Beyond the learning curve: a review of complex cases in robotic thoracic surgery

Robot-assisted minimally invasive bronchial resection with primary anastomosis for schwannoma arising from left main bronchus: a case report

Background

Tracheobronchial schwannomas are extremely rare, which account for lower than 0.2% in all pulmonary tumors. In large part because of the rarity and insufficient reported clinical details, tracheobronchial schwannoma lacks guidelines or expert consensus for diagnosis and treatment, and the delay in diagnosis can range from months to years. The main treatment option is surgery. Endoscopic intervention can also be selected. An increasing number of thoracic surgery cases were performed on the robotic platforms in recent years. With their assistance, surgeons can accomplish the high technique required surgical procedures with ease.

Case Description

In this case, a 48-year-old female had a history of shortness of breath for more than 1 year. The chest computed tomography (CT) and bronchoscopy examination revealed a new growth of nodule in the left main bronchus. The nodule was considered a schwannoma by transbronchial biopsy, which was removed by robot-assisted bronchial resection with primary anastomosis. The application of Da Vinci Si robotic surgical system benefited the process of this surgery. Pathology and immunohistochemistry results confirmed the diagnosis of schwannomas. The patient tolerated the treatment without any complications. No sign of recurrence was discovered at present, 6 months after the intervention.

Conclusions

We reported the first sleeve resection for bronchial schwannoma using Da Vinci robotic surgical system. The clinical details of tracheobronchial schwannoma should be revealed more specifically to achieve more systematic diagnosis and treatment.

Outcomes of robot-assisted versus video-assisted mediastinal mass resection during the initial learning curve

To compare the learning curve of mediastinal mass resection between robot-assisted surgery and thoracoscopic surgery. Retrospective perioperative data were collected from 160 mediastinal mass resection cases. Data included 80 initial consecutive video-assisted thoracoscopic surgery (VATS) resection cases performed from February 2018 to February 2020 and 80 initial consecutive robotic-assisted thoracic surgery (RATS) resection cases performed from March 2020 to March 2023. All cases were operated on by a thoracic surgeon. The clinical characteristics and perioperative outcomes of the two groups were compared. The operation time in both the RATS group and VATS group was analyzed using the cumulative sum (CUSUM) method. Based on this method, the learning curves of both groups were divided into a learning period and mastery period. The VATS group and the RATS group crossed the inflection point in the 27th and 21st case, respectively. Subsequently, we found that the learning period was longer than the mastery period with statistically significant differences in terms of the operating time, and postoperative hospital stay in the VATS group and the RATS group. A certain amount of VATS experience can shorten the learning curve for RATS.

Effect of da Vinci robot-assisted versus traditional thoracoscopic bronchial sleeve lobectomy

OBJECTIVE

To analyze the short-term effect of Da Vinci robot-assisted thoracoscopic (RATS) bronchial sleeve lobectomy, so as to summarize its safety and effectiveness.

METHODS

It was a retrospective single-center study with the inclusion of 22 cases receiving RATS lobectomy and 49 cases of traditional thoracoscopic surgery. Further comparison was performed focusing on the baseline characteristics and perioperative performance of the two groups.

RESULTS

Compared with the traditional thoracoscopic surgery group, RATS group had more advantages in the number of lymph nodes dissected (P = 0.003), shorter postoperative length of stay in the hospital (P = 0.040), shorter drainage time (P = 0.022), reduced drainage volume (P = 0.001). Moreover, this study found for the first time that there was a shortening in the operation of sleeve lobectomy by using Da Vinci robot-assisted surgical system (P = 0.001). The operation cost of RATS group is more expensive (96000 ± 9100.782 vs 63000 ± 5102.563 yuan; P＜0.001).

CONCLUSION

Compared with the traditional thoracoscopic bronchial sleeve lobectomy, RATS lobectomy shows advantages of higher operating sensitivity, shorter operation time, faster postoperative recovery, and more lymph nodes dissected. Collectively, RATS bronchial sleeve lobectomy is safe and effective in operation.

Learning Curve of Perclose ProGlide Utilization During Percutaneous Coronary Intervention

OBJECTIVE

This study aimed to investigate the learning curve (LC) of Perclose ProGlide (Chicago, IL: Abbott Laboratories) utilization for percutaneous coronary intervention (PCI) for the first time.

METHODS

The study was conducted in a prospective manner and the final sample of the study was determined as 80 patients. Patients' characteristics, diameter of common femoral artery (CFA), distance from skin to CFA, degree of calcification (<50% or ≥50%), procedure-related parameters, complications, and success of procedures were recorded. Patients were equally divided into four groups and groups were compared according to patient demographic properties, procedure-related parameters, complications, and success.

RESULTS

The mean age and mean BMI of the study population were 55.5 years and 27.5 kg/m², respectively. The mean procedure time was 144.8 minutes (min) in group 1, 138.9 min in group 2, 122.2 min in group 3, and 101.1 min in group 4, and the difference was statistically shorter in favor of group 3 and group 4 (p=0.023). Moreover, mean fluoroscopy time significantly decreased after 20 cases (p=0.030). Hospitalization period was significantly shortened following 40 procedures (p=0.031). Complications were detected in five patients in group 1, four patients in group 2, and one patient in group 4 (p=0.044). Success was significantly higher in group 3 and group 4 in comparison to group 1 and group 2 (p=0.040).

CONCLUSION

This study showed that procedure time and hospitalization time significantly decreased after 40 cases and fluoroscopy time significantly decreased after 20 cases. Moreover, after 40 procedures, the success of Perclose ProGlide utilization during PCI significantly increased and complications of the procedure significantly decreased.

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.

Approaches and outcomes of Robotic-Assisted Thoracic Surgery (RATS) for lung cancer: a narrative review

Robotic-Assisted Thoracic Surgery (RATS) is considered one of the main issues of present thoracic surgery. RATS is a minimally invasive surgical technique allowing enhanced view, accurate and complex movements, and high ergonomics for the surgeon. Despite these advantages, its application in lung procedures has been limited, mainly by its costs. Since now many different approaches have been proposed and the experience in RATS for lungs ranges from wedge resection to pneumonectomy and is mainly related to lung cancer. The present narrative review explores main approaches and outcomes of RATS lobectomy for lung cancer. A non-systematic review of literature was conducted using the PubMed search engine. An overview of lung robotic surgery is given, and main approaches of robotic lobectomy for lung cancer are exposed. Initial experiences of biportal and uniportal RATS are also described. So far, retrospective analysis reported satisfactory robotic operative outcomes, and comparison with VATS might suggest a more accurate lymphadenectomy. Some Authors might even suggest better perioperative outcomes too. From an oncological standpoint, no definitive prospective study has yet been published but several retrospective analyses report oncological outcomes comparable to those of VATS and open surgery. Literature suggests that RATS for lung procedures is safe and effective and should be considered as a valid additional surgical option.

Establishment of Thoracic Surgical Difficulty Assessment Scale based on Delphi method

OBJECTIVES

The difficulty of surgery, which is related to surgical safety, has only been mentioned as a subjective perception for a long time. There are few studies to quantitatively and systematically evaluate the difficulty of thoracic surgery. This study aims to establish a quantitative evaluation index system for thoracic surgical difficulty, and to evaluate its reliability and validity.

METHODS

During the 2 national thoracic surgery academic conferences, the factors that may affect the difficulty of thoracic surgery were evaluated by the thoracic surgeons via semi open questionnaires, and then the evaluation item pool of thoracic surgery difficulty was established. The importance of each indicator in the evaluation item pool was graded by 2 rounds of Delphi method. The average score, full score rate and coefficient of variation of each index were calculated, and the composite index method was used to decide whether to delete the indicator.Finally, the difficulty evaluation scale of thoracic surgery was constructed. The surgical data of patients with thoracic tumors were collected. The scale was used to evaluate the difficulty of thoracic surgery for lung, esophageal, and mediastinal tumors. The reliability and validity of the scale were evaluated by the commonly used difficulty evaluation indexes: Operation time, intraoperative estimated blood loss, Visual Analog Scale (VAS), side injury rate, and blood transfusion rate as standards.

RESULTS

A total of 230 questionnaires were distributed in the 2 rounds of survey, and 149 valid questionnaires were collected after eliminating duplicate questionnaires. Through 2 rounds of Delphi consultation with 20 experts, the difficulty evaluation indexes were scored and screened, and the difficulty evaluation scale of thoracic surgery was established. It included 5 main indexes (surgical decision-making, operation space, separation interface, reconstruction method, and surgical materials) and 16 secondary indexes [American Society of Anesthesiologists (ASA) classification, surgical trauma, operator experience, space size, space depth, space source, space adjacent, interface content, anatomical gap, visual field, interface size, reconstruction complexity, reconstruction scope, autologous materials, artificial biomaterials and instruments]. After weighting, the total score of Thoracic Surgery Difficulty Evaluation Scale was from 1 to 3. A Score at 1 standed for simplicity, and score at 3 standed for difficulty. Further data were collected for 127 cases of thoracic tumor surgery. The difficulty scores of surgery for lung, esophageal, and mediastinal tumor were 1.69±0.26, 1.86±0.18, and 1.56±0.31, respectively, and the Cronbach's α coefficients of the scale in 3 tumor surgeries were 0.993, 0.974, and 0.989, repectively, and the Spearman Brown coefficients were 0.996, 0.984, and 0.996, respectively. The Spearman correlation coefficients of operation difficulty score with operation time, estimated blood loss, and VAS were 0.360 and 0.634, 0.632 and 0.578, 0.696 and 0.875, respectively (all P<0.05). The incidence of postoperative complications in the difficult operation group (difficulty score >1.85) was higher than that in the non-difficult operation group (P=0.02).

CONCLUSIONS

The quantitative Thoracic Surgical Difficulty Assessment Scale has been successfully established, which shows good reliability and validity in thoracic tumor surgery. The Thoracic Surgical Difficulty Assessment Scale has broad application prospects in reducing the difficulty of the surgery, controlling surgical complications, and training surgeons.