Transitioning from video-assisted thoracic surgical lobectomy to robotics for lung cancer: Are there outcomes advantages?

1000 Robotic-assisted lobectomies for primary lung cancer: 16 years single center experience

OBJECTIVE

This study aimed at describing our high-volume single center experience in robotic-assisted thoracic surgery (RATS) to evaluate short outcome and feasibility of the technique, the adequacy of oncological results, and the learning curve.

METHODS

We retrospectively analyzed data from 1000 consecutive patients who underwent lobectomy and systematic lymphadenectomy for primary lung cancer using RATS approach between May 2007 and May 2023.

RESULTS

Nine-hundred ninety-seven patients (99.7 %) underwent lobectomy, whereas 3 (0.03 %) patients bilobectomy. Conversion rate to open surgery was 3.7 %. Minor complications occurred in 213 (21.3 %) patients, major complications in 29 patients (2.9 %). The 30-day and 90-day operative mortality was 0 % and 0.1 %, respectively. The median number of N1 + N2 stations resected was 5 (range 0-9), with a median number of 17 of N1 + N2 lymph nodes resected (range 0-55). The oncological outcome was evaluated only on the subgroup of patients (n = 895) with non-small cell lung cancer. Pathological lymph node upstaging from cN0 to pN1/pN2 was evident in 147 patients (17.3 %): 9 % from cN0 to pN1 and 7.1 % from cN0 to pN2. With a median follow-up of 3.9, 5-year OS and DFS were respectively 89.3 % and 83.6 % for stage I, 74 % and 66.5 % for stage II, and 61 % and 36.4 % for stage IIIA.

CONCLUSIONS

Better vision and excellent instrument maneuverability of the robotic surgical system allowed excellent results in terms of early, adequate oncological outcome comparable to open surgery literature data, and acceptable learning curve.

ULTRAMINI ABSTRACT

1000 consecutive patients who underwent lobectomy and systematic lymphadenectomy for primary lung cancer using RATS approach have been analyzed with the aim to describe our high-volume single center experience, and to evaluate short outcome and feasibility of the technique, the adequacy of oncological results, and the learning curve.

Comparison of the Learning Curve between Uniportal and Robotic Thoracoscopic Approaches in Pulmonary Segmentectomy during the Implementation Period Using Cumulative Sum Analysis

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.

Long-Term Oncologic Outcomes in Robot-Assisted and Video-Assisted Lobectomies for Non-Small Cell Lung Cancer

This study compares long-term outcomes in patients undergoing video-assisted thoracic surgery (VATS) and robotic-assisted thoracic surgery (RATS) lobectomy for non-small cell lung cancer (NSCLC); all consecutive patients who underwent RATS or VATS lobectomy for NSCLC between July 2015 and December 2021 in our center were enrolled in a single-center prospective study. The primary outcomes were overall survival (OS), disease-free survival (DFS), and recurrence rate. The secondary outcomes were complication rate, length of hospitalization (LOS), duration of chest tubes (LOD), and number of lymph node stations harvested. A total of 619 patients treated with RATS (n = 403) or VATS (n = 216) were included in the study. There was no significant difference in OS between the RATS and VATS groups (3-year OS: 75.9% vs. 82.3%; 5-year OS: 70.5% vs. 68.5%; p = 0.637). There was a statistically significant difference in DFS between the RATS and VATS groups (3-year DFS: 92.4% vs. 81.2%; 5-year DFS: 90.3% vs. 77.6%; p < 0.001). Subgroup analysis according to the pathological stage also demonstrated a significant difference between RATS and VATS groups in DFS in stage I (3-year DFS: 94.4% vs. 88.9%; 5-year DFS: 91.8% vs. 85.2%; p = 0.037) and stage III disease (3-year DFS: 82.4% vs. 51.1%; 5-year DFS: 82.4% vs. 37.7%; p = 0.024). Moreover, in multivariable Cox regression analysis, the surgical approach was significantly associated with DFS, with an HR of 0.46 (95% CI 0.27-0.78, p = 0.004) for RATS compared to VATS. VATS lobectomy was associated with a significantly higher recurrence rate compared to RATS (21.8% vs. 6.2%; p < 0.001). LOS and LOD, as well as complication rate and in-hospital and 30-day mortality, were similar among the groups. RATS lobectomy was associated with a higher number of lymph node stations harvested compared to VATS (7 [IQR:2] vs. 5 [IQR:2]; p < 0.001). In conclusion, in our series, RATS lobectomy for lung cancer led to a significantly higher DFS and significantly lower recurrence rate compared to the VATS approach. RATS may allow more extensive nodal dissection, and this could translate into reduced recurrence.

Robot-assisted thoracic surgery for stages IIB-IVA non-small cell lung cancer: retrospective study of feasibility and outcome

Robot-assisted thoracic surgery (RATS) for higher stages non-small cell lung carcinoma (NSCLC) remains controversial. This study reports the feasibility of RATS in patients with stages IIB-IVA NSCLC. A single-institute, retrospective study was conducted with patients undergoing RATS for stages IIB-IVA NSCLC, from January 2015 until January 2020. Unforeseen N2 disease was excluded. Data were collected from the Dutch Lung Cancer Audit database. Conversion rate, radical (R0) resection rate, local recurrence rate and complications were analyzed, as were risk factors for conversion. RATS was performed in 95 patients with NSCLC clinical or pathological stages IIB (N = 51), IIIA (N = 39), IIIB (N = 2) and IVA (N = 3). 10.5% had received neoadjuvant chemoradiotherapy. Pathological staging was T3 in 33.7% and T4 in 34.7%. RATS was completed in 77.9% with a radical resection rate of 94.8%. Lobectomy was performed in 67.4% of the total resections. Conversion was for strategic (18.9%) and emergency (3.2%) reasons. Pneumonectomy (p = 0.001), squamous cell carcinoma (p < 0.001), additional resection of adjacent structures (p = 0.025) and neoadjuvant chemoradiation (p = 0.017) were independent risk factors for conversion. Major post-operative complications occurred in ten patients (10.5%) including an in-hospital mortality of 2.1% (n = 2). Median recurrence-free survival was estimated at 39.4 months (CI 16.4-62.5). Two- and 5-year recurrence-free survival rates were 53.8% and 36.7%, respectively. This study concludes that RATS is safe and feasible in higher staged NSCLC tumors after exclusion of unforeseen N2 disease. It brings new perspective on the potential of RATS in higher stages, dealing with larger and more invasive tumors.

A real-world experience of transition to robotic-assisted thoracic surgery (RATS) for lung resections

Objective

We report our experience of transition to robotic-assisted thoracic surgery (RATS) for lung resections with the da Vinci Xi surgical system, exposing short-term results.

Materials and methods

This is a single-center, retrospective analysis of RATS lung resections performed between April 2021 and September 2022 during our new robotic program. The surgical approach evolved over time, starting from a four-arm approach with four incisions. Alternative RATS approaches were subsequently evaluated, such as uniportal and biportal.

Results

During a 17-month period, 29 lung resections were performed. Of them, 16 were lobectomies, 7 were segmentectomies, and 6 were wedge resections. The most common indication for anatomical lung resection was non-small cell lung cancer. A uniportal approach was used for two simple segmentectomies and a biportal RATS was performed in five lobectomies and two segmentectomies. A mean number of 8.1 lymph nodes and a mean of 2.6 N2 and 1.9 N1 stations were resected during surgery, and no nodal upstaging was observed. Negative resection margins were 100%. There were two (7%) conversions, one to open surgery and one to video-assisted thoracic surgery (VATS). Eight (28%) patients experienced complications with no 30-day mortality.

Discussion

High-ergonomic and high-quality views were immediately observed. After some procedures, we abandoned uniportal RATS because of the possibility of arm collisions and the necessity of a VATS-skilled surgeon at the operating table.

Conclusion

RATS for lung resections was safe and effective, and from the surgeon's standpoint, several practical advantages over VATS were observed. Further analysis on outcomes will help better understand the value of this technology.

The Influence of Preoperative Nutritional and Systemic Inflammatory Status on Perioperative Outcomes following Da Vinci Robot-Assisted Thoracic Lung Cancer Surgery

Background: Nutrition is an important factor in the outcome of any disease process. We evaluated the relationship of nutritional status and inflammatory status of non-small cell lung cancer (NSCLC) patients undergoing robotic-assisted thoracic surgery (RATS) with postoperative complications. Methods: This prospective cohort study included 107 NSCLC patients undergoing surgical treatment, between 2019 and 2021. Nutritional status and inflammatory status were assessed before pulmonary resection using anthropometric assessment, blood tests, and body mass index (BMI). Results: The BMI was 27.5 ± 4.4. Based on BMI, 29% (n = 31) were classified as normal weight, 43% (n = 46) as overweight, and 28% (n = 30) as obese. The mean neutrophil/lymphocyte ratio (NLR) was 2.16 ± 0.85, the platelet/lymphocyte ratio (PLR) was 121.59 ± 44.21, and the lymphocyte/monocyte ratio (LMR) was 3.52 ± 1.17. There was no increase in the number of intraoperative complications or bleeding (p = 0.696), postoperative complications (p = 0.569), mean hospital stay (p = 0.258) or duration of chest drain (p = 0.369). Higher inflammatory status, with an NLR > 1.84, was associated with more overall postoperative complications (p = 0.028), only in univariate analysis, but this significance was not maintained on multivariate analysis. Conclusions: BMI was not a predictor of increased postoperative risk in this cohort; therefore, weight should not deter surgeons from using RATS for pulmonary resection.

Setting a quality indicator for actual surgery time relative to scheduled surgery time in the context of increasing robotic-assisted thoracic surgery cases

OBJECTIVE

This study aimed to demonstrate to the involved departments the goal of increasing the number of robotic-assisted thoracic surgery (RATS) cases/surgeons and acceptable surgery times.

METHODS

This retrospective study included 1572 patients who underwent thoracic surgery from fiscal year (FY) 2018 to FY 2021. The factors evaluated included the number of surgery cases and actual and scheduled surgery times.

RESULTS

The total number of RATS and total surgery cases increased after the quality indicator (QI) setting (n = 363, 360, 417, and 432 in FY 2018, 2019, 2020, and 2021, respectively). In FY 2020, 93.3% of the QI target was achieved, while in FY 2021, 88% was achieved. The number of RATS lobectomy/segmentectomy increased as the FY progressed (n = 31, 47, 58, and 116 in FY 2018, 2019, 2020, and 2021, respectively). The mean surgical time by RATS starters decreased in FY 2020 and 2021 (171.4 min.; 74 cases; seven RATS starters) compared with those in FY 2018 and 2019 (198.0 min.; 57 cases; six RATS starters) (P = 0.002).

CONCLUSIONS

The goal of increasing the number of surgery cases and RATS cases/surgeons within the given framework was achieved by setting the QI.

Similar outcomes after newly implemented rats approach compared to standard vats for anatomical lung resection. A propensity-score matched analysis

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.

Training Cardiothoracic Residents in Robotic Lobectomy Is Cost-Effective With No Change in Clinical Outcomes

Objective: Our objective was to evaluate for any changes in quality or cost when robotic lung resection is used with significant trainee participation. Methods: All anatomic lung resections between January 2006 and June 2016 were identified from a prospectively maintained database. Clinical data were recorded by double entry. Cost and cancer-related data were gathered from the business analytics department and tumor registry. Robotic outcomes were compared to an ongoing thoracotomy and video-assisted thoracic surgery (VATS) experience. Propensity scores using age, sex, and comorbidities were assigned for statistical analysis. Survival was evaluated using the Kaplan-Meier method. Results: Of 523 consecutive cases, 483 were included (211 robotic, 210 thoracotomy, 62 VATS). There were 74 robotic cases (35%) performed by trainees as the console surgeon. Length of stay was shortest for robotics (3 days) compared to thoracotomy (7 days, P < 0.001) and VATS (5 days, P = 0.010). Complications occurred in 33% of robotic cases, 42% of VATS cases (P = 0.854), and 52% of thoracotomy cases (P < 0.001). Stage I non-small cell lung cancer 3-year overall survival for robotics, thoracotomy, and VATS was 79.5%, 74.3%, and 74.0%, respectively (P > 0.25). There was no significant difference in negative margin rates. Total cost related to the hospitalization for surgery was $5,721 less for robotics compared to thoracotomy (P = 0.003) but comparable to VATS. Trainees served as console surgeon in 0% of cases in the first 2 years of robotics but increased to 79% in the last year of the study. Conclusions: Robotic lung resection can be safely performed and taught in an academic medical center without sacrificing quality or cost.

Comparison of the long-term oncologic outcomes of robotic-assisted and video-assisted thoracoscopic lobectomy for resectable non-small cell lung carcinoma

The current oncologic outcomes of robotic-assisted lobectomy compared to video-assisted thoracoscopic lobectomy are currently not well defined. This study compares the overall survival and recurrence-free survival rates between the two approaches for patients with resectable non-small cell lung carcinoma. This is a retrospective review of 200 patients diagnosed with resectable primary lung carcinoma who underwent minimally invasive lobectomy from March 2014 to May 2018. A total of 100 patients underwent thoracoscopic lobectomy and 100 patients underwent robotic-assisted lobectomy by a single surgeon. The data collected included patient demographics, tumor characteristics, surgical margin status, total number of lymph nodes harvested, lymph node upstaging rate, and overall survival and recurrence-free survival. The patients in each group were similar in age, gender, smoking status, pulmonary function, tumor histology, and pathologic stage. The postoperative mortality and complication rates were similar as well. The median number of total lymph nodes and N2 lymph nodes were significantly higher in the robotic lobectomy group (p < 0.0001). The Kaplan-Meier survival rates of overall survival (p = 0.097) and recurrence-free survival (p = 0.769) were similar between the two surgical approaches. The results of this report suggest that thoracoscopic and robotic-assisted lobectomy have similar long-term oncologic outcomes. There may be an advantage for robotic-assisted lobectomy in the total number of lymph nodes harvested during lobectomy.

Robotic-assisted lobectomy for malignant lung tumors

Objectives:

For patients with lung cancer, surgical resection remains the best curative option and is associated with the longest disease-free survival. We present our institutional outcomes treating pulmonary malignancy with robotic lobectomy over the course of 1 year.

Methods:

A retrospective review was conducted on patients who underwent robotic pulmonary lobectomy for malignancy at a single institution in 2018.

Results:

Over the course of 1 year, 166 patients underwent robotic lobectomy for pulmonary neoplasm. The mean age of the patients was 75 years; 73% were current or prior smokers and 52% of the patients were male. The mean body mass index was 28 kg/m². Conversion to open thoracotomy occurred in 7% of patients. The mean total hospital length of stay (LOS) was 3 days. Histopathological examination revealed a mean tumour size of 2.7 cm with 11 lymph nodes harvested. Left-sided tumours had a significantly higher number of lymph nodes harvested when compared to right-sided tumours (11.6 vs. 9.8, P = 0.01), despite sampling the recommended minimum of three N2 stations. The most common pathology was adenocarcinoma (65%), followed by squamous cell carcinoma (17%) The 30-day operative mortality was 0.6%.

Conclusions:

Robotic video-assisted thoracoscopic surgery is a safe, feasible and oncologically adequate procedure for lung malignancies. Comparison of our outcomes to previously reported national averages suggests a similar hospital LOS, lymph node harvest, conversion rate to open thoracotomy and 30-day mortality rate. We acknowledge the limitations of this non-randomised, retrospective study. Future research on robotic lobectomies is encouraged.

Training residents in robotic thoracic surgery

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.

The robotic surgery learning curve of a surgeon experienced in video-assisted thoracoscopic surgery compared with his own video-assisted thoracoscopic surgery learning curve for anatomical lung resections

OBJECTIVES

Robotic surgery, although it shares some technical features with video-assisted thoracoscopic surgery (VATS), offers some advantages, such as ergonomic design and a 3-dimensional view. Thus, the learning curve for robotic lung resection could be expected to be shorter than that of VATS for surgeons who are proficient in VATS. The goal of this study was to analyse the robotic learning curve of a VATS experienced surgeon and to compare it to his own VATS learning curve for anatomical lung resections.

METHODS

We conducted a retrospective observational study based on the prospectively recorded data of the first 150 anatomical lung resections performed with VATS (75 cases) and with the robotic (75 cases) approach by the same surgeon in our centre. Learning curves were analysed using the cumulative sum method to assess the trends for total operating time and surgical failure (intraoperative complications, conversion, technical postoperative complications and reintervention) across case sequences. Subsequently, using adequate statistical tests, we compared the postoperative outcomes in both groups.

RESULTS

The median operating time was similar for both approaches (P = 0.401). Surgical failure rate was higher for the robotic cases (21.3% vs 12%; P = 0.125). Based on cumulative sum analyses, operating time decreased starting with case 34 in the VATS group and with case 32 in the robotic cohort. Surgical failure tended to decline starting with case 28 in the VATS group and with case 32 in the robotic group. Perioperative results were similar in both groups.

CONCLUSIONS

When we compared robotic and VATS learning curves for anatomical lung resection, we did not find any differences. Postoperative outcomes were also similar with both approaches.

Robotic lobectomy: how to teach thoracic residents

Robotic thoracic surgery emerged at the beginning of the 21st century and keep presenting the continuous development of its robotic systems, tools, and associated techniques. Strong clinical results including safety and oncological outcomes have fostered the dissemination of the robotic platform all over the world. However, there are still some safety concerns, especially regarding more elaborated procedures as lung resections, during the learning curve. In consequence, training programs for surgeons and surgery residents have been proposed to put into operation a strong and complete curriculum for robotic surgery and increase safety during the learning process. Also, the implementation of the training program makes the process complete and efficient. Lung lobectomies are complex procedures especially because of pulmonary arteries and pulmonary veins dissection, which demands quite accurate skills. Consequently, it is believed that specific training of thoracic surgery residents in robotic lobectomy is capital. The ideal curriculum must include technical content and broad psychomotor training using virtual reality models and also physical and animal models. Valid evaluation methods can be used from the first skill training to daily clinical practice. At the beginning as a console surgeon, the resident must initiate gradually with small procedures and progress to more complex surgeries before performing the whole lobectomy.

Similar outcomes after newly implemented rats approach compared to standard vats for anatomical lung resection. A propensity-score matched analysis

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.

Long-term and short-term outcomes of robot- versus video-assisted anatomic lung resection in lung cancer: a systematic review and meta-analysis

OBJECTIVES

Minimally invasive thoracic surgery has evolved with the introduction of robotic platforms. This study aimed to compare the long-term and short-term outcomes of the robot-assisted thoracic surgery (RATS) and video-assisted thoracic surgery (VATS) for anatomic lung resection.

METHODS

We searched published studies that investigated RATS and VATS in anatomic lung resection. Long-term outcomes (disease-free survival and overall survival) and short-term outcomes (30-day mortality, postoperative complications, conversion rate to open surgery and lymph node upstaging) were extracted. The features were compared and tested as hazard ratios (HRs) and odds ratios (ORs) at a 95% confidence interval (CI).

RESULTS

Twenty-five studies with 50 404 patients (7135 for RATS and 43 269 for VATS) were included. The RATS group had a longer disease-free survival than the VATS group (HR: 0.76; 95% CI: 0.59-0.97; P = 0.03), and the overall survival showed a similar trend but was not statistically significant (HR: 0.77; 95% CI: 0.57-1.05; P = 0.10). The RATS group showed a significantly lower 30-day mortality (OR: 0.55; 95% CI: 0.38-0.81; P = 0.002). No significant difference was found in postoperative complications (OR: 1.01; 95% CI: 0.87-1.16; P = 0.94), the conversion rate to open surgery (OR: 0.92; 95% CI: 0.56-1.52; P = 0.75) and lymph node upstaging (OR: 0.89; 95% CI: 0.52-1.54; P = 0.68).

CONCLUSIONS

RATS has comparable short-term outcomes and potential long-term survival benefits for anatomic lung resection compared with VATS.

Learning curve in robotic-assisted lobectomy for non-small cell lung cancer is not steep after experience in video-assisted lobectomy; single-surgeon experience using cumulative sum analysis

BACKGROUND

Robotic assistance in lung lobectomy has been suggested to enhance the adoption of minimally invasive techniques among surgeons. However, little is known of learning curves in different minimally invasive techniques. We studied learning curves in robotic-assisted versus video- assisted lobectomies for lung cancer.

METHODS

A single surgeon performed his first 75 video-assisted thoracic surgery (VATS) lobectomies from April 2007 to November 2012, and his 75 first robotic-assisted thoracic surgery (RATS) lobectomies between August 2011 and May 2018. A retrospective chart review was done. Cumulative sum (CUSUM) analysis was used to identify the learning curve.

RESULTS

No operative deaths occurred for VATS patients or RATS patients. Conversion-to-open rate was significantly lower in the RATS group (2.7% vs. 13.3%, p = 0.016). Meanwhile, 90-day mortality (1.3% vs. 5.3%, p = 0.172), postoperative complications (24% vs. 24%, p = 0.999), re- operation rates (4% vs. 5.3%, p = 0.688), operation time (170±56 min vs. 178±66 min, p = 0.663) and length of stay (8.9 ± 7.9 days vs. 8.2 ± 5.8 days, p = 0.844) were similar between the two groups. Based on CUSUM analysis, learning curves were similar for both procedures, although slightly shorter for RATS (proficiency obtained with 53 VATS cases vs. 45 RATS cases, p = 0.198).

CONCLUSIONS

Robotic-assisted thoracoscopic lung lobectomy can be implemented safely and efficiently in an expert center with earlier experience in VATS lobectomies. However, there seems to be a learning curve of its own despite the surgeon's previous experience in conventional thoracoscopic surgery.

Introduction of robotic surgery leads to increased rate of segmentectomy in patients with lung cancer

Background

Pulmonary segmentectomy provides an anatomic lung resection while avoiding removal of excess normal lung tissue. This may be beneficial in patients with minimal pulmonary reserve who present with early-stage non-small cell lung cancer (NSCLC). However, the operative performance of a segmentectomy using a video-assisted thoracoscopic approach can be technically challenging. We hypothesized that introduction of the robotic surgical system would facilitate the performance of a segmentectomy as measured by an increase in the proportion of segmentectomies being pursued.

Methods

We completed a retrospective analysis of thoracoscopic and robotic anatomic lung resections, including lobectomies and segmentectomies, performed in patients with primary lung cancer from the time of initiation of the robotic thoracic surgery program in November 2017 to November 2019. We compared the proportion of thoracoscopic and robotic segmentectomies performed during the first year compared to the second year of the data collection period.

Results

A total of 138 thoracoscopic and robotic anatomic lung resections were performed for primary lung cancer. Types of lung cancer resected (adenocarcinoma, squamous cell carcinoma, or other), tumor size based on clinical T staging (T1–T4), and tumor location were not significantly different between years (P=0.44, P=0.98, and P=0.26, respectively). The proportion of segmentectomies increased from 8.6% during the first year to 25.0% during the second year (P=0.01). One out of 6 (16.7%) segmentectomies were performed using the robot during the first year versus 15 out of 17 (88.2%) during the second year (P=0.003).

Conclusions

Use of the robot led to a significant increase in the number of segmentectomies performed in patients undergoing anatomic lung resection. With increasing lung cancer awareness and widely available screening, a greater number of small, early-stage tumors suitable for segmentectomy will likely be detected. We conclude that robotic-assisted surgery may facilitate the challenges of performing a minimally invasive segmentectomy.

Video-assisted thoracoscopy for lung cancer: who is the future of thoracic surgery?

As the computer processing technique and display technology evolved dramatically, the surgical approach to early-stage non-small cell lung cancer (NSCLC) has made a rapid progress within the past few years. Currently, the gold standard for NSCLC is lobectomy. After the introduction of video-assisted thoracoscopic surgery (VATS), lung resection can now be conducted mini-invasively, enabling better prognosis for patients and better operation condition for surgeons. At the very beginning, the conventional two-dimensional (2D) system enabled operators to have a closer, magnified and illuminated view inside the body cavity than open thoracotomy. With the introduction of the glasses-assisted three-dimensional (3D) and glasses-free 3D display system, multiple viewing angles were further enhanced, thus a more stable, easier to master and less invasive video-assisted thoracoscopic surgery (VATS) appeared. However, given that the standard VATS is associated with limited maneuverability and stereoscopy, it restricts the availability in more advanced cases. Hopefully, most of the limitations of standard VATS can be overcome with the robotic-assisted thoracic surgery (RATS). The RATS system consists of a remote console and a robotic unit with 3 or 4 arms that can duplicate surgeons’ movements. Also, it provides a magnified, 3D and high definition (HD) operation field to surgeons, allowing them to perform more complicated procedures. Apart from these, some new technologies are also invented in combination with the existing surgery system to solve difficult problems. It is hoped that the higher costs of innovative surgical technique can be offset by the better patient outcomes and improved benefits in cost-effectiveness.

Switching from Thoracoscopic to Robotic Platform for Lobectomy: Report of Learning Curve and Outcome

OBJECTIVE

The optimal minimally invasive surgical management for patients with non-small-cell lung cancer (NSCLC) is unclear. For experienced video-assisted thoracoscopic surgery (VATS) surgeons, the increased costs and learning curve are strong barriers for adoption of robotics. We examined the learning curve and outcome of an experienced VATS lobectomy surgeon switching to a robotic platform.

METHODS

We conducted a retrospective review to identify patients who underwent a robotic or VATS lobectomy for NSCLC from 2016 to 2018. Analysis of patient demographics, perioperative data, pathological upstaging rates, and robotic approach (RA) learning curve was performed.

RESULTS

This study evaluated 167 lobectomies in total, 118 by RA and 49 by VATS. Patient and tumor characteristics were similar. RA had significantly more lymph node harvested (14 versus 10; P = 0.004), more nodal stations sampled (5 versus 4; P < 0.001), and more N1 nodes (8 versus 6; P = 0.010) and N2 nodes (6 versus 4; P = 0.017) resected. With RA, 22 patients were upstaged (18.6%) compared to 5 patients (10.2%) with VATS (P = 0.26). No differences were found in perioperative outcome. Operative time decreased significantly with a learning curve of 20 cases, along with a steady increase in lymph node yield.

CONCLUSIONS

RA can be adopted safely by experienced VATS surgeons. Learning curve is 20 cases, with RA resulting in superior lymph node clearance compared to VATS. The potential improvement in upstaging and oncologic resection for NSCLC may justify the associated investments of robotics even for experienced VATS surgeons.

Efficacy and Safety of Robot-assisted Thoracic Surgery (RATS) Compare with Video-assisted Thoracoscopic Surgery (VATS) for Lung Lobectomy in Patients with Non-small Cell Lung Cancer

BACKGROUND

In the past decade, many researchers focused on Robotic- Assisted Thoracoscopic Surgery (RATS), which has been introduced as an alternative minimally invasive approach, versus Video- Assisted Thoracoscopic Surgery (VATS) for lung lobectomy in patients with non-small cell lung cancer. However, the advantage of RVATS compared to VATS is still under investigation. The results are unclear.

AIM

The aim of this study is to compare the efficacy and safety of Robot-assisted Thoracic Surgery (RATS) lobectomy versus Video-assisted Thoracic Surgery (VATS) for lobectomy in patients with Non- Small Cell Lung Cancer (NSCLC).

METHODS

A systematic electronic search of online electronic databases: Pubmed, Embase, Cochrane library updated in June 2017. The meta-analysis was performed including the studies are designed as randomized or non- randomized controlled.

RESULTS

Twenty retrospective cohort studies met our inclusion criteria. The pooled analysis of mortality showed that RATS lobectomy significantly reduced the mortality rate when compared with VATS lobectomy (RR =0.53, 95% CI 0.37 - 0.76; P = 0.0005). With the pooled result of duration of surgery indicated that RATS has a tendency towards longer surgery time (SMD= 0.52, 95% CI 0.23- 0.81; P < 0.0004=). However, the meta-analysis on the median length of hospital stay (MD =0.00, 95% CI -0.03 - 0.03; P = 0.91), number of dissected lymph nodes station (SMD =0.39, 95% CI -0.60 - 1.38; P = 0.44), the number of removed lymph nodes (SMD =0.98, 95% CI -0.61 - 2.56; P = 0.23), mean duration of drainage (SMD =0.29, 95% CI -0.15 - 0.73; P = 0.20), prolonged air leak (RR =1.01, 95% CI 0.84 - 1.21; P = 0.93), arrhythmia (RR =1.06, 95% CI 0.88 - 1.26; P = 0.54) (P= 0.54), pneumonia (RR =0.89, 95% CI 0.69 - 1.13; P = 0.33), the incidence of conversion (RR =0.82, 95% CI 0.54 - 1.26; P = 0.37) and morbidity (RR =1.05, 95% CI 0.90 - 1.23; P = 0.055) all showed no significant differences between RATS and VATS lobectomy.

CONCLUSIONS

RATS result in better mortality as compared with VATS. However, robotics seems to have longer operative time and higher hospital costs, without superior advantages in morbidity rates and oncologic efficiency. Since the advantages of RATS has been performed in some area, the continuation of a comparative investigation with VATS may be necessary. And some efforts need to be taken into consideration to reduce the operative time and cost.

Comparison of robotic-assisted lobectomy with video-assisted thoracic surgery for stage IIB-IIIA non-small cell lung cancer

Background

With the rapid development of surgical technics and instruments, more and more locally advanced non-small cell lung cancer (NSCLC) patients are being treated by minimally invasive surgery (MIS), including video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS). The aim of this retrospective study was to compare the perioperative and long-term outcomes of patients who underwent lobectomy by these two surgical approaches.

Methods

We performed a retrospective review of the prospectively collected database of our hospital to identify patients with clinical stage IIB-IIIA NSCLC who underwent video-assisted thoracoscopic or robotic lobectomy. Perioperative outcomes, recurrence, and overall survival (OS) were compared.

Results

From January 2014 to January 2017, there were at total of 121 patients, including 36 robotic lobectomy patients and 85 VATS lobectomy patients. One patient (2.8%) in the RATS group and 5 patients (5.9%) in the VATS group were converted to thoracotomy (P=0.79). No perioperative death was observed in both groups. The postoperative morbidity was similar between the two groups (13.9% for RATS vs. 15.3% for VATS; P=0.84). Robotic lobectomy was associated with a shorter length of postoperative hospital stay (4 vs. 5 d, P<0.01) and more counts of lymph nodes harvested (13 vs. 10, P<0.01). The median disease-free survival (DFS) for the RATS and VATS groups were 31.1 and 33.8 months, respectively. The corresponding 3-year DFS was 40.3% in the RATS group and 47.6% in the VATS group (P=0.74). The 3-year OS was 75.7% in RATS and 77.0% in the VATS group (P=0.75).

Conclusions

For selected NSCLC patients with lymph node involvement, robotic lobectomy is safe and effective with a low complication rate and similar long-term outcome compared with VATS lobectomy. Moreover, the robotic approach resulted in shorter postoperative length of stay and greater lymph node assessment.

Postoperative outcomes of robotic-assisted lobectomy in obese patients with non-small-cell lung cancer

OBJECTIVES

The aim of this study was to assess the postoperative outcomes of robotic-assisted lobectomy in obese patients to determine the impact of the robotic approach on a high-risk population who were candidates for major pulmonary resection for non-small-cell lung cancer (NSCLC).

METHODS

Between January 2007 and August 2018, we retrospectively reviewed the medical records of 224 obese patients (body mass index ≥ 30) who underwent pulmonary lobectomy at our institution via robotic-assisted thoracic surgery (RATS, n = 51) or lateral muscle-sparing thoracotomy (n = 173).

RESULTS

Forty-two patients were individually matched with those who had the same pathological tumour stage and similar comorbidities and presurgical treatment. The median operative time was significantly longer in the RATS group compared to that in the thoracotomy group (200 vs 158 min; P = 0.003), whereas the length of stay was significantly better for the RATS group (5 vs 6 days; P = 0.047). Postoperative complications were significantly more frequent after open lobectomy than in the RATS group (42.9% vs 16.7%; P = 0.027). After a median follow-up of 4.4 years, the 5-year overall survival rate was 67.6% [95% confidence interval (CI) 45.7–82.2] for the RATS group, and 66.1% (95% CI 46.8–79.9) for the open surgery group (log-rank P = 0.54). The 5-year cumulative incidence of cancer-related deaths was 24.8% (95% CI 9.7–43.5) for the RATS group and 23.6% (95% CI 10.8–39.2) for the open surgery group (Gray’s test, P = 0.69).

CONCLUSIONS

RATS is feasible and safe for obese patients with NSCLC with advantages compared to open surgery in terms of early postoperative outcomes. In addition, the long-term survival rate was comparable to that of the open approach.

Robotic Versus Video-assisted Lobectomy/Segmentectomy for Lung Cancer: A Meta-analysis

: Objective: To compare the safety/efficacy of the robotic-assisted lobectomy/segmentectomy (RAL/S) with the video-assisted lobectomy/segmentectomy (VAL/S) for radical lung cancer resection.

BACKGROUND

It remains uncertain whether the newly developed RAL/S is comparable with the VAL/S.

METHODS

A comprehensive search of online databases was performed. Perioperative outcomes were synthesized. Cumulative meta-analysis was performed to evaluate the temporal trend of pooled outcomes. Specific subgroups (propensity score matching studies, pure lobectomy studies) were examined.

RESULTS

Analysis of 14 studies including a total of 7438 patients was performed. RAL/S was performed on 3239 patients, whereas the other 4199 patients underwent VAL/S. The 30-day mortality [0.7% vs 1.1%; odds ratio (OR) 0.53, P = 0.045] and conversion rate to open surgery (10.3% vs 11.9%; OR 0.57, P < 0.001) were significantly lower in patients who underwent RAL/S than VAL/S. Meanwhile, the postoperative complications (27.5% vs 28.2%; OR 0.95, P = 0.431), operation time [176.63 vs 162.74 min; standardized mean difference (SMD) 0.30, P = 0.086], duration of hospitalization (4.90 vs 5.23 days; SMD -0.08, P = 0.292), days to tube removal (4.10 vs 3.53 days; SMD 0.25, P = 0.120), retrieved lymph node (11.96 vs 10.67; SMD 0.46, P = 0.381), and retrieved lymph node station (4.98 vs 4.32; SMD 0.83, P = 0.261) were similar between the 2 groups. The cumulative meta-analyses suggested that the relative effects between 2 groups have already stabilized. All outcomes of subgroup and overall analyses were similar.

CONCLUSIONS

This up-to-date meta-analysis confirms that RAL/S is a feasible and safe alternative to VAL/S for radical resection of lung cancer. Future studies should focus on the long-term benefits and cost effectiveness of RAL/S compared with VAL/S.

Compare the prognosis of Da Vinci robot-assisted thoracic surgery (RATS) with video-assisted thoracic surgery (VATS) for non-small cell lung cancer: A Meta-analysis

To determine if there are advantages to transitioning to Da Vinci robotics by a surgeon compared to the video-assisted thoracic surgical lobectomy.A systematic electronic search of online electronic databases: PubMed, Embase, and Cochrane library updated on December 2017. Publications on comparison Da Vinci-robot-assisted thoracic surgery (RATS) and video-assisted thoracic surgery (VATS) for non-small cell lung cancer were collected. Meta-analysis RevMan 5.3 software (The Cochrane collaboration, Oxford, UK) was used to analyze the combined pooled HRs using fixed or random-effects models according to the heterogeneity.Fourteen retrospective cohort studies were included. No statistical difference was found between the 2 groups with respect to conversion to open, dissected lymph nodes number, hospitalization time after surgery, duration of surgery, drainage volume after surgery, prolonged air leak, and morbidity (P > .05).Da Vinci-RATS lobectomy is a feasible and safe technique and can achieve an equivalent surgical efficacy when compared with VATS. There does not seem to be a significant advantage for an established VATS lobectomy surgeon to transition to robotics based on clinical outcomes.

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.

Successful Transition to Robotic-Assisted Lobectomy With Previous Proficiency in Thoracoscopic Lobectomy

OBJECTIVE

The learning curve and the advantages of transitioning to robotic-assisted lobectomy by a surgeon who is proficient in thoracoscopic lobectomy is currently unknown. The cost of robotic lobectomy has been reported to be higher than thoracoscopic lobectomy and there is no significant decrease in hospital length of stay.

METHODS

This is a retrospective review of 228 patients diagnosed with lung carcinoma who underwent minimally invasive lobectomy from March 2014 to May 2018. A total of 114 patients underwent thoracoscopic lobectomy and 114 patients underwent robotic-assisted lobectomy. The data collected included patient demographics, tumor characteristics, morbidity, mortality, operative times, and hospital length of stay.

RESULTS

A total of 114 patients underwent thoracoscopic lobectomy and 114 patients underwent robotic-assisted lobectomy. The patients in each group were similar in age, gender, smoking status, FEV-1, tumor histology, and pathologic stage. The mortality and complication rates were similar. The mean number of total lymph nodes and N2 lymph nodes were significantly higher in the robotic lobectomy group (P < 0.0001). The mean operative time was shorter in the robotic group. The median hospital length of stay (4 days) was similar between the 2 groups (P = 0.99).

CONCLUSION

The results of this report suggest that thoracoscopic and robotic-assisted lobectomy have similar outcomes when a surgeon proficient in the thoracoscopic technique completely transitions to the robotic-assisted technique. The learning curve was relatively accelerated in this single-surgeon experience. There may be an advantage for robotic-assisted lobectomy in the total number of lymph nodes harvested.

Four-arm robotic lung resection versus muscle-sparing mini-thoracotomy: retrospective experience

Background

Robotic surgery was introduced in the early 2000s but its use remains limited, particularly in thoracic surgery. Here we compare the first consecutive 185 four-arm robotic procedures carried out in our institution vs. muscle-sparing video-assisted mini-thoracotomy (MSMT), our previous minimally invasive approach for anatomical lung resection.

Methods

One hundred and eighty-five consecutive patients undergoing surgery using the four-arm robotic technique between February 2014 and December 2016 were compared to a control historical series of 136 consecutive patients undergoing surgery by MSMT in the same institution. The same senior surgeon performed all surgical procedures. Comparisons between the two groups were performed using the Chi² test for qualitative data and the Wilcoxon, Mann-Whitney or Student's t-test for quantitative data.

Results

The demographic and clinical characteristics of the patients were similar in the two groups. In the robotic group, median (min-max) length of hospital stay (LOS) was significantly shorter (by 2 days) than in the MSMT group {7 days [3-63] vs. 9 days [5-63], respectively; P<0.0001}. The rate of complications was similar in the two groups, but the complications appeared to be less severe in patients undergoing robotic surgery (switch from Clavien-Dindo grade III and IV to grade II) although further studies are required to confirm this due to the large number of missing data.

Conclusions

In a senior thoracic surgery practice, the switch from a minimally invasive technique to robotic surgery was safe and beneficial in patients undergoing anatomical lung resection in terms of LOS and possible complication severity.

Postoperative pain after lobectomy: robot-assisted, video-assisted and open thoracic surgery

Surgical resection is the optimal procedure for early stage non-small cell lung cancer (NSCLC). Open thoracotomy, video-assisted thoracic surgery (VATS) and robot-assisted thoracic surgery (RATS) are different surgical modalities with possible different outcomes. The aim of this study was to analyze differences in outcome with a focus on postoperative pain. Patients undergoing lobectomy at the Maasstad Hospital in 2015 and 2016 were included. Postoperative pain was scored according to the Numerical Rating Scale (NRS). Additionally, duration of chest tube drainage and thoracic epidural analgesia (TEA), hospital length of stay and type of surgery were assessed. Lobectomy was performed in 57 patients. There was no significant difference in type of surgery, age, gender, right-sided surgery, postoperative NRS scores, duration of chest tube drainage and epidural anesthesia, and hospital length of stay (p > 0.05). Operative time for RATS was significantly longer (p = 0.002). Postoperative pain scores and other outcomes did not differ between the three different modalities in surgery for NSCLC. In the future, more minimally invasive surgery will be used in pulmonary surgery with thoracotomy as a safe alternative in selected cases. Future studies have to demonstrate if RATS will overcome the differences concerning cost-effectiveness over VATS.

Learning Curve of Robotic Lobectomy for Early-Stage Non-Small Cell Lung Cancer by a Thoracic Surgeon Adept in Open Lobectomy

OBJECTIVE

The aim of the study was to characterize the clinical outcomes and learning curve during the adoption of a robotic platform for lobectomy for early-stage non-small cell lung cancer by a thoracic surgeon experienced in open thoracotomy.

METHODS

Retrospective review of 157 consecutive patients (57 open thoracotomies, 100 robotic lobectomies) treated with lobectomy for clinical stage I or II non-small cell lung cancer between 2007 and 2014. Clinical outcomes were compared between the open thoracotomy group and five consecutive groups of 20 robotic lobectomies. We used the following six metrics to evaluate learning curve: operative time, conversion to open, estimated blood loss, hospitalization duration, overall morbidity, and pathologic nodal upstaging.

RESULTS

The robotic and open thoracotomy groups had equivalent preoperative characteristics, except for a higher proportion of clinical stage IA patients in the robotic cohort. The robotic group, as a whole, had lower intraoperative blood loss, less overall morbidity, shorter chest tube duration, and shorter length of hospital stay as compared with the open thoracotomy group. Operative time demonstrated a bimodal learning curve. Conversion rate diminished from 22.5% in the first two robotic groups to 6.7% in the latter three groups. The rate of pathologic nodal upstaging was statistically equivalent to the open thoracotomy group.

CONCLUSIONS

Adoption of a robotic platform for lobectomy for early-stage non-small cell lung cancer by an experienced open thoracic surgeon is safe and feasible, with fewer complications, less blood loss, and equivalent nodal sampling rate even during the learning curve. The conversion to open rate significantly dropped after the first 40 robotic lobectomies, and operative time for robotic lobectomy approached open thoracotomy after 60 cases, after a bimodal curve.

Robotic thoracic surgery: a support team to replace the bedside surgeon

Establishing a new robotics program presents a unique set of challenges that differ from routine operative procedures. These include training robotic staff, operating room logistics, and surgeon training. As the surgeon moves away from the patient bedside, the responsibilities of the bedside team and circulating staff must increase to fill that void. Therefore, a critical element of robotic thoracic surgery is the training of the robotic team to facilitate fluid movement of the patient through the surgical process. We report our process in establishing a thoracic robotics program with an emphasis on the training personnel.

Robotic-Assisted Versus Thoracoscopic Lobectomy Outcomes From High-Volume Thoracic Surgeons

BACKGROUND

Reports of surgical outcomes comparing proficient surgeons who perform either robotic-assisted or video-assisted thoracoscopic lobectomy are lacking. We evaluate the comparative effectiveness of robotic-assisted and video-assisted thoracoscopic lobectomies by surgeons who performed 20 or more annual surgical procedures in a national database.

METHODS

Patients 18 years or older, who underwent elective lobectomy by surgeons who performed 20 or more annual lobectomies by robotic-assisted or thoracoscopic approach from January 2011 through September 2015, were identified in the Premier Healthcare database with the use of codes from the ninth revision of the International Statistical Classification of Diseases and Related Health Problems. Propensity-score matching based on patient and hospital characteristics and by year was performed 1:1 to identify comparable cohorts for analysis (n = 838 in each cohort). All tests were two-sided, with statistical significance set at p less than 0.05.

RESULTS

A total of 23,779 patients received an elective lobectomy during the study period: 9,360 were performed by video-assisted thoracoscopic approach and 2,994 were by robotic-assisted approach. Propensity-matched comparison of lobectomies performed by surgeons who performed 20 or more procedures annually (n = 838) showed that robotic-assisted procedures had a longer mean operative time by 25 minutes (mean 247.1 minutes vs 222.6 minutes, p < 0.0001) but had a lower conversion-to-open rate (4.8% vs 8.0%, p = 0.007) and a lower 30-day complication rate (33.4% vs 39.2%, p = 0.0128). Transfusion rates and 30-day mortality rates were similar between the two cohorts.

CONCLUSIONS

When surgical outcomes are limited to surgeons who perform 20 or more annual procedures, the robotic-assisted approach is associated with a lower conversion-to-open rate and lower 30-day complication rate when than video-assisted thoracoscopic surgeons, with a mean operative time difference of 25 minutes.

Anaesthetic issues in robotic-assisted minimally invasive surgery

Over the past decade there has been an exponential increase in the number of robotic-assisted surgical procedures performed in Australia and internationally. Despite this growth, there are no level I or II studies examining the anaesthetic implications of these procedures. Available observational studies provide insight into the significant challenges for the anaesthetist. Most anaesthetic considerations overlap with those of non-robotic surgery. However, issues with limited patient access and extremes of positioning resulting in physiological disturbances and risk of injury are consistently demonstrated concerns specific to robotic-assisted procedures.

Training in robotic thoracic surgery

The best way to teach robotic thoracic surgery is still being decided. New trainees, experienced video-assisted thoracoscopic surgery (VATS) surgeons, and predominantly open surgeons each have different needs when it comes to learning robotic surgery. The data shows that the learning curve and ability to learn robotics initially appears to be shorter and easier than surgeons learning VATS. Though the absolute best method for teaching is still under investigation, multiple centers have started to create systematic methods of teaching robotic surgery that increases resident autonomy while still protecting the patient.

Thoracoscopic Surgery for a Congenital Bronchoesophageal Fistula With Pulmonary Sequestration in an Adult Woman

A congenital bronchoesophageal fistula with pulmonary sequestration is rare in adults. Here, we report the case of an adult woman having congenital bronchoesophageal fistula with intralobar pulmonary sequestration who successfully underwent thoracoscopic resection and showed a good postoperative course.

Robot-assisted thoracic surgery for complex procedures

Background

As an option for minimally invasive thoracic surgery, robot-assisted thoracic surgery (RATS) has shown comparable perioperative outcomes to those achieved by traditional video-assisted thoracic surgery (VATS). It is unknown whether RATS might have any potential benefits in more complex thoracic surgical procedures, which usually require open surgery instead of VATS. The current study presents a preliminary result regarding the use of RATS in complex thoracic operations in an attempt to address this unresolved question.

Methods

Data from a prospectively collected and maintained surgical database were collected on patients who underwent RATS between February 2012 and August 2014. We defined complex RATS as those operations involving difficult dissections, complex sutures or excision of very large tumors (>8 cm) which would have required open surgery in our hospital before the introduction of RATS. The characteristics and peri-operative outcomes of patients receiving complex RATS were reviewed.

Results

Of the 120 patients undergoing RATS, 30 of them were classified as having undergone complex RATS, 21 to remove lung tumors and 9 to remove mediastinal tumors. The indications for complex RATS included 21 difficult dissections, 10 complex sutures, and 7 very large tumors (8 patients had two indications). There are three conversions to thoracotomy for pulmonary arterial bleeding. There was one mortality resulted from post-pneumonectomy pulmonary hypertension and sepsis. Patients with difficult dissection had longer operative time and hospital stay, and more bleeding and postoperative morbidity.

Conclusions

RATS for complex thoracic procedures is feasible, especially for complex suturing and excision of very large mediastinal tumors, but more attention is needed for patients needing difficult dissections. Advanced preparation for conversion is necessary during this difficult operation.

Robotic versus thoracoscopic lung resection: A systematic review and meta-analysis

BACKGROUND

Robotic video-assisted surgery (RVATS) has been reported to be equally effective to video-assisted surgery (VATS) in lung resection (pneumonectomy, lobectomy, and segmentectomy). Operation time, mortality, drainage duration, and length of hospitalization of patients undergoing either RVATS or VATS are compared in this meta-analysis.

METHODS

A systematic research for articles meeting our inclusion criteria was performed using the PubMed database. Articles published from January 2011 to January 2016 were included. We used results of reported mortality, operation time, drainage duration, and hospitalization length for performing this meta-analysis. Mean difference and logarithmic odds ratio were used as summary statistics.

RESULTS

Ten studies eligible were included into this analysis (5 studies for operation time, 3 studies for chest in tube days, 4 studies for length of hospitalization, and 6 studies for mortality). We were able to include 3375 subjects for RVATS and 58,683 subjects for VATS. Patients were mainly treated for lung cancer, metastatic foci, and benign lesions. We could not detect any difference between operation time; however, we found 2 trends showing that drainage duration and length of hospitalization are shorter for following RVATS than for following VATS. Mortality also is lower in patients undergoing RVATS.

CONCLUSIONS

Therefore, we conclude that RVATS is a suitable minimal-invasive procedure for lung resection and suitable alternative to VATS. RVATS is as time-efficient as VATS and shows a trend to reduced hospital stay and drainage duration. More and better studies are required to provide reliable, unbiased evidence regarding the relative benefits of both methods.

Perioperative outcomes of robotic surgery for the treatment of lung cancer compared to a conventional video-assisted thoracoscopic surgery (VATS) technique

Aim

To conduct a meta-analysis to determine the relative merits between robotic video-assisted thoracoscopic surgery (R-VATS) and conventional video-assisted thoracoscopic surgery (VATS) for lung cancer.

Results

Fifteen studies matched the selection criterion, which reported 8827 subjects, of whom 1704 underwent R-VATS and 7123 underwent VATS. Compared the perioperative outcomes with VATS, reports of R-VATS indicated unfavorable outcomes considering the operative time (SMD = 0.48, 95% CI 0.15 to 0.81). Meanwhile, the number of dissected lymph nodes (SMD = 0.12, 95% CI -0.27 to 0.51) and hospital stay following surgery (SMD = -0.1; 95% CI -0.27 to 0.07), conversion (RR = 0.68; 95% CI 0.42 to 1.11), morbidity (RR = 0.99, 95% CI 0.92 to 1.07) and mortality (RR = 0.33, 95% CI 0.1 to 1.09) were similar for both procedures.

Materials and Methods

A literature search was performed to identify comparative studies reporting perioperative outcomes for R-VATS and VATS for lung cancer. Pooled risk ratio (RR) and standardized mean differences (SMDs) with 95% confidence intervals (95% CIs) were calculated using either the fixed effects model or the random effects model.

Conclusions

There is no difference in terms of perioperative outcomes between R-VATS and VATS except for the operative time which is significantly high for R-VATS. Further studies are required to confirm these results.

Long-term Survival Based on the Surgical Approach to Lobectomy For Clinical Stage I Nonsmall Cell Lung Cancer: Comparison of Robotic, Video-assisted Thoracic Surgery, and Thoracotomy Lobectomy

OBJECTIVE

To compare the long-term outcomes among robotic, video-assisted thoracic surgery (VATS), and open lobectomy in stage I nonsmall cell lung cancer (NSCLC).

BACKGROUND

Survival comparisons between robotic, VATS, and open lobectomy in NSCLC have not yet been reported. Some studies have suggested that survival after VATS is superior, for unclear reasons.

METHODS

Three cohorts (robotic, VATS, and open) of clinical stage I NSCLC patients were matched by propensity score and compared to assess overall survival (OS) and disease-free survival (DFS). Univariate and multivariate analyses were performed to identify factors associated with the outcomes.

RESULTS

From January 2002 to December 2012, 470 unique patients (172 robotic, 141 VATS, and 157 open) were included in the analysis. The robotic approach harvested a higher number of median stations of lymph nodes (5 for robotic vs 3 for VATS vs 4 for open; P < 0.001). Patients undergoing minimally invasive approaches had shorter median length of hospital stay (4 d for robotic vs 4 d for VATS vs 5 d for open; P < 0.001). The 5-year OS for the robotic, VATS, and open matched groups were 77.6%, 73.5%, and 77.9%, respectively, without a statistically significant difference; corresponding 5-year DFS were 72.7%, 65.5%, and 69.0%, respectively, with a statistically significant difference between the robotic and VATS groups (P = 0.047). However, multivariate analysis found that surgical approach was not independently associated with shorter OS and DFS.

CONCLUSIONS

Minimally invasive approaches to lobectomy for clinical stage I NSCLC result in similar long-term survival as thoracotomy. Use of VATS and robotics is associated with shorter length of stay, and the robotic approach resulted in greater lymph node assessment.

Robotic Lobectomy Utilizing the Robotic Stapler

A drawback of robotic lobectomy is the inability of the operating surgeon to perform stapler division of the pulmonary vessels and bronchi. With the advent of the robotic stapler, the surgeon is able to control this instrument from the console. The robotic stapler presents certain challenges. This article outlines techniques to use the robotic stapler for the safe and predictable performance of lobectomies.

Transition from video-assisted thoracic surgery to robotic pulmonary surgery

The "da Vinci Surgical System" is a robotic surgical system that utilizes multi-jointed robotic arms and a high-resolution three-dimensional video-monitoring system. We report on the state of transition from video-assisted thoracoscopic surgery (VATS) to robotic pulmonary surgery, the surgical outcomes of robotic surgery compared to VATS, and the future of robotic surgery. Surgery utilizing the da Vinci Surgical System requires a console surgeon and assistant who have been certified by Intuitive Surgical, Inc., the system manufacturer. On the basis of the available medical literature, a robotic lobectomy has a learning curve that extends over approximately 20 cases for a surgeon who has mastered VATS. Surgery using the da Vinci System is safe, is associated with lower morbidity and mortality rates than thoracotomy, leads to shorter postoperative hospital stays, and ensures improved postoperative quality of life. Currently, no prospective studies comparing it to VATS have been conducted. The various studies that have compared robotic surgery and VATS have reported different results. At the present time, the benefits to patients of robotic surgery compared to VATS remain unclear. Areas in which robotic surgery may be superior to VATS include the superior operability of robotic surgery that improves safety and decreases the incidence of complication. To show that the costly robotic surgery is superior to VATS, prospective multicenter randomized studies need to be conducted. The da Vinci robot-assisted surgical system has already been highly evaluated for its safety, with recent studies reporting satisfactory outcomes. It remains necessary to verify whether the benefits to patients justify the higher cost of robotic surgery. Future developments in the field of robotic engineering will likely lead to the creation of systems that are even less invasive and allow for more advanced surgical techniques.

Robotic lung cancer surgery: review of experience and costs

Use of robot-assisted techniques is growing fast in several surgical disciplines, now including thoracic surgery. The paper reviews experience of robotic surgery to resect lung cancer and in particular analyzes data on the costs of these procedures in comparison to open surgery and video-assisted thoracoscopic surgery (VATS). Retrospective studies published over 14 years show that robotic surgery for lung cancer has the advantages of minimally invasive surgery for patients, and some advantages over VATS for the surgeon. Limited data indicate that oncological outcomes are comparable with those of VATS and open surgery, while lymph node dissection may be more radical. Other studies indicate that robotic surgery for lung cancer offers no advantages either in terms of costs or outcomes. The high costs of purchase, maintenance and consumables are a concern and continue to limit uptake of robot systems in thoracic surgery. Most studies-but not all-indicate that robotic surgery for lung cancer is more expensive than VATS and open surgery. However limited data also indicate that hospitals can make a profit from robotic thoracic surgery, as costs seem to be lower than reimbursements from paying bodies. Nevertheless robotic thoracic surgery is still too expensive for many public hospitals, particularly in low income countries. Entry of new surgical robot manufacturers onto the market will bring much-needed competition that may also lead to cost reduction.

Tips and tricks to decrease the duration of operation in robotic surgery for lung cancer

Minimally invasive surgery (MIS) for lung cancer has been associated with decreased perioperative morbidity while maintaining similar long-term survival when compared to open thoracotomy. Robotic thoracic surgery constitutes an evolutionary step in this field, beckoning dramatic advancements both in visualization as well as surgical instrument range of motion and ergonomics. As such, robotic thoracic surgery is growing in adoption worldwide. One of its oft-cited disadvantages, however, is increased operative time, especially for less-experienced surgeons. We describe an assortment of tips and tricks that we conclude can safely reduce robotic operative duration.