of stay was down trending, which was 4 days [IQR: 3-7] for the first 500 cases and 3 days [IQR: 3-5] (p = 0.0001) for the second. The inflation-adjusted direct and indirect hospital costs were significantly lower in the second 500 cases (p < 0.0001). The complications rates, hospital costs, and hospital length of stay for robotic-assisted anatomic pulmonary resection decreased significantly over time at a single institution. Continuous improvement in perioperative outcomes may be observed with increasing institutional experience.
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Affiliation(s)
- Robert E Merritt
- Division of Thoracic Surgery, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, N847A Doan Hall, Columbus, OH, 43210, USA.
| | - Desmond M D'Souza
- Division of Thoracic Surgery, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, N847A Doan Hall, Columbus, OH, 43210, USA
| | | | - Peter J Kneuertz
- Division of Thoracic Surgery, The Ohio State University Wexner Medical Center, 410 West 10th Avenue, N847A Doan Hall, Columbus, OH, 43210, USA
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18
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Evaluating the implementation of robotic thoracic surgery on a Veterans Administration Hospital. J Robot Surg 2022; 17:365-374. [PMID: 35670989 PMCID: PMC9170878 DOI: 10.1007/s11701-022-01427-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/10/2022] [Indexed: 11/28/2022]
Abstract
Robotic thoracic surgery has demonstrated benefits. We aimed to evaluate implementation of a robotic thoracic surgery program on postoperative outcomes at our Veteran’s Administration Medical Center (VAMC). We retrospectively reviewed our VAMC database from 2015 to 2021. Patients who underwent surgery with intention to treat lung nodules were included. Primary outcome was patient length of stay (LOS). Patients were grouped by surgical approach and stratified to before and after adoption of robotic surgery. Univariate comparison of postoperative outcomes was performed using Wilcoxon rank sums and chi-squared tests. Multivariate regression was performed to control for ASA class. P values < 0.05 were considered significant. Outcomes of 108 patients were assessed. 63 operations (58%) occurred before and 45 (42%) after robotic surgery implementation. There were no differences in patient preoperative characteristics. More patients underwent minimally invasive surgery (MIS) in the post-implementation era than pre-implementation (85% vs. 42%, p < 0.001). Robotic operations comprised 53% of operations post-implementation. On univariate analysis, patients in the post-implementation era had a shorter LOS vs. pre-implementation, regardless of surgical approach (mean 4.7 vs. 6.0 days, p = 0.04). On multivariate analysis, patients who underwent MIS had a shorter LOS [median 4 days (IQR 2–6 days) vs. 7 days (6–9 days), p < 0.001] and were more likely to be discharged home than to inpatient facilities [OR (95% CI) 13.00 (1.61–104.70), p = 0.02]. Robotic thoracic surgery program implementation at a VAMC decreased patient LOS and increased the likelihood of discharging home. Implementation at other VAMCs may be associated with improvement in some patient outcomes.
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19
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Kneuertz PJ, Abdel-Rasoul M, D'Souza DM, Zhao J, Merritt RE. Segmentectomy for clinical stage I non-small cell lung cancer: National benchmarks for nodal staging and outcomes by operative approach. Cancer 2022; 128:1483-1492. [PMID: 34994403 DOI: 10.1002/cncr.34071] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 10/26/2021] [Accepted: 11/29/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Segmentectomy is increasingly used for parenchyma sparing anatomical resection for small stage I non-small cell lung cancer (NSCLC). This study characterizes the national outcomes for lymph node assessment and perioperative outcomes of segmentectomy for clinical stage I NSCLC by robotic-assisted surgery (RATS), video-assisted thoracoscopic surgery (VATS), and open thoracotomy approach. METHODS A retrospective cohort study was conducted of patients who underwent segmentectomy for clinical stage I NSCLC captured in the national Society of Thoracic Surgeons General Thoracic Surgery Database between years 2012 and 2018. Inverse probability of treatment weighting (IPTW) was used to balance baseline characteristics. Lymph node (LN) staging and 30-day outcomes were compared by approach. RESULTS A total of 3680 patients (VATS 61.9%, RATS 20%, open 18%) underwent segmentectomy. The IPTW adjusted rate of pathologic LN upstaging (pN1/pN2) was 6.2% (RATS 6.3%, VATS 5.6%, open 8.6%; P = .05). On multivariate analysis, there was no differences in pN1/N2 upstaging between RATS (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.44-1.49) or VATS (OR, 0.96; 95% CI, 0.57-1.63) with open segmentectomy. The RATS and VATS approach was associated with fewer postoperative events (RATS 31.3%, VATS 28.8%, open 38.3%; P < .001) and shorter length of stay (RATS 4.3 days, VATS 4.4 days, open 5.2 days; P < .001) as compared with thoracotomy. RATS segmentectomy-specific complications included a higher rate of pneumothorax after chest tube removal and discharge with chest tube. Major complications were lower after RATS and VATS as compared with open segmentectomy (RATS 5.9%, VATS 4.5%, open 7.2%; P = .028). CONCLUSIONS Segmentectomy by VATS and robotic approach resulted in similar high rates of lymph node upstaging as a global marker of the quality of lymph node dissection and were associated with lower overall morbidity and shorter length of stay as compared with open thoracotomy. These national outcomes may serve as benchmarks for future comparative studies.
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Affiliation(s)
- Peter J Kneuertz
- Department of Surgery, Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Desmond M D'Souza
- Department of Surgery, Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Jing Zhao
- Center for Biostatistics, The Ohio State University, Columbus, Ohio
| | - Robert E Merritt
- Department of Surgery, Thoracic Surgery Division, The Ohio State University Wexner Medical Center, Columbus, Ohio
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20
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Robotic-assisted left lower-lobe pulmonary lobectomy: Eleven steps. JTCVS Tech 2021; 10:473-479. [PMID: 34977788 PMCID: PMC8691657 DOI: 10.1016/j.xjtc.2021.05.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/28/2021] [Indexed: 11/24/2022] Open
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21
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Gray KD, Bott MJ. Commentary: Setting the standard for robotic pulmonary resection. JTCVS Tech 2021; 10:480. [PMID: 34977789 PMCID: PMC8691213 DOI: 10.1016/j.xjtc.2021.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 08/02/2021] [Accepted: 08/02/2021] [Indexed: 11/26/2022] Open
Affiliation(s)
- Katherine D. Gray
- Department of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Matthew J. Bott
- Department of Thoracic Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
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22
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Alicuben ET, Wightman SC, Shemanski KA, David EA, Atay SM, Kim AW. Training residents in robotic thoracic surgery. J Thorac Dis 2021; 13:6169-6178. [PMID: 34795968 PMCID: PMC8575838 DOI: 10.21037/jtd-2019-rts-06] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Accepted: 11/12/2020] [Indexed: 11/06/2022]
Abstract
With growing integration of robotic technology in thoracic surgery, the need for structured training has never been greater with trainees expressing desire for additional experience. Determining the ideal education program is challenging as the collective experience is still relatively early and growing with many experienced surgeons still becoming facile with the platform. Understanding differences between robotic and thoracoscopic approaches including lung retraction and dissection, use of carbon dioxide insufflation, and lack of tactile feedback serves as the foundation for building a skillset. Currently, there is no standard accepted curriculum for residents. Inclusion of these trainees in structured programs has been shown to be safe with equivalent patient outcomes. There are multiple curricula under development, all of which incorporate use of simulation technology, dual console, and clear, graduated responsibilities within operations. These include introduction to the robotic system prior to progressing to bedside assistance and finally to time as console surgeon. The importance of clear definition of training milestones with deliberate graduation to more complex tasks once competency has been demonstrated cannot be overstated. It is crucial for surgeons practicing robotic surgery to make efforts to further the training of residents, but there has not been any perfect and suitable program identified yet.
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Affiliation(s)
- Evan T Alicuben
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Sean C Wightman
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Kimberly A Shemanski
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Elizabeth A David
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Scott M Atay
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Anthony W Kim
- Division of Thoracic Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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23
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Toker A, Kakuturu J. From learning how to fly to becoming a war pilot. Eur J Cardiothorac Surg 2021; 61:297-298. [PMID: 34587252 DOI: 10.1093/ejcts/ezab426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Alper Toker
- Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, WV, USA
| | - Jahnavi Kakuturu
- Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, WV, USA
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Su L, Ho H, Stock CT, Quadri SM, Williamson C, Servais EL. Surgeon experience is associated with prolonged air leak after robotic-assisted pulmonary lobectomy. Ann Thorac Surg 2021; 114:434-441. [PMID: 34400135 DOI: 10.1016/j.athoracsur.2021.07.033] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 06/26/2021] [Accepted: 07/06/2021] [Indexed: 11/01/2022]
Abstract
BACKGROUND Prolonged air leak (>5 days) following robotic-assisted pulmonary lobectomy is a significant complication. This study aimed to determine patient and surgeon factors that can predict prolonged air leak (PAL) after robotic lobectomy for lung cancer. METHODS We performed a retrospective review from a single-center experience of robotic-assisted lobectomy for lung cancer. Perioperative variables including surgeon case experience, patient demographics, DLCO, FEV1, BMI, and smoking status were evaluated. RESULTS A total of 305 robotic-assisted lobectomies performed by four surgeons met inclusion criteria from June 2016 to February 2019. Thirty-day post-operative mortality was 1.2%. 27 out of 305 (8.8%) patients developed PAL. We grouped surgeon robotic experience by 10 case increments. When adjusted for age and gender, the odds for PAL decreased by 15% for every 10 robotic lobectomies our surgeons performed (OR=0.85, 95% CI: 0.74-0.99, p=0.0384). Logistic regression models showed a linear transition curve was at the 50th case. Female gender (OR=2.62, 95% CI: 1.03-6.69, p=0.0314) and younger age (OR=0.61; 95% CI: 0.41-0.91, p=0.0184) were statistically significant risk factors for PAL. Cumulative sum analysis similarly showed strong association between experience and PAL. Preoperative DLCO, FEV1, BMI, and smoking status were not statistically significant predictive factors. CONCLUSIONS These results show that surgeon robotic case experience is associated with the rate of postoperative PAL - as the number of robotic lobectomies increases, the rate of PAL significantly decreases. It is imperative to emphasize a learning curve exists for this approach that directly impacts patient outcomes.
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Affiliation(s)
- Lowell Su
- Division of Thoracic and Cardiovascular Surgery, Lahey Hospital and Medical Center, Burlington, MA;; Department of Surgery, Tufts University School of Medicine, Boston, MA
| | - Helen Ho
- Division of Thoracic and Cardiovascular Surgery, Lahey Hospital and Medical Center, Burlington, MA
| | - Cameron T Stock
- Division of Thoracic and Cardiovascular Surgery, Lahey Hospital and Medical Center, Burlington, MA;; Department of Surgery, Tufts University School of Medicine, Boston, MA
| | - Syed M Quadri
- Division of Thoracic and Cardiovascular Surgery, Lahey Hospital and Medical Center, Burlington, MA;; Department of Surgery, Tufts University School of Medicine, Boston, MA
| | - Christina Williamson
- Division of Thoracic and Cardiovascular Surgery, Lahey Hospital and Medical Center, Burlington, MA;; Department of Surgery, Tufts University School of Medicine, Boston, MA
| | - Elliot L Servais
- Division of Thoracic and Cardiovascular Surgery, Lahey Hospital and Medical Center, Burlington, MA;; Department of Surgery, Tufts University School of Medicine, Boston, MA.
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25
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Smith MJ, Lee J, Brodsky AL, Figueroa MA, Stamm MH, Giard A, Luker N, Friedman S, Huncke T, Jain SK, Pothuri B. Optimizing Robotic Hysterectomy for the Patient Who Is Morbidly Obese with a Surgical Safety Pathway. J Minim Invasive Gynecol 2021; 28:2052-2059.e3. [PMID: 34139329 DOI: 10.1016/j.jmig.2021.06.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/24/2021] [Accepted: 06/09/2021] [Indexed: 01/04/2023]
Abstract
STUDY OBJECTIVE Obesity is a growing worldwide epidemic, and patients classified as obese undergoing gynecologic robotic surgery are at increased risk for surgical complications. This study aimed to evaluate the feasibility and outcomes of a surgical safety protocol known as the High BMI [Body Mass Index] Pathway (HBP) for patients with BMI ≥40 kg/m2 undergoing planned robotic hysterectomy. Our primary outcome was the rate of all-cause perioperative complications in patients undergoing surgery with the use of the HBP. DESIGN A retrospective cohort study. SETTING An academic teaching hospital. PATIENTS A total of 138 patients classified as morbidly obese (BMI ≥40 kg/m2) undergoing robotic hysterectomy. INTERVENTIONS The HBP was developed by a multidisciplinary team and was instituted on January 1, 2016, as a quality improvement project. Patients classified as morbidly obese undergoing robotic hysterectomy after this date were compared with consecutive historical controls. MEASUREMENTS AND MAIN RESULTS Seventy-two patients underwent robotic hysterectomies on the HBP and were compared with 66 controls. There were no differences in age, BMI, blood loss, number of comorbidities, or cancer diagnosis. Since the implementation of the HBP, there has been a decrease in anesthesia time (-57.0 minutes; p = .001) and total operating room time (-47.0 min; p = .020), as well as lower estimated blood loss (median 150 mL [interquartile range 100-200] vs 200 mL [interquartile range 100-300]; p = .002) and reduction in overnight hospital admissions (33.3% vs 63.6%; p <.001). In the HBP group, there were fewer all-cause complications (19.4% vs 37.9%; p = .023) and infectious complications (8.3% vs 33.3%; p = .001), and there was no increase in the readmission rates (p = .400). In multivariable analysis, the HBP reduced all-cause complications (odds ratio 0.353; p = .010) after controlling for the covariate (total time in the operating room). CONCLUSION The HBP is a feasible method of optimizing the outcome for patients classified as morbidly obese undergoing major gynecologic surgery. Initiation of the HBP can lead to decreased anesthesia and operating times, all-cause complications, and overnight hospital admissions without increasing readmission rates.
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Affiliation(s)
- Maria J Smith
- Department of Obstetrics and Gynecology, NYU Langone Health (Dr. Smith), New York, NY
| | - Jessica Lee
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, University of Texas Southwestern Medical Center (Drs. Lee), Dallas, TX
| | - Allison L Brodsky
- Department of Obstetrics and Gynecology, University of California San Diego (Drs. Brodsky), San Diego, CA
| | - Melissa A Figueroa
- NYU Medical Center, NYU Langone Health (Mss. Figueroa, Giard, and Luker, and Mr. Stamm)
| | - Matthew H Stamm
- NYU Medical Center, NYU Langone Health (Mss. Figueroa, Giard, and Luker, and Mr. Stamm)
| | - Audra Giard
- NYU Medical Center, NYU Langone Health (Mss. Figueroa, Giard, and Luker, and Mr. Stamm)
| | - Nadia Luker
- NYU Medical Center, NYU Langone Health (Mss. Figueroa, Giard, and Luker, and Mr. Stamm)
| | - Steven Friedman
- Department of Population Health, NYU Langone Health (Mr. Friedman)
| | - Tessa Huncke
- Department of Anesthesiology, NYU Langone Health (Drs. Huncke and Jain), New York, NY
| | - Sudheer K Jain
- Department of Anesthesiology, NYU Langone Health (Drs. Huncke and Jain), New York, NY
| | - Bhavana Pothuri
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, NYU Langone Health (Dr. Pothuri).
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Gómez-Hernández MT, Fuentes MG, Novoa NM, Rodríguez I, Varela G, Jiménez MF. Similar outcomes after newly implemented rats approach compared to standard vats for anatomical lung resection. A propensity-score matched analysis. Cir Esp 2021; 100:S0009-739X(21)00135-4. [PMID: 33985760 DOI: 10.1016/j.ciresp.2021.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 02/12/2021] [Accepted: 04/06/2021] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Outcomes after the introduction of surgical innovations can be impaired by learning periods. The aim of this study is to compare the short-term outcomes of a recently implemented RATS approach to a standard VATS program for anatomical lung resections. METHODS Retrospective review of consecutive patients undergoing pulmonary anatomical resection through a minimally invasive approach since RATS approach was applied in our department (June 01, 2018, to November 30, 2019). Propensity score matching was performed according to patients' age, gender, ppoFEV1, cardiac comorbidity, type of malignancy, and type of resection. Outcome evaluation includes: overall morbidity, significant complications (cardiac arrhythmia, pneumonia, prolonged air leak, and reoperation), 30-day mortality, and length of hospital stay. Data were compared by two-sided chi-square or Fisher's exact test for categorical and Mann-Whitney U test for continuous variables. RESULTS A total of 273 patients (206 VATS, 67 RATS) were included in the study. After propensity score matching, data of 132 patients were analyzed. The thirty-days mortality was nil. Overall morbidity (RATS: 22.4%, VATS: 29.2%; p=0.369), major complications (RATS: 9% vs VATS: 9.2%; p=0.956) and the rates of specific major complications (cardiac arrhythmia RATS: 4.5%, VATS: 4.6%, p=1; pneumonia RATS:0%, VATS:4.6%, p=0.117; prolonged air leak RATS: 7.5%; VATS: 4.6%, p=0.718) and reoperation (RATS: 3%, VATS: 1.5%, p=1) were comparable between both groups. The median length of stay was 3 days in both groups (p=0.101). CONCLUSIONS A RATS program for anatomical lung resection can be implemented safely by experienced VATS surgeons without increasing morbidity rates.
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Affiliation(s)
| | - Marta G Fuentes
- Service of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain
| | - Nuria M Novoa
- Service of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain
| | - Israel Rodríguez
- Service of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain
| | | | - Marcelo F Jiménez
- Service of Thoracic Surgery, Salamanca University Hospital, Salamanca, Spain; Salamanca Institute of Biomedical Research, Spain
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Berlth F, Knospe L, Jansen-Winkeln B, Hadzijusufovic E, Tagkalos E, Niebisch S, Moulla Y, Chalopin C, Köhler H, Maktabi M, Lang H, Grimminger P, Gockel I. [Status of minimally invasive gastrectomy : Current advancements: robotic surgery and intraoperative imaging for gastric cancer]. Chirurg 2021; 92:528-534. [PMID: 33760929 DOI: 10.1007/s00104-021-01391-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2021] [Indexed: 01/08/2023]
Abstract
The surgical treatment of gastric cancer has arrived at a turning point towards the routine application of minimally invasive techniques. After the first results of prospective randomized trials from Asia confirmed the surgical and oncological safety, the latest results of international trials provided evidence for minimally invasive gastrectomy of advanced gastric cancer in a multimodal setting. A new addition in the field of minimally invasive procedures is robotic-assisted surgical techniques, which have already been implemented for these indications in many centers in Germany. The technical advantages that are applicable in the robotics setting in comparison to laparoscopy lead to a rapid dissemination of the procedure but still need to be evaluated in controlled trials. Further developments for the surgical treatment of gastric cancer are found in the field of intraoperative imaging procedures. In this field various technologies are available, such as fluorescence imaging using a near-infrared camera, which requires the use of a fluorescent agent or the hyperspectral camera system, which does not require the application of a fluorophore and merges pictures from visible and non-visible wavelengths to a functional image. It is to be expected that in the future various technological advancements can make a valuable contribution to the surgical treatment of gastric cancer in the clinical routine, especially if they support and facilitate the use of minimally invasive surgical techniques.
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Affiliation(s)
- Felix Berlth
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Langenbeckstraße 1, 55133, Mainz, Deutschland.
| | - Luise Knospe
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Boris Jansen-Winkeln
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Edin Hadzijusufovic
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Langenbeckstraße 1, 55133, Mainz, Deutschland
| | - Evangelos Tagkalos
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Langenbeckstraße 1, 55133, Mainz, Deutschland
| | - Stefan Niebisch
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Yusef Moulla
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Claire Chalopin
- Innovation Center Computer Assisted Surgery (ICCAS), Universität Leipzig, Leipzig, Deutschland
| | - Hannes Köhler
- Innovation Center Computer Assisted Surgery (ICCAS), Universität Leipzig, Leipzig, Deutschland
| | - Marianne Maktabi
- Innovation Center Computer Assisted Surgery (ICCAS), Universität Leipzig, Leipzig, Deutschland
| | - Hauke Lang
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Langenbeckstraße 1, 55133, Mainz, Deutschland
| | - Peter Grimminger
- Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Langenbeckstraße 1, 55133, Mainz, Deutschland
| | - Ines Gockel
- Klinik und Poliklinik für Viszeral‑, Transplantations‑, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Leipzig, Deutschland
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Abstract
The proportion of robot-assisted thoracic surgery (RATS) is continuously increasing. The main areas of clinical application are anatomical lung resections with lymphadenectomy and resection of mediastinal tumors. Especially in the area of the thymus robot-assisted procedures can now be considered the gold standard. Overall, the limitations of video-assisted thoracoscopic surgery (VATS) can be overcome by the use of robot-assisted surgery and thus a larger proportion of patients can be treated with minimally invasive procedures. The safety of the RATS procedure has been repeatedly demonstrated, although it remains difficult to demonstrate scientifically measurable benefits. With the introduction of new systems on the market further technical evolution and improvement can be expected in the future.
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Power AD, Merritt RE, Abdel-Rasoul M, Moffatt-Bruce SD, D'Souza DM, Kneuertz PJ. Estimating the risk of conversion from video-assisted thoracoscopic lung surgery to thoracotomy-a systematic review and meta-analysis. J Thorac Dis 2021; 13:812-823. [PMID: 33717554 PMCID: PMC7947549 DOI: 10.21037/jtd-20-2950] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Background Understanding the risk of conversion from video-assisted thoracic surgery (VATS) to thoracotomy is important when considering patient selection and preoperative surgical risk assessment. This review aims to estimate the rate of intraoperative conversions to thoracotomy, predictive factors, and associated outcomes for VATS anatomic lung resections. Methods PubMed/MEDLINE and EMBASE were searched systematically in May of 2020. Observational studies examining conversions of VATS anatomic resections to thoracotomy were included. Conversion rates, causes, risk factors, and post-operative outcomes were reviewed and analyzed in aggregate. Results Twenty retrospective studies were reviewed, with a total of 72,932 patients undergoing VATS anatomic lung resection. The median conversion rate was 9.6% (95% CI: 6.6–13.9%). Nine studies reported a total of 114 emergency conversions, with a median incidence rate of 1.3% (95% CI: 0.6–2.8%). The most common reasons for thoracotomy were vascular injury/bleeding, difficulty lymph node dissection, and adhesions, accounting for 27.9%, 26.2% and 19% of conversions, respectively. Risk factors for conversion varied, but frequently included nodal disease, large tumors, and induction therapy. The risk of complications (OR 2.06; 95% CI: 1.77–2.40) and mortality (OR 4.11; 95% CI: 1.59–10.61) were significantly increased following conversions. There was also a significant increase in chest tube duration and length of stay following conversion. Conclusions The risk of conversion to thoracotomy may be as high as one in ten patients undergoing VATS anatomic lung resections, but may vary significantly based on patient selection. Although emergent conversions are rare, the need for thoracotomy may significantly increase postoperative morbidity and mortality.
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Affiliation(s)
- Alexandra D Power
- Division of Thoracic Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Robert E Merritt
- Division of Thoracic Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Mahmoud Abdel-Rasoul
- Center for Biostatistics, The Ohio State University College of Medicine, Columbus, OH, USA
| | - Susan D Moffatt-Bruce
- Division of Thoracic Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Desmond M D'Souza
- Division of Thoracic Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Peter J Kneuertz
- Division of Thoracic Surgery, Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
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Sandhaus T, Durand M, Möller T, Egberts J, Steinert M. Robotic surgery for thoracic surgery. Eur Surg 2020. [DOI: 10.1007/s10353-020-00674-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
SummaryIndications for the use of RATS vary between the facilities but correspond as far as possible to other minimally invasive surgical findings. In general, RATS is currently a therapeutic option for the management of early-stage NSCLC without mediastinal lymph node involvement in oncological surgery, although depending on the planned intervention and the surgical facility, hilar lymph node involvement may be accepted
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Suda T, Ishizawa H, Nagano H, Negi T, Kawai H, Tochii D, Tochii S, Hoshikawa Y. Early outcomes in 147 consecutive cases of subxiphoid single-port thymectomy and evaluation of learning curves. Eur J Cardiothorac Surg 2020; 58:i44-i49. [PMID: 32620967 DOI: 10.1093/ejcts/ezaa183] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 03/23/2020] [Accepted: 05/02/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The aim of the present study was to examine some initial results and learning curves concerning subxiphoid single-port thymectomy (SSPT), thereby clarifying the safety of this surgical approach and describing the precautions for adopting it. METHODS From March 2011 to August 2019, a total of 203 patients underwent thymectomy for either anterior mediastinal tumours or myasthenia gravis at Fujita Health University Hospital. Of these 203 patients, 147 patients who had undergone SSPT were selected as participants for the present study. RESULTS Of the 147 cases, transition to a different approach was required in three (2.0%) cases: two (1.3%) cases transitioned to median sternotomy, whereas one (0.7%) case transitioned to the side chest trans-intercostal approach. The two cases that transitioned to median sternotomy were the second cases for different operators after they began performing this technique. There were six (4.0%) cases with complications and no deaths. The operation time cumulative summation learning curve analysis revealed that the curves descended from the 38th case. In the 83 cases handled by one surgeon, the learning curves descended from the 31st case. CONCLUSIONS SSPT is a safe modality with few complications and no associated cases of mortality reported. Operators are required to experience 31-38 cases until the operation time for SSPT was stabilized. Special care should be exercised to prevent vascular damage in the vicinity of the innominate veins during the early stages after SSPT introduction.
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Affiliation(s)
- Takashi Suda
- Department of Thoracic Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Hisato Ishizawa
- Department of Thoracic Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Hiromitsu Nagano
- Department of Thoracic Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Takahiro Negi
- Department of Thoracic Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Hiroshi Kawai
- Department of Thoracic Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Daisuke Tochii
- Department of Thoracic Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Sachiko Tochii
- Department of Thoracic Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
| | - Yasushi Hoshikawa
- Department of Thoracic Surgery, Fujita Health University School of Medicine, Toyoake, Aichi, Japan
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Abstract
The number of interventions using robot-assisted thoracic surgery (RATS) is increasing in Germany, following the previous international development. Robot-assisted surgery provides some technical advantages and can overcome existing limitations of video-assisted thoracic surgery (VATS), especially in the case of extended resections, thus enabling the proportion of minimally invasive operations to be further increased. The safety of the procedure, even in extended resections, has repeatedly been demonstrated but whether there are clinically relevant benefits from RATS is currently the subject of scientific discussions. In addition, a further technical evolution of the RATS can be postulated by the upcoming market introduction of new robotic systems.
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Affiliation(s)
- Thorben Möller
- Klinik für Allgemein‑, Viszeral‑, Thorax‑, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Christian-Albrechts-Universität zu Kiel, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Deutschland
| | - Matthias Steinert
- Klinik für Herz- und Thoraxchirurgie - Sektion Thoraxchirurgie, Universitätsklinikum Jena, Jena, Deutschland
| | - Thomas Becker
- Klinik für Allgemein‑, Viszeral‑, Thorax‑, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Christian-Albrechts-Universität zu Kiel, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Deutschland
| | - Jan-Hen Drik Egberts
- Klinik für Allgemein‑, Viszeral‑, Thorax‑, Transplantations- und Kinderchirurgie, Universitätsklinikum Schleswig-Holstein, Christian-Albrechts-Universität zu Kiel, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Deutschland.
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Abstract
Minimally invasive surgery for diseases of the chest offsets the morbidity of painful thoracic incisions while allowing for meticulous dissection of major anatomic structures. This benefit translates to improved outcomes and recovery following the surgical management of benign and malignant esophageal pathologic condition, mediastinal tumors, and lung resections. This anatomic region is particularly amenable to a robotic approach given the fixed space and need for complex intracorporeal dissection. As robotic platforms continue to evolve, more complex thoracic surgical interventions will be facilitated, translating to improved outcomes for our patients.
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Affiliation(s)
- Gary Schwartz
- Department of Thoracic Surgery & Lung Transplantation, Baylor University Medical Center, Texas A&M Health Science Center, 3410 Worth Street, Suite 545, Dallas, TX 75246, USA.
| | - Manu Sancheti
- Emory Saint Joseph's Hospital, Emory Healthcare, 5665 Peachtree Dunwoody Road #200, Atlanta, GA 30342, USA
| | - Justin Blasberg
- Yale School of Medicine, Lauder Hall, 310 Cedar Street, New Haven, CT 06510, USA
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