Outcomes of major complications after robotic anatomic pulmonary resection

Preoperative exercise training decreases complications of minimally invasive lung cancer surgery: A randomized controlled trial

OBJECTIVE

Limited evidence exists regarding the efficacy of preoperative exercise in reducing short-term complications after minimally invasive surgery in patients with non-small cell lung cancer. This study aims to investigate the impact of preoperative exercise on short-term complications after minimally invasive lung resection.

METHODS

In this prospective, open-label, randomized (1:1) controlled trial at Xiangya Hospital, China (September 2020 to February 2022), patients were randomly assigned to a preoperative exercise group with 16-day alternate supervised exercise or a control group. The primary outcome assessed was short-term postoperative complications, with a follow-up period of 30 days postsurgery.

RESULTS

A total of 124 patients were recruited (preoperative exercise group n = 62; control n = 62). Finally, 101 patients (preoperative exercise group; n = 51 and control; n = 50) with a median age of 56 years (interquartile range, 50-62 years) completed the study. Compared with the control group, the preoperative exercise group showed fewer postoperative complications (preoperative exercise 3/51 vs control 10/50; odds ratio, 0.17; 95% CI, 0.04-0.86; P = .03) and shorter hospital stays (mean difference, -2; 95% CI, -3 to -1; P = .01). Preoperative exercise significantly improved depression, stress, functional capacity, and quality of life (all P < .05) before surgery. Furthermore, preoperative exercise demonstrated a significantly lower minimum blood pressure during surgery and lower increases in body temperature on day 2 after surgery, neutrophil-to-lymphocyte ratio, and neutrophil count after surgery (all P < .05). Exploratory research on lung tissue RNA sequencing (5 in each group) showed downregulation of the tumor necrosis factor signaling pathway in the preoperative exercise group compared with the control group.

CONCLUSIONS

Preoperative exercise training decreased short-term postoperative complications in patients with non-small cell lung cancer.

Robotic Anatomical Pulmonary Resections: An Australian Experience

BACKGROUND

Robotic thoracic surgery is a minimally invasive technique that allows the surgeon to perform delicate, accurate surgical manoeuvres within the chest cavity without rib spreading. Previous studies have suggested potential benefits of the robotic platform in nodal upstaging due to its versatility, seven degrees of freedom of movement, and superior vision. However, there is currently a paucity of robust clinical data from Australia.

AIMS

This study aimed to assess the perioperative safety and oncological efficacy of anatomical pulmonary resections performed using the robotic platform. Endpoints included mortality and major morbidity outcomes according to Clavien-Dindo classification and rate of pathological nodal upstaging compared with preoperative imaging using positron emission tomography.

METHODS

A single-surgeon retrospective analysis was performed using data collected from two institutions from July 2021 to May 2022, after ethics committee approval. Consecutive patients who underwent anatomical robotic resections were included in the study, with subsequent analysis of patients who had confirmed primary lung cancer.

RESULTS

A total of 52 patients underwent robotic anatomical pulmonary resection during the study period. Safety was demonstrated by 0% mortality and a 9.6% major complication rate, which was related to chest tube insertion for prolonged air leak or intensive care unit monitoring during treatment of atrial arrhythmia. After excluding patients who did not have primary lung cancer, 48 patients remained for further analysis; pathological nodal upstaging was observed in nine (18.8%) of these patients. On multivariate analysis, the total number of lymph nodes harvested was found to be a statistically significant predictor of nodal upstaging. Complete microscopic resection (R0) was achieved in 100% of patients.

CONCLUSIONS

This study represents the most extensive documentation of robotic thoracic procedures in Australia in the existing literature. It demonstrated a satisfactory safety profile with a relatively high rate of nodal upstaging, possibly reflecting the ability of the robotic instruments to perform comprehensive and complete nodal resection at the time of anatomical pulmonary resection.

Prolonged air leak after robotic lung resection: a narrative review

Background and Objective

Prolonged air leak (PAL) following lung resection is related to an increase in morbidity and both direct and indirect costs. In recent years, robotic-assisted thoracic surgery (RATS) has proved to be a safe technique with comparable perioperative outcomes of video-assisted thoracic surgery (VATS), optimal oncological results, and potential advantages in case of sublobar resection. We here focus on the incidence and clinical impact of PAL in the field of robotic surgery and discuss the therapeutic strategies currently available.

Methods

We conducted a search on PubMed/MEDLINE and Scopus database from inception until May 27^th 2022 to select the relevant literature published in English exploring the occurrence of PAL following RATS.

Key Content and Findings

The implementation of robotic surgery led to a significant reduction in PAL occurrence after pulmonary resection compared to open thoracotomy, while there is still no clear advantage with respect to VATS. However, the enhanced dexterity and improved visualization of the robot seem to particularly valuable in case of sublobar lung resection, especially complex ones. Accurate selection of patients based on the presence of risk factors allows the implementation of intraoperative measures in order to reduce the occurrence of PAL.

Conclusions

Robotic lung resection is a safe technique, advantageous compared to traditional open thoracotomy in terms of PAL occurrence reduction and it is a valid alternative to manual VATS. Moreover, with the extension of indications for sublobar resection in the treatment of early stage lung cancer, RATS may prove to be the technique of choice thanks to its intrinsic advantages.

Iatrogenic Rupture of Saline Breast Implant Following Robotic-Assisted Lung Surgery

Breast implants are prevalent in the United States. Patients with breast implants may be susceptible to iatrogenic implant rupture during cardiothoracic surgery. To our knowledge, however, this complication has never been described following robot-assisted thoracic surgery (RATS). We described a patient who developed a rupture of a saline breast implant after undergoing a robot-assisted left lower lobectomy. We hypothesized that a tear to the breast implant may have occurred either during the extraction of one of the surgical ports or during the forceful extraction of the resected specimen. This case highlights another potential complication of minimally invasive thoracic surgery. For patients with breast implants undergoing thoracic RATS, extra care should be made to the site of port placement and the avoidance of excessive force during surgery.

Robotic lung resection: a narrative review of the current role on primary lung cancer treatment

Background and Objective

Robotic-assisted thoracic surgery (RATS) has increasingly been applied to primary lung cancer treatment. Given the many facilities provided by the robotic platform in the manipulation of tissues and precision of movements, there is continuous enquiring about its contribution to the improvement of surgical outcomes. Also, the possibility to perform complex resections in a minimally invasive way using a robotic approach starts to become possible as the centers' learning curve expands. We propose to perform a review of the current status of robotic surgery for lung cancer focusing on key frontier points: sublobar resections, quality of lymphadenectomy, complex resections, postoperative outcomes, and innovative technologies to arrive.

Methods

We performed a narrative review of the literature aggregating the most current references available in English.

Key Content and Findings

According to the current data, the flourishing of the robotic platform seems to be in line with the spread of sublobar resections. The technological benefits inherent to the platform, also seem to promote an increase in the quality of lymphadenectomy and a shorter learning curve when compared to video-assisted thoracic surgery (VATS) with equivalent oncological results. Its application in complex resections such as bronchial sleeve already presents consistent results and new technology acquisitions such as three-dimensional reconstructions, augmented reality and artificial intelligence tend to be implemented collaborating with the digitization of surgery.

Conclusions

Robotic surgery for lung cancer resection is at least equivalent to the VATS approach considering the currently available literature. However, more practice time and prospective clinical trials are needed to identify more exact benefits.

Causes and management of intraoperative complications in robot-assisted anatomical pulmonary resection for lung cancer

Background

To perform safe robot-assisted anatomical lung resections, the details of intraoperative complications need to be shared among thoracic surgeons. However, only limited data are available.

Methods

This retrospective, single-institutional study evaluated 134 patients who underwent robot-assisted anatomical lung resection. We examined the causes, management, and outcomes of all intraoperative complications.

Results

Of the 134 eligible patients, 118 (88%) underwent lobectomy and 16 (12%) underwent segmentectomy. Intraoperative complications occurred in 17 (12.7%) patients. These complications included pulmonary artery (PA) injuries in seven patients, pulmonary vein (PV) injuries in three, azygos vein (AV) injury in one, superior vena cava (SVC) injury in one, bronchial injuries in three, and lung injuries in four. Most PA injuries were at a distal side and controlled by pressure, fibrin sealant, or stapling of the proximal side. In the three PV injuries, right upper PV was sandwiched by robotic instruments, V6 was punctured by the tip of the Maryland bipolar forceps, and the distal side of V2t was injured during tunneling of a minor interlobar fissure. These were controlled the same way as the PA injuries. The AV injury occurred during hilar lymph node (LN) dissection and was controlled by suturing. The SVC injury was caused by interference of the robotic forceps and the suction tube outside the field of view during upper mediastinal LN dissection. The injury was controlled by continuous pressure while layering polyglycolic acid sheets and fibrin glue. In the three bronchial injuries, B10 was injured during subcarinal LN dissection, right main bronchus was injured during upper bronchus dissection and the stapling failure of the bronchus occurred by strong traction. They were all repaired by suturing. All lung parenchymal injuries were caused by manipulation of robotic instruments outside the field of view. The lung injuries were repaired by suturing with pledgets. No cases were converted to thoracotomy. The 30-day mortality rate was 0.7%. The cause of mortality was pneumonia.

Conclusions

In robot-assisted anatomical pulmonary resection for lung cancer, most major intraoperative complications can be safely managed robotically without conversion to thoracotomy.

A new technique for introduction of a surgical stapler in robot-assisted lobectomy for lung cancer

BACKGROUND

The da Vinci Si version of robot lacks a vascular stapler that can be controlled by the operating surgeon at the surgical console for dividing the pulmonary vessels. Therefore, in order to initiate and safely perform robotic anatomical lobectomy for lung cancer, it is important to develop a safe method for introducing the surgical stapler.

METHOD

We performed a retrospective study of the first 42 consecutive patients who underwent robotic lobectomy for lung cancer at Nippon Medical School Hospital between January 2019 and December 2020.

RESULTS

Up to case 18, we performed Robot-assisted thoracoscopic surgery (RATS) lobectomy using the four-arm approach with two assistant ports. For dividing the pulmonary vessels, the surgical stapler was introduced through the assist ports. However, since this is not the port position usually used in video-assisted thoracoscopic surgery (VATS), there were many difficult situations.From case 19 onwards of RATS lobectomy, we began to use a total port approach using three robotic arms and two assistant ports. For resecting the pulmonary vessels or bronchi with endoscopic staplers, the port for the robotic arm was removed and the endoscopic staplers were placed through a 12-mm Xcel bladeless port. This change resulted in a shorter operation time, less blood loss, and less robotic arm interference. There has been no case that developed intraoperative complications during RATS lobectomy.

CONCLUSION

The new total port approach, with three robotic arms, for introducing surgical staplers during RATS using the da Vinci Si robotic system appears to be feasible.

A Multiple-Center Nomogram to Predict Pneumonectomy Complication Risk for Non-Small Cell Lung Cancer Patients

OBJECTIVE

This study aimed to construct a nomogram to quantitatively predict pneumonectomy complication risks for non-small cell lung cancer (NSCLC) patients.

METHODS

Data from 1052 NSCLC patients who underwent pneumonectomy were retrospectively retrieved from the databases of three thoracic centers. Multivariable logistic regression was used to investigate postoperative morbidity predictors. Clinical parameters and operative features were analyzed using univariable and multivariable logistic regression analyses, and a nomogram to predict the risk of postoperative complications was constructed using bootstrap resampling. A receiver operating characteristic (ROC) curve was used to estimate the discrimination power for the nomogram.

RESULTS

A total of 212 patients (20.2%) had major complications. After regression analysis, forced expiratory volume in 1 s, Charlson Comorbidity Index score, male sex, and right-sided pneumonectomy were identified and entered into the nomogram. The nomogram showed a robust discrimination, with an area under the ROC curve of 0.753 (95% confidence interval 0.604-0.818). The calibration curves for the probability of postoperative complications showed optimal agreement between the nomogram and the actual probability.

CONCLUSIONS

Based on preoperative data, we developed a nomogram for predicting complication risks after pneumonectomy. This model may be helpful for thoracic surgeons in selecting appropriate patients for adopting prophylactic measures after surgery.