Training residents in robotic thoracic surgery

Robotic-assisted thoracic surgery training in France: a nation-wide survey from young surgeons

OBJECTIVES

Evaluate theoretical and practical training of thoracic surgeons-in-training in robotic-assisted thoracic surgery (RATS) in France.

METHODS

A survey was distributed to thoracic surgeons-in-training in France from November 2022 to February 2023.

RESULTS

We recruited 101 thoracic surgeons-in-training (77% response rate). Over half had access to a surgical robotics system at their current institution. Most (74%) considered robotic surgery training essential, 90% had attended a robotic procedure. Only 18% had performed a complete thoracic robotic procedure as the main operator. A complete RATS procedure was performed by 42% of fellows and 6% of residents. Of the remaining surgeons, 23% had performed part of a robotic procedure. Theoretical courses and simulation are well developed; 72% of residents and 91% of fellows had undergone simulation training in the operating room, at training facilities, or during congress amounting to <10 h (for 73% of the fellows and residents), 10-20 h (17%), 20-30 h (8%) or >30 h (3%). Access to RATS was ≥1 day/week in 71% of thoracic departments with robotic access. Fellows spent a median of 2 (IQR 1-3) semesters in departments performing robotic surgery. Compared with low-volume centres, trainees at high-volume centres performed significantly more complete robotic procedures (47% vs 13%; P = 0.001), as did fellows compared with residents.

CONCLUSIONS

Few young surgeons perform complete thoracic robotic procedures during practical training, and access remains centre dependent. Opportunities increase with seniority and exposure; however, increasing availability of robotic devices, theoretical formation, and simulation courses will increase opportunities.

Results of an exploratory survey within ESTS membership in 2022 on current trend of robotic-assisted thoracic surgery and its training perspectives

OBJECTIVES

Robotic-assisted thoracic surgery (RATS) is increasingly used in our specialty. We surveyed European Society of Thoracic Surgeons membership with the objective to determine current status of robotic thoracic surgery practice including training perspectives.

METHODS

A survey of 17 questions was rolled out with 1 surgeon per unit responses considered as acceptable.

RESULTS

A total of 174 responses were obtained; 56% (97) were board-certified thoracic surgeons; 28% (49) were unit heads. Most responses came from Italy (20); 22% (38) had no robot in their institutions, 31% (54) had limited access and only 17% (30) had full access including proctoring. Da Vinci Xi was the commonest system in 56% (96) centres, 25% (41) of them had dual console in all systems, whereas RATS simulator was available only in half (51.18% or 87). Video-assisted thoracic surgery (VATS) was the most commonly adopted surgical approach in 81% of centres (139), followed by thoracotomy in 67% (115) and RATS in 36% (62); 39% spent their training time on robotic simulator for training, 51% on robotic wet/dry lab, which being no significantly different to 46-59% who had training on VATS platform. There was indeed huge overlap between simulator models or varieties usage; 52% (90) reported of robotic surgery not a part of training curriculum with no plans to introduce it in future. Overall, 51.5% (89) responded of VATS experience being helpful in robotic training in view of familiarity with minimally invasive surgery anatomical views and dissection; 71% (124) reported that future thoracic surgeons should be proficient in both VATS and RATS. Half of the respondents found no difference in earlier chest drain removal with either approach (90), 35% (60) reported no difference in postoperative pain and 49% (84) found no difference in hospital stay; 52% (90) observed better lymph node harvest by RATS.

CONCLUSIONS

Survey concluded on a positive response with at least 71% (123) surgeons recommending to adopt robotics in future.

Assessment of Quality Outcomes and the Learning Curve for Robot-Assisted Anatomical Lung Resections

Background: To determine the perioperative quality assessment results and learning curves for robot-assisted anatomical lung resection. Methods: We analyzed the data of the initial 400 patients who underwent lobectomies or segmentectomies by 1 surgeon from January 2020 to November 2021. The learning curve was analyzed using cumulative sum analysis. Results: The surgical experience was divided into an initial phase (1st-40th procedures), a transition phase (41st-131st procedures), and a proficient phase (132nd procedure onward). The operative time showed a conspicuously continuous improvement over the 400 consecutive patients. After the 120th procedure, there were significant improvements in the rate of persistent air leakage (11.7% versus 3.9%; P = .003), chest tube duration (3.92 ± 1.91 versus 2.99 ± 1.31, P = .00), and postoperative hospital stay (6.22 ± 2.02 versus 4.93 ± 1.44, P = .00). Conclusions: In conclusion, 40 patients were necessary to pass the learning curve, and technical proficiency with favorable perioperative outcomes was achieved after 120-130 patients.

Suggested robotic-assisted thoracic surgery training curriculum

Robotic-assisted surgery, a technological advancement in the field of surgery, has become increasingly popular among surgeons of many specialties over time. Robotic-assisted thoracic surgery (RATS) is comparable to video-assisted thoracic surgery (VATS) in terms of patient care outcomes; however, the perception of increased operative time and a lack of cost-effectiveness have led to controversy regarding its alleged benefits. Nevertheless, robotic surgery is one of the preferred options for minimally invasive surgery by some thoracic surgeon over VATS, due to its ability to provide 3-D vision, precise wrist movements, enhanced magnification, and instrument stability and articulation. Notably, trainees in the field of thoracic surgery experience difficulty gaining knowledge and learning skills associated with RATS due to its complexity, limited access to robotic instruments, the lack of a standardized curriculum for trainees, and lack of mentorship or proctorship, thus leading to a steeper learning curve compared to laparoscopic or VATS procedures that are cost-friendly, easy to learn, and feasible to practice. Nevertheless, focusing on RATS training for thoracic surgeons will keep them familiar with robotic techniques, including the pre-operative setup and intra-operative process, which will ultimately decrease operative times. In this paper, we will review the literature, express and discuss the most viable training curriculum from authors' point of view to help achieve this goal.

Learning Curve of Robotic Lobectomy for the Treatment of Lung Cancer: How Does It Impact on the Autonomic Nervous System of the Surgeon?

OBJECTIVE

Our purpose is to define the learning curve for robot-assisted thoracoscopic surgery lobectomy by reporting the experience of a single surgeon.

MATERIAL AND METHODS

We progressively collected the data concerning the surgical performance of a single male thoracic surgeon, from the beginning of his robotic activity as first operator from January 2021 to June 2022. We evaluated several pre-, intra- and postoperative parameters concerning patients and intraoperative cardiovascular and respiratory outcomes of the surgeon, recorded during surgical interventions, in order to evaluate his cardiovascular stress. We used cumulative sum control charts (CUSUM) to analyze the learning curve.

RESULTS

A total of 72 lung lobectomies were performed by a single surgeon in this period. Analyzing the CUSUM of several parameters, the inflection point identifying the transition beyond the surgeon learning phase was reached at cases 28, 22, 27 and 33 when considering operating time, mean heart rate, max heart rate and mean respiratory rate, respectively.

CONCLUSIONS

The learning curve for robotic lobectomy seems to be safe and feasible with a correct robotic training program. The analysis of a single surgeon from the beginning of his robotic activity demonstrates that confidence, competence, dexterity and security are achieved after about 20-30 procedures, without compromising efficiency and oncological radicality.