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Walker RJB, Stukel TA, de Mestral C, Nathens A, Breau RH, Hanna WC, Hopkins L, Schlachta CM, Jackson TD, Shayegan B, Pautler SE, Karanicolas PJ. Hospital learning curves for robot-assisted surgeries: a population-based analysis. Surg Endosc 2024; 38:1367-1378. [PMID: 38127120 DOI: 10.1007/s00464-023-10625-6] [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: 09/07/2023] [Accepted: 11/29/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Robot-assisted surgery has been rapidly adopted. It is important to define the learning curve to inform credentialling requirements, training programs, identify fast and slow learners, and protect patients. This study aimed to characterize the hospital learning curve for common robot-assisted procedures. STUDY DESIGN This cohort study, using administrative health data for Ontario, Canada, included adult patients who underwent a robot-assisted radical prostatectomy (RARP), total robotic hysterectomy (TRH), robot-assisted partial nephrectomy (RAPN), or robotic portal lobectomy using four arms (RPL-4) between 2010 and 2021. The association between cumulative hospital volume of a robot-assisted procedure and major complications was evaluated using multivariable logistic models adjusted for patient characteristics and clustering at the hospital level. RESULTS A total of 6814 patients were included, with 5230, 543, 465, and 576 patients in the RARP, TRH, RAPN, and RPL-4 cohorts, respectively. There was no association between cumulative hospital volume and major complications. Visual inspection of learning curves demonstrated a transient worsening of outcomes followed by subsequent improvements with experience. Operative time decreased for all procedures with increasing volume and reached plateaus after approximately 300 RARPs, 75 TRHs, and 150 RPL-4s. The odds of a prolonged length of stay decreased with increasing volume for patients undergoing a RARP (OR 0.87; 95% CI 0.82-0.92) or RPL-4 (OR 0.77; 95% CI 0.68-0.87). CONCLUSION Hospitals may adopt robot-assisted surgery without significantly increasing the risk of major complications for patients early in the learning curve and with an expectation of increasing efficiency.
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Affiliation(s)
- Richard J B Walker
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
| | - Thérèse A Stukel
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
| | - Charles de Mestral
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
- Division of Vascular Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Avery Nathens
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- ICES, Toronto, Canada
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Rodney H Breau
- Division of Urology, Department of Surgery, University of Ottawa, Ottawa, Canada
- Clinical Epidemiology, The Ottawa Hospital Research Institute, Ottawa, Canada
| | - Waël C Hanna
- Division of Thoracic Surgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Laura Hopkins
- Division of Oncology, Saskatchewan Cancer Agency, Saskatoon, Canada
| | | | - Timothy D Jackson
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Bobby Shayegan
- Juravinski Cancer Centre, McMaster University, Hamilton, Canada
| | - Stephen E Pautler
- Divisions of Urology and Surgical Oncology, Departments of Surgery and Oncology, Western University, London, Canada
| | - Paul J Karanicolas
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Canada.
- Institute of Health Policy, Management, and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
- Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Canada.
- Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room T2 16, Toronto, ON, M4N 3M5, Canada.
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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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Lampridis S, Maraschi A, Le Reun C, Routledge T, Billè A. Robotic versus Video-Assisted Thoracic Surgery for Lung Cancer: Short-Term Outcomes of a Propensity Matched Analysis. Cancers (Basel) 2023; 15:2391. [PMID: 37190319 PMCID: PMC10136784 DOI: 10.3390/cancers15082391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 04/12/2023] [Accepted: 04/18/2023] [Indexed: 05/17/2023] Open
Abstract
Robot-assisted thoracic surgery (RATS) has gained popularity for the treatment of lung cancer, but its quality outcome measures are still being evaluated. The purpose of this study was to compare the perioperative outcomes of lung cancer resection using RATS versus video-assisted thoracic surgery (VATS). To achieve this aim, we conducted a retrospective analysis of consecutive patients who underwent lung cancer surgery between July 2015 and December 2020. A propensity-matched analysis was performed based on patients' performance status, forced expiratory volume in 1 s% of predicted, diffusing capacity of the lungs for carbon monoxide% of predicted, and surgical procedure (lobectomy or segmentectomy). Following propensity matching, a total of 613 patients were included in the analysis, of which 328 underwent RATS, and 285 underwent VATS, with satisfactory performance indicators. The results of the analysis indicated that RATS had a significantly longer operating time than VATS (132.4 ± 37.3 versus 122.4 ± 27.7 min; mean difference of 10 min 95% CI [confidence interval], 4.2 to 15.9 min; p = 0.001). On the other hand, VATS had a significantly higher estimated blood loss compared to RATS (169.7 ± 237.2 versus 82.2 ± 195.4 mL; mean difference of 87.5 mL; 95% CI, 48.1 to 126.8 mL; p < 0.001). However, there were no significant differences between the groups in terms of the duration of chest tubes, length of hospital stay, low- and high-grade complications, as well as readmissions and mortality within 30 days after surgery. Moreover, the number of dissected lymph-node stations was significantly higher with VATS than RATS (5.9 ± 1.5 versus 4.8 ± 2.2; mean difference of 1.2; 95% CI, 0.8 to 1.5; p = 0.001). Nonetheless, the percentage of patients who were upstaged after histopathological analysis of the resected lymph nodes was similar between the two groups. In conclusion, RATS and VATS yielded comparable results for most of the short-term outcomes assessed. Further research is needed to validate the implementation of RATS and identify its potential benefits over VATS.
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Affiliation(s)
- Savvas Lampridis
- Department of Thoracic Surgery, Guy’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK
| | - Alessandro Maraschi
- Department of Thoracic Surgery, Guy’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK
| | - Corinne Le Reun
- Independent Biostatistician, 97180 Sainte-Anne, Guadeloupe, France
| | - Tom Routledge
- Department of Thoracic Surgery, Guy’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK
| | - Andrea Billè
- Department of Thoracic Surgery, Guy’s Hospital, Guy’s and St Thomas’ NHS Foundation Trust, London SE1 9RT, UK
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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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Alwatari Y, Khoraki J, Wolfe LG, Ramamoorthy B, Wall N, Liu C, Julliard W, Puig CA, Shah RD. Trends of utilization and perioperative outcomes of robotic and video-assisted thoracoscopic surgery in patients with lung cancer undergoing minimally invasive resection in the United States. JTCVS OPEN 2022; 12:385-398. [PMID: 36590738 PMCID: PMC9801282 DOI: 10.1016/j.xjon.2022.07.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 06/04/2022] [Accepted: 07/05/2022] [Indexed: 04/27/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate utilization and perioperative outcomes of video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracoscopic surgery (RATS) for lung cancer in the United States using a nationally representative database. METHODS Hospital admissions for lobectomy or sublobar resection (segmentectomy or wedge resection) using VATS or RATS in patients with nonmetastatic lung cancer from October 2015 through December 2018 in the National Inpatient Sample were studied. Patient and hospital characteristics, perioperative complications and mortality, length of stay (LOS), and total hospital cost were compared. Logistic regression was used to assess whether the surgical approach was independently associated with adverse outcomes. RESULTS There were 83,105 patients who had VATS (n = 65,375) or RATS (n = 17,710) for lobectomy (72.7% VATS) or sublobar resection (84.2% VATS). Utilization of RATS for lobectomy and sublobar resection increased from 19.2% to 34% and 7.3% to 22%, respectively. Mortality, LOS, and conversion rates were comparable. The cost was higher for RATS (P <.01). Multivariate analyses showed comparable RATS and VATS complications with no independent association between the minimally invasive surgery approach used and adverse surgical outcomes, except for a decreased risk of pneumonia with RATS, relative to VATS sublobar resection (P <.01). Thoracic complication rates and LOS decreased after RATS lobectomy in 2018, compared with previous years (P <.005). CONCLUSIONS The utilization of robotic-assisted lung resection for cancer has increased in the United States between 2015 and 2018 for sublobar resection and lobectomy. In adjusted regression analysis, compared with VATS, patients who underwent RATS had similar complication rates and LOS. The robotic approach was associated with increased total hospital cost. LOS and thoracic complication rates trended down after RATS lobectomy.
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Key Words
- HCUP, Healthcare Cost and Utilization Project
- ICD-10, International Classification of Diseases, 10th Revision
- ICD-10-CM, International Classification of Diseases, 10th Revision, Clinical Modification
- ICD-10-PCS, International Classification of Diseases, 10th Revision Procedure Coding System
- LOS, length of stay
- MIS, minimally invasive surgery
- NIS, National Inpatient Sample
- Q4, fourth quarter
- RATS, robotic-assisted thoracoscopic surgery
- VATS, video-assisted thoracoscopic surgery
- lung cancer
- robotic
- video-assisted thoracoscopic surgery
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Affiliation(s)
- Yahya Alwatari
- Address for reprints: Yahya Alwatari, MD, 1200 E Marshall St, Richmond, VA 23298.
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Fiorelli A, Cascone R, Carlucci A, Natale G, Noro A, Bove M, Santini M. Bleeding during Learning Curve of Thoracoscopic Lobectomy: CUSUM Analysis Results. Thorac Cardiovasc Surg 2022; 71:317-326. [PMID: 35135026 DOI: 10.1055/s-0042-1742362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The management of intraoperative bleeding during thoracoscopic lobectomy is challenging, especially for non-experienced surgeons. We evaluated intraoperative bleeding in relation to learning curve of thoracoscopic lobectomy, the strategies to face it, the outcomes, and the target case number for gaining the technical proficiency. METHODS This was a retrospective single center study including consecutive patients undergoing thoracoscopic lobectomy for lung cancer. Based on cumulative sum analysis, patients were divided into early and late experience groups, and the differences on surgical outcomes, with particular focus on vascular injury, were statistically compared. RESULTS Eight-three patients were evaluated. Cumulative sum charts showed a decreasing of operative time, blood loss, and hospital stay after the 49th, the 43th, and the 39th case, respectively. Early (n = 49) compared with late experience group (n = 34) was associated with higher conversion rate (p = 0.08), longer operative time (p <0.0001), greater blood loss (p <0.0001), higher transfusion rate (p = 0.01), higher postoperative air leak rate (p = 0.02), longer chest tube stay (p <0.0001), and hospitalization (p <0.0001). Six patients (7%) had intraoperative bleeding during early phase of learning curve, successfully treated by thoracoscopy in four cases. Patients with vascular injury (n = 6) compared with control group (n = 77) presented a longer operative time (p = 0.003), greater blood loss (p = 0.0001), and higher transfusion rate (p = 0.001); no significant differences were found regarding postoperative morbidity (p = 0.57), length of chest tube stay (p = 0.07), and hospitalization (p = 0.07). CONCLUSION Technical proficiency was achieved after 50 procedures. All vascular injuries occurred in the early phase of learning curve; they were safely managed, without affecting surgical outcomes.
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Affiliation(s)
- Alfonso Fiorelli
- Thoracic Surgery Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Roberto Cascone
- Thoracic Surgery Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Annalisa Carlucci
- Thoracic Surgery Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Giovanni Natale
- Thoracic Surgery Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Antonio Noro
- Thoracic Surgery Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Mary Bove
- Thoracic Surgery Unit, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Mario Santini
- Thoracic Surgery Unit, University of Campania Luigi Vanvitelli, Naples, Italy
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Park JH, Park S, Kang CH, Na BS, Bae SY, Na KJ, Lee HJ, Park IK, Kim YT. Early Outcomes of Robotic Versus Video-Assisted Thoracoscopic Anatomical Resection for Lung Cancer. J Chest Surg 2022; 55:49-54. [PMID: 35115422 PMCID: PMC8824642 DOI: 10.5090/jcs.21.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/23/2021] [Accepted: 11/26/2021] [Indexed: 11/29/2022] Open
Abstract
Background We compared the safety and effectiveness of robotic anatomical resection and video-assisted thoracoscopic surgery (VATS). Methods A retrospective analysis was conducted of the records of 4,283 patients, in whom an attempt was made to perform minimally invasive anatomical resection for lung cancer at Seoul National University Hospital from January 2011 to July 2020. Of these patients, 138 underwent robotic surgery and 4,145 underwent VATS. Perioperative outcomes were compared after propensity score matching including age, sex, height, weight, pulmonary function, smoking status, performance status, comorbidities, type of resection, combined bronchoplasty/angioplasty, tumor size, clinical T/N category, histology, and neoadjuvant treatment. Results In total, 137 well-balanced pairs were obtained. There were no cases of 30-day mortality in the entire cohort. Conversion to thoracotomy was required more frequently in the VATS group (VATS 6.6% vs. robotic 0.7%, p=0.008). The complete resection rate (VATS 97.8% vs. robotic 98.5%, p=1.000) and postoperative complication rate (VATS 17.5% vs. robotic 19.0%, p=0.874) were not significantly different between the 2 groups. The robotic group showed a slightly shorter hospital stay (VATS 5.8±3.9 days vs. robotic 5.0±3.6 days, p=0.052). N2 nodal upstaging (cN0/pN2) was more common in the robotic group than the VATS group, but without statistical significance (VATS 4% vs. robotic 12%, p=0.077). Conclusion Robotic anatomical resection in lung cancer showed comparable early outcomes when compared to VATS. In particular, robotic resection presented a lower conversion-to-thoracotomy rate. Furthermore, a robotic approach might improve lymph node harvesting in the N2 station.
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Affiliation(s)
- Ji Hyeon Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Samina Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Bub Se Na
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - So Young Bae
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Kwon Joong Na
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun Joo Lee
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - In Kyu Park
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Young Tae Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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