Robotic lobectomy for non-small cell lung cancer

Proficiency of Robotic Lobectomy Based on Prior Surgical Technique in The Society of Thoracic Surgeons General Thoracic Database

BACKGROUND

Robotic lobectomy represents a paradigm shift for many surgeons. It is unknown if a surgeon's prior operative approach influences development of proficiency. We compared outcomes based on prior lobectomy experience and used cumulative sum analysis to assess proficiency.

METHODS

Using The Society of Thoracic Surgeons General Thoracic Database we grouped surgeons as de novo, open-to-robotic, or video-assisted thoracoscopic surgery (VATS)-to-robotic. Operative time, blood transfusion, mortality, and major morbidity were primary outcomes. Unacceptable and acceptable thresholds were determined by review of the literature. Proficiency was defined as 20 consecutive cases without crossing an upper control line. Surgeons were assessed individually, and proficiency was assessed by transition group.

RESULTS

From 2009 to 2016, 271 surgeons performed 5619 robotic lobectomies for clinical stage I/II non-small cell lung cancer. Of these, 65 surgeons (24%) performed ≥20 lobectomies (4483 cases). Initial proficiency for an operative time target of 250 minutes was 40% for de novo compared with 14% for open-to-robotic and 21% for VATS-to-robotic surgeons, with improvement to 47%, 29%, and 21%, respectively, after 20 cases. Initial and sustained proficiency related to major morbidity was similar for open-to-robotic and VATS-to-robotic but lower for de novo at 40%. After 20 cases most were proficient (de novo, 93%; open-to-robotic, 100%; and VATS-to-robotic, 86%). Proficiency for 30-day mortality and blood transfusion was high in all groups.

CONCLUSIONS

Outcomes among all transition groups improved with experience. Operating room duration proficiency was challenging for all groups. Cumulative sum may be useful to monitor proficiency in not only subsequent studies but in clinical practice.

Robotic lobectomy: The first Indian report

INTRODUCTION

Even today, open lobectomy involves significant morbidity. Video-assisted thoracic surgery (VATS) lobectomy results in lesser blood loss, pain, and hospital stay compared to lobectomy by thoracotomy. Despite being an excellent procedure in expert hands, VATS lobectomy is associated with a longer learning curve because of its inherent basic limitations. The da Vinci surgical system was developed essentially to overcome these limitations. In this study, we report our initial experience with robotic pulmonary resections using the Completely Portal approach with four arms. To the best of our knowledge this is the first series of robotic lobectomy reported from India.

MATERIAL AND METHODS

Data on patient characteristics, operative details, complications, and postoperative recovery were collected in a prospective manner for patients who underwent Robotic Lung resection at our institution between March 2012 and April 2014 for various indications including both benign and malignant cases.

RESULTS

Between March 2012 to April 2014, a total of 13 patients were taken up for Robotic Lobectomy with a median age of 57 years. The median operative time was 210 min with a blood loss of 33 ml. R0 clearance was achieved in all patients with malignant disease. The median lymph node yield in nine patients with malignant disease was 19 (range 11-40). There was one intra-operative complication and two postoperative complications. The median hospital stay was 7 days with median duration to chest tube removal being 3 days.

CONCLUSION

Robotic lobectomy is feasible and safe. It appears to be oncologically sound surgical treatment for early-stage lung cancer. Comparable benefits over VATS needs to be further evaluated by long-term studies.