Learning curve for robot-assisted lobectomy of lung cancer

Learning curve of junior surgeons in robot-assisted pedicle screw placement: a comparative cohort study

OBJECTIVE

Robot-assisted technology has been gradually applied to pedicle screw placement in spinal surgery. This study was designed to detailedly evaluate the learning curve of junior surgeons in robot-assisted spine surgery.

METHODS

From December 2020 to February 2022, 199 patients requiring surgical treatment with posterior pedicle screw fixation were prospectively recruited into the study. The patients were randomized to the robot-assisted group (the RA group) or the conventional freehand group (the CF group). Under the senior specialist's supervision, pedicle screws were placed by two junior fellows without prior experience. Cumulative summation (CUSUM) analysis was performed on the learning curve of pedicle screw placement for performing quantitative assessment based on the time of screw insertion.

RESULTS

In total, 769 and 788 pedicle screws were placed in the RA and CF groups. Compared with the CF group, the learning duration in the RA group was shorter in the upper thoracic region (57 vs. 70 screws), but longer in the lower thoracic (62 vs. 58 screws) and the lumbosacral region (56 vs. 48 screws). The slope of learning curve was lower in the RA group than in the CF group. The screw accuracy in the RA group was superior to that in the CF group, especially in upper thoracic region (89.4% vs. 76.7%, P < 0.001). This disparity of accuracy became wider in deformity cases. In the upper thoracic region, the mean placement time was 5.34 ± 1.96 min in the RA group and 5.52 ± 2.43 min in the CF groups, while in the lower thoracic and lumbosacral regions, the CF group's mean placement times were statistically shorter. Three screw-related neural complications occurred in the CF group.

CONCLUSION

Robot-assisted technique has its advantages in the upper thoracic region and deformity cases, which is easier and safer to insert pedicle screws. The robot-assisted technique allowed a short learning curve for junior surgeons and exhibited consistently excellent results even in the early application period.

Starting a robotic thoracic surgery program: From wedge resection to sleeve lobectomy in six months. Initial conclusions

INTRODUCTION

Robot-assisted thoracic surgery (RATS) is a rapidly expanding technique. In our study, we aimed to analyze the results of the process to adopt robotic surgery in our Department of Thoracic Surgery.

METHODS

This is an intention-to-treat analysis of a series of consecutive patients operated on using the RATS approach in our hospital from January 2021 to March 2022. Data were registered for patient characteristics, type of surgery, operative times, conversion rate, chest tube duration, length of hospital stay and complications. The IBM SPSS® statistical software was used for the statistical analysis. A cumulative sum analysis of the operating time was performed to define the learning curve.

RESULTS

During the study period, 51 patients underwent robotic surgery, including pulmonary and non-pulmonary interventions. In addition, 15 patients (29.4%) underwent non-pulmonary interventions: one pleural (2%), 2 diaphragmatic (3.9%), and 12 mediastinal (23.5%). Among the mediastinal surgeries, one conversion was necessary (8.3%) for a complex vascular malformation, and 11 were completed by RATS, including 7 (58.3%) thymomas, 3 (25%) pleuro-pericardial cysts, and one (8.3%) neurogenic tumor. Mean operative time was 141 min (104-178), mean chest tube duration was 0.9 days (0-2), and mean length of stay was 1.45 days (1-2). Thirty-six patients underwent lung surgery (70.6%). The complete RATS resections (34; 94.4%) included: 3 wedge resections (11.1%), 2 segmentectomies (3.7%), 28 lobectomies (81.5%), and one sleeve lobectomy (3.7%). Mean surgery time was 194.56 min (141-247), chest tube duration was 3.92 days (1-8), and length of stay was 4.6 days (1-8). Complications occurred in 4 patients (11.1%). No 90-day mortalities were registered.

CONCLUSIONS

The implementation of RATS was achieved with good clinical results and operative times for all indications. A rapid learning curve was accomplished in short time. Previous VATS experience, patient selection, team training and program continuity are fundamental to successfully develop a RATS program.

Robotic Lobectomy Is Cost-effective and Provides Comparable Health Utility Scores to Video-assisted Lobectomy: Early Results of the RAVAL Trial

OBJECTIVE

The aim of this study was to determine if robotic-assisted lobectomy (RPL-4) is cost-effective and offers improved patient-reported health utility for patients with early-stage non-small cell lung cancer when compared with video-assisted thoracic surgery lobectomy (VATS-lobectomy).

BACKGROUND

Barriers against the adoption of RPL-4 in publicly funded health care include the paucity of high-quality prospective trials and the perceived high cost of robotic surgery.

METHODS

Patients were enrolled in a blinded, multicentered, randomized controlled trial in Canada, the United States, and France, and were randomized 1:1 to either RPL-4 or VATS-lobectomy. EuroQol 5 Dimension 5 Level (EQ-5D-5L) was administered at baseline and postoperative day 1; weeks 3, 7, 12; and months 6 and 12. Direct and indirect costs were tracked using standard methods. Seemingly Unrelated Regression was applied to estimate the cost effect, adjusting for baseline health utility. The incremental cost-effectiveness ratio was generated by 10,000 bootstrap samples with multivariate imputation by chained equations.

RESULTS

Of 406 patients screened, 186 were randomized, and 164 analyzed after the final eligibility review (RPL-4: n=81; VATS-lobectomy: n=83). Twelve-month follow-up was completed by 94.51% (155/164) of participants. The median age was 68 (60-74). There were no significant differences in body mass index, comorbidity, pulmonary function, smoking status, baseline health utility, or tumor characteristics between arms. The mean 12-week health utility score was 0.85 (0.10) for RPL-4 and 0.80 (0.19) for VATS-lobectomy ( P =0.02). Significantly more lymph nodes were sampled [10 (8-13) vs 8 (5-10); P =0.003] in the RPL-4 arm. The incremental cost/quality-adjusted life year of RPL-4 was $14,925.62 (95% CI: $6843.69, $23,007.56) at 12 months.

CONCLUSION

Early results of the RAVAL trial suggest that RPL-4 is cost-effective and associated with comparable short-term patient-reported health utility scores when compared with VATS-lobectomy.

Learning Curves for Robot-Assisted Pedicle Screw Placement: Analysis of Operative Time for 234 Cases

BACKGROUND AND OBJECTIVES

Robot-assisted pedicle screw placement is associated with greater accuracy, reduced radiation, less blood loss, shorter hospital stays, and fewer complications than freehand screw placement. However, it can be associated with longer operative times and an extended training period. We report the initial experience of a surgeon using a robot system at an academic medical center.

METHODS

We retrospectively reviewed all patients undergoing robot-assisted pedicle screw placement at a single tertiary care institution by 1 surgeon from 10/2017 to 05/2022. Linear regression, analysis of variance, and cumulative sum analysis were used to evaluate operative time learning curves. Operative time subanalyses for surgery indication, number of levels, and experience level were performed.

RESULTS

In total, 234 cases were analyzed. A significant 0.19-minute decrease in operative time per case was observed (r = 0.14, P = .03). After 234 operations, this translates to a reduction in 44.5 minutes from the first to last case. A linear relationship was observed between case number and operative time in patients with spondylolisthesis (-0.63 minutes/case, r = 0.41, P < .001), 2-level involvement (-0.35 minutes/case, r = 0.19, P = .05), and 4-or-more-level involvement (-1.29 minutes/case, r = 0.24, P = .05). This resulted in reductions in operative time ranging from 39 minutes to 1.5 hours. Continued reductions in operative time were observed across the learning, experienced, and expert phases, which had mean operative times of 214, 197, and 146 minutes, respectively ( P < .001). General proficiency in robot-assisted surgery was observed after the 20th case. However, 67 cases were required to reach mastery, defined as the inflection point of the cumulative sum curve.

CONCLUSION

This study documents the long-term learning curve of a fellowship-trained spine neurosurgeon. Operative time significantly decreased with more experience. Although gaining comfort with robotic systems may be challenging or require additional training, it can benefit surgeons and patients alike with continued reductions in operative time.

Characteristics of the learning curve in robotic thoracic surgery in an emerging country

It is not established which factors impact the learning curve (LC) in robotic thoracic surgery (RTS), especially in emerging countries. The aim of this study is to analyze LC in RTS in Brazil and identify factors that can accelerate LC. We selected the first cases of two Brazilian surgeons who started their LC. We used CUSUM and the Lowess technique to measure LC for each surgeon and Poisson regression to assess factors associated with shorter console time (CT). 58 patients were operated by each surgeon and included in the analysis. Surgeries performed were different: Surgeon I (SI) performed 54 lobectomies (93.11%), whereas Surgeon II (SII) had a varied mix of cases. SI was proctored in his first 10 cases (17.24%), while SII in his first 41 cases (70.68%). The mean interval between surgeries was 8 days for SI and 16 days for SII. There were differences in the LC phases of the two surgeons, mainly regarding complications and conversions. There was shorter CT by 30% in the presence of a proctor, and by 20% with the Da Vinci Xi. Mix of cases did not seem to contribute to faster LC. Higher frequency between surgeries seems to be associated with a faster curve. Presence of proctor and use of bolder technologies reduced console time. We wonder if in phase 3 it is necessary to keep a proctor on complex cases to avoid serious complications. More studies are necessary to understand which factors impact the LC.

Robotic versus Video-Assisted Thoracic Surgery for Lung Cancer: Short-Term Outcomes of a Propensity Matched Analysis

Robot-assisted thoracic surgery (RATS) has gained popularity for the treatment of lung cancer, but its quality outcome measures are still being evaluated. The purpose of this study was to compare the perioperative outcomes of lung cancer resection using RATS versus video-assisted thoracic surgery (VATS). To achieve this aim, we conducted a retrospective analysis of consecutive patients who underwent lung cancer surgery between July 2015 and December 2020. A propensity-matched analysis was performed based on patients' performance status, forced expiratory volume in 1 s% of predicted, diffusing capacity of the lungs for carbon monoxide% of predicted, and surgical procedure (lobectomy or segmentectomy). Following propensity matching, a total of 613 patients were included in the analysis, of which 328 underwent RATS, and 285 underwent VATS, with satisfactory performance indicators. The results of the analysis indicated that RATS had a significantly longer operating time than VATS (132.4 ± 37.3 versus 122.4 ± 27.7 min; mean difference of 10 min 95% CI [confidence interval], 4.2 to 15.9 min; p = 0.001). On the other hand, VATS had a significantly higher estimated blood loss compared to RATS (169.7 ± 237.2 versus 82.2 ± 195.4 mL; mean difference of 87.5 mL; 95% CI, 48.1 to 126.8 mL; p < 0.001). However, there were no significant differences between the groups in terms of the duration of chest tubes, length of hospital stay, low- and high-grade complications, as well as readmissions and mortality within 30 days after surgery. Moreover, the number of dissected lymph-node stations was significantly higher with VATS than RATS (5.9 ± 1.5 versus 4.8 ± 2.2; mean difference of 1.2; 95% CI, 0.8 to 1.5; p = 0.001). Nonetheless, the percentage of patients who were upstaged after histopathological analysis of the resected lymph nodes was similar between the two groups. In conclusion, RATS and VATS yielded comparable results for most of the short-term outcomes assessed. Further research is needed to validate the implementation of RATS and identify its potential benefits over VATS.

The learning curve of the robotic-assisted lobectomy-a systematic review and meta-analysis

Background

Early studies have illustrated the robotic lobectomy to be safe, oncologically effective, and economically feasible as a therapeutic modality in the treatment of thoracic malignancies. The 'challenging' learning curve seemingly associated with the robotic approach, however, continues to be an often-cited factor to its ongoing uptake, with the overwhelming volume of these surgeries being performed in centers of excellence where extensive experience with minimal access surgery is the norm. An exact quantification of this learning curve challenge, however, has not been made, begging the question of whether this is an outdated assumption, versus fact. This systematic review and meta-analysis sort to clarify the learning curve for robotic-assisted lobectomy based on the existing literature.

Methods

An electronic search of four databases was performed to identify relevant studies outlining the learning curve of robotic lobectomy. The primary endpoint was a clear definition of operator learning (e.g., cumulative sum chart, linear regression, outcome-specific analysis, etc.) which could be subsequently aggregated or reported. Secondary endpoints of interest included post-operative outcomes and complication rates. A meta-analysis using a random effects model of proportions or means was applied, as appropriate.

Results

The search strategy identified twenty-two studies relevant for inclusion. A total of 3,246 patients (30% male) receiving robotic-assisted thoracic surgery (RATS) were identified. The mean age of the cohort was 65.3±5.0 years. Mean operative, console and dock time was 190.5±53.8, 125.8±33.9 and 10.2±4.0 minutes, respectively. Length of hospital stay was 6.1±4.6 days. Technical proficiency with the robotic-assisted lobectomy was achieved at a mean of 25.3±12.6 cases.

Conclusions

The robotic-assisted lobectomy has been illustrated to have a reasonable learning curve profile based on the existing literature. Current evidence on the oncologic efficacy and purported benefits of the robotic approach will be bolstered by the results of upcoming randomized trials, which will be critical in supporting RATS uptake.

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.

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.

Trends of utilization and perioperative outcomes of robotic and video-assisted thoracoscopic surgery in patients with lung cancer undergoing minimally invasive resection in the United States

OBJECTIVE

The objective of this study was to evaluate utilization and perioperative outcomes of video-assisted thoracoscopic surgery (VATS) or robotic-assisted thoracoscopic surgery (RATS) for lung cancer in the United States using a nationally representative database.

METHODS

Hospital admissions for lobectomy or sublobar resection (segmentectomy or wedge resection) using VATS or RATS in patients with nonmetastatic lung cancer from October 2015 through December 2018 in the National Inpatient Sample were studied. Patient and hospital characteristics, perioperative complications and mortality, length of stay (LOS), and total hospital cost were compared. Logistic regression was used to assess whether the surgical approach was independently associated with adverse outcomes.

RESULTS

There were 83,105 patients who had VATS (n = 65,375) or RATS (n = 17,710) for lobectomy (72.7% VATS) or sublobar resection (84.2% VATS). Utilization of RATS for lobectomy and sublobar resection increased from 19.2% to 34% and 7.3% to 22%, respectively. Mortality, LOS, and conversion rates were comparable. The cost was higher for RATS (P <.01). Multivariate analyses showed comparable RATS and VATS complications with no independent association between the minimally invasive surgery approach used and adverse surgical outcomes, except for a decreased risk of pneumonia with RATS, relative to VATS sublobar resection (P <.01). Thoracic complication rates and LOS decreased after RATS lobectomy in 2018, compared with previous years (P <.005).

CONCLUSIONS

The utilization of robotic-assisted lung resection for cancer has increased in the United States between 2015 and 2018 for sublobar resection and lobectomy. In adjusted regression analysis, compared with VATS, patients who underwent RATS had similar complication rates and LOS. The robotic approach was associated with increased total hospital cost. LOS and thoracic complication rates trended down after RATS lobectomy.

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.

[Port-only 4-Arms Robotic Segmentectomy Under Artificial Pneumothorax]

BACKGROUND

At present, robotic surgery is widely used in thoracic surgery, which has higher maneuverability, precision, and stability, especially for small space complex operations and reconstructive surgery. The advantages of robotic lung segment resection under full orifice artificial pneumothorax are obvious.

METHODS

Based on a large number of clinical practices, we established a set of surgical methods for 4-arm robotic lung segment resection under a port-only artificial pneumothorax. 98 cases of robotic lung segment resection were performed with this method from January 2019 to August 2022. The clinical experience was summarized.

RESULTS

Robotic lung segment resection under port-only artificial pneumothorax has obvious advantages in the anatomy of lung segment vessels and bronchi. It is characterized by less bleeding, shorter operation time, adequate exposure, and flexible operation.

CONCLUSIONS

This surgical model we propose optimizes the operation mode and technique of lung segment resection, makes each step procedural, reduces collateral damage, and is easy to learn and master, which is believed to cure more lung cancer patients with less trauma.

Robotic approach for pediatric pulmonary resection: preliminary investigation and comparative study with thoracoscopic approach

BACKGROUND

Minimal invasive pulmonary resection in children is challenging, irrespective of whether it is conducted using a robot or a thoracoscope. This study presents the preliminary results of pediatric robotic pulmonary resection (RPR) and comparison outcomes with conventional thoracoscopic pulmonary resection (TPR).

METHODS

This is a retrospective study conducted in patients underwent RPR (RPR group; n=30) and TPR (TPR group; n=44). The clinical data, including operative time, post-operative body temperature, surgical complications, surgeon's workload (by NASA-TLX), postoperative hospital stay, and scar score (using the SCAR scale), of both the RPR and TPR groups were collected and compared.

RESULTS

Both groups had similar age and weight. The youngest patient belonged to the RPR group and was 6 months old and weighed 8 kg. One case in the RPR group and two in the TPR group were converted to thoracotomy. RPR had a longer total operative time (148.3±36.8 min), but a shorter pure operative time (103.9±28.5 min) than those of the TPR group [118.3±22.5 (P<0.001) and 111.4±18.3 min (P=0.045), respectively]. Compared to the TPR group, fewer patients in the RPR group reported fever postoperatively (2/29 vs. 11/42, P=0.039). The workload of the surgeons was also lower in the RPR group (55.2±4.7 vs. 62.9±6.0, P<0.01). No significant difference was observed in perioperative complications, drainage length, postoperative hospital stays, and scar score of the two groups.

CONCLUSIONS

The safety and effectiveness of the robotic approach are similar to those of the thoracoscopic surgery for pediatric pulmonary resection in children heavier than 8 kg. In addition, the robotic approach shows improved operative dissection efficiency and accuracy for patients and reduced workload for surgeons. Hence, it is beneficial to both surgeons and patients.

A universal incision for robot-assisted thoracic surgery

Objective

This paper aimed to design and explore the versatility of the incision for the robot-assisted thoracic surgery.

Methods

The concept of universal incision was designed and put forward. The clinical data of 342 cases of robot-assisted thoracic surgery were summarized, including sex, age, clinical diagnosis, operative method, operative time, conversion to thoracotomy, intraoperative blood loss, number of lymph node dissections, postoperative hospital stays, postoperative pathology, and postoperative complications of the patients.

Results

The 342 cases of robot-assisted surgery included 178 pulmonary surgery cases (94 lobectomy cases, 75 segmentectomy cases, 6 wedge resection cases, and 3 sleeve lobectomy cases), 112 esophageal surgery cases (107 McKeown approach cases and 5 esophageal leiomyoma resection cases), and 52 mediastinal tumor cases (42 anterior mediastinum cases and 10 posterior mediastinum cases). Among these, two cases were converted to thoracotomy (both esophageal cases), and the rest were successful with no massive intraoperative bleeding and no perioperative death.

Conclusion

The universal incision of robot-assisted thoracic surgery is safe and feasible and is suitable for most cases of thoracic surgery.

The role of the bedside assistant in robot-assisted surgery: A critical synthesis

INTRODUCTION

Robot-assisted surgery has grown exponentially since its inception and first approval in the United States in the year 2000. The surgeon operating with the assistance of the robot sits remotely to the patient and another practitioner assists at the bedside. The role of the bedside assistant and the training that is required to undertake this role are understudied topics.

AIM

To explore the functions, training and professional development of the bedside assistant in robot-assisted surgery and propose the necessary foundations for the safe enactment of the role in the United Kingdom.

METHODS

Through critical interpretative synthesis, relevant literature was systematically searched and analysed to inform integration of evidence.

RESULTS

Seventy-three studies were retrieved from the literature, across several health care disciplines and surgical specialities. These were critically analysed to inform a theoretically sound account grounded on evidence.

CONCLUSION

The role, functions and skills of the bedside assistant in robot-assisted surgery vary across contexts. These were analysed and critically synthetised to produce several keys to the success of bedside assistants in robot-assisted surgery in the context of the United Kingdom and of its national regulations.

Learning curves of robot-assisted pedicle screw fixations based on the cumulative sum test

BACKGROUND

In robot-assisted (RA) spine surgery, the relationship between the surgical outcome and the learning curve remains to be evaluated.

AIM

To analyze the learning curve of RA pedicle screw fixation (PSF) through fitting the operation time curve based on the cumulative summation method.

METHODS

RA PSFs that were initially completed by two surgeons at the Beijing Jishuitan Hospital from July 2016 to March 2019 were analyzed retrospectively. Based on the cumulative sum of the operation time, the learning curves of the two surgeons were drawn and fit to polynomial curves. The learning curve was divided into the early and late stages according to the shape of the fitted curve. The operation time and screw accuracy were compared between the stages.

RESULTS

The turning point of the learning curves from Surgeons A and B appeared in the 18^th and 17^th cases, respectively. The operation time [150 (128, 188) min vs 120 (105, 150) min, P = 0.002] and the screw accuracy (87.50% vs 96.30%, P = 0.026) of RA surgeries performed by Surgeon A were significantly improved after he completed 18 cases. In the case of Surgeon B, the operation time (177.35 ± 28.18 min vs 150.00 ± 34.64 min, P = 0.024) was significantly reduced, and the screw accuracy (91.18% vs 96.15%, P = 0.475) was slightly improved after the surgeon completed 17 RA surgeries.

CONCLUSION

After completing 17 to 18 cases of RA PSFs, surgeons can pass the learning phase of RA technology. The operation time is reduced afterward, and the screw accuracy shows a trend of improvement.

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.

Analysis of the short-term outcomes of biportal robot-assisted lobectomy

BACKGROUND

The present study aimed to assess the short-term consequences of biportal robot-assisted lobectomy, validating its safety and effectiveness.

METHODS

A retrospective analysis evaluated the clinical data and short-term results of 18 patients in the single medical group of the centre who underwent biportal robot-assisted lobectomy plus lymph node dissection from November 2020 to March 2021.

RESULTS

Lobectomy and lymph node dissection could be successfully accomplished in all 18 patients with the assistance of a biportal robot; there was no conversion to thoracotomy during the operation. There were 10 males and 8 females with their ages ranging from 37 to 73 (58.83 ± 9.07) years. The total operation time was 74-146 (105.06 ± 18.22) min. Punching time was 2-9 (5.11 ± 1.74) min. Docking time was 8-16 (11.94 ± 2.41) min. Console time was 50-104 (78.06 ± 17.40) min. Chest closing time was 8-17 (10.28 ± 2.74) min. Blood loss was 60-132 (94.11 ± 41.41) ml. The number of lymph nodes dissected was 16-30 (21.78 ± 4.13). Chest tube duration was 2-10 (4.06 ± 1.98) days. Drainage on the first day following surgery was 100-500 (337.22 ± 117.01) ml. Total drainage was 370-1100 (692.78 ± 161.01) ml. Duration of hospital stay was 4-12 (5.89 ± 1.94) days. The median 24 and 72 h visual analogue score scores were 4 (3-7) and 3 (2-5). Total cost (¥) was 51 000-85 000 (68 000 ± 10 000), respectively. There was one case of atrial fibrillation and one case of pulmonary infection. The complication rate was 11.11%. No serious complications were recorded after surgery, and no deaths occurred within 30 days post-surgery. The final pathological diagnosis revealed 10 cases of squamous cell carcinoma, 7 cases of adenocarcinoma and 1 case of benign disease.

CONCLUSION

The biportal robot-assisted lobectomy was found to be safe and effective in the treatment of lung cancer.

Robot-Assisted Thoracic Surgery in Non-small Cell Lung Cancer

Lobectomy is the standard treatment for early non-small cell lung cancer. Various surgical techniques for lobectomy have been developed, and minimally invasive thoracic surgery, such as video-assisted thoracic surgery or robot-assisted thoracic surgery, has been considered as an alternative to conventional open thoracotomy. The recently robotic lobectomy technique has developed since the first case series was published in 2002. Several studies have reported that robotic lobectomy has comparable oncologic and perioperative outcomes to those of video-assisted thoracic surgery lobectomy and open lobectomy. However, robotic lobectomy remains a challenge for surgeons because of the steep learning curve, reduced tactile sensation, difficulty in port placement, and challenges in cooperation between the surgeon and assistant. Many studies have reported on robotic lobectomy, but few have presented surgical techniques for robotic lobectomy. In this article, the surgical techniques and optimal performance of robotic lobectomy are described in detail for all 5 types of lobectomy for surgeons beginning with robotic lobectomy.

Robotic anatomical lung resections: Analysis of the learning curve

INTRODUCTION

Robotic surgery has become a safe and effective approach for the treatment of pulmonary surgical pathology. However, the adoption of new surgical techniques requires the evaluation of the learning curve. The objective of this study is to analyze the learning curve of robotic anatomical lung resections.

METHODS

Retrospective analysis of all robotic anatomical lung resections performed by the same surgeon between June 2018 and March 2020. The learning curve was evaluated using CUSUM charts to estimate trend changes in surgical time, surgical failure and the occurrence of post-operative cardiorespiratory complications throughout the sequence of cases.

RESULTS

The study included a total of 73 cases. The median duration of all complications was 120 min (interquartile range: 90-150 min), the prevalence of surgical failure was 23.29%, while 4/73 patients had any postoperative cardiorespiratory complication. Based on the CUSUM analysis, the learning curve was divided into 3 different phases: phase i (from the first to the 14th intervention), phase ii (between the 15th and 30th intervention) and phase iii (from the 31st intervention).

CONCLUSIONS

The learning curve for robotic anatomical lung resections can be divided into 3 phases. The technical competence that guarantees satisfactory perioperative outcomes was achived in phase iii from the 31st intervention.

[Robot-assisted thoracic surgery-Areas of application and limitations]

The proportion of robot-assisted thoracic surgery (RATS) is continuously increasing. The main areas of clinical application are anatomical lung resections with lymphadenectomy and resection of mediastinal tumors. Especially in the area of the thymus robot-assisted procedures can now be considered the gold standard. Overall, the limitations of video-assisted thoracoscopic surgery (VATS) can be overcome by the use of robot-assisted surgery and thus a larger proportion of patients can be treated with minimally invasive procedures. The safety of the RATS procedure has been repeatedly demonstrated, although it remains difficult to demonstrate scientifically measurable benefits. With the introduction of new systems on the market further technical evolution and improvement can be expected in the future.

Robotic anatomical lung resections: Analysis of the learning curve

INTRODUCTION

Robotic surgery has become a safe and effective approach for the treatment of pulmonary surgical pathology. However, the adoption of new surgical techniques requires the evaluation of the learning curve. The objective of this study is to analyze the learning curve of robotic anatomical lung resections.

METHODS

Retrospective analysis of all robotic anatomical lung resections performed by the same surgeon between June 2018 and March 2020. The learning curve was evaluated using CUSUM charts to estimate trend changes in surgical time, surgical failure and the occurrence of post-operative cardiorespiratory complications throughout the sequence of cases.

RESULTS

The study included a total of 73 cases. The median duration of all complications was 120min (interquartile range: 90-150min), the prevalence of surgical failure was 23.29%, while 4/73 patients had any postoperative cardiorespiratory complication. Based on the CUSUM analysis, the learning curve was divided into 3 different phases: phase i (from the first to the 14th intervention), phase ii (between the 15th and 30th intervention) and phase iii (from the 31st intervention).

CONCLUSIONS

The learning curve for robotic anatomical lung resections can be divided into 3 phases. The technical competence that guarantees satisfactory perioperative outcomes was achived in phase iii from the 31st intervention.

Robotic-assisted tracheobronchial surgery

Robotic technology is positioned to transform the approach to tracheobronchial surgery. With its magnified 3D view, intuitive controls, wristed-instruments, high-fidelity simulation platforms, and the steady implementation of new technical improvement, the robot is well-suited to manage the careful dissection and delicate handling of the airway in tracheobronchial surgery. This innovative technology has the potential to promote the widespread adoption of minimally invasive techniques for this complex thoracic surgery.

Impact of bedside assistant on outcomes of robotic thyroid surgery: A STROBE-compliant retrospective case-control study

The importance of bedside assistants has been well established in various robotic procedures. However, the effect of assistants on the surgical outcomes of thyroid surgery remains unclear. We investigated the effects of a dedicated robot assistant (DRA) in robotic thyroidectomy. We also evaluated the learning curve of the DRA.Between January 2016 and December 2019, 191 patients underwent robotic total thyroidectomy, all of which were performed by a single surgeon. The DRA participated in 93 cases, while non-dedicated assistants (NRAs) helped with 98 cases. Demographic data, pathologic data, operative times, and postoperative complications were recorded and analyzed.Robotic thyroidectomy was successful in all 191 patients, and none required conversion to the conventional open procedure. Mean operative time was shorter in the DRA group than in the NRA group (183.2 ± 33.6 minutes vs 203.1 ± 37.9 minutes; P < .001). There were no significant differences in terms of sex distribution, age, preoperative serum thyroid stimulating hormone level, or pathologic characteristics between the groups. Cumulative summation analysis showed that it took 36 cases for the DRA to significantly reduce operative time. Mean operative time decreased significantly in the subgroup including the 37th to the 93rd DRA cases compared with the subgroup including only the first 36 DRA cases (199.7 ± 37.3 minutes vs 172.8 ± 26.4 minutes; P < .001). NRA group showed no definite decrease of operation time, which indicated that the NRAs did not significantly deviate from the mean performance.Increased experience of the bedside assistant reduced operative times in the robotic thyroidectomy. Assistant training should be considered as a component of robotic surgery training programs.

Perioperative outcomes of robot-assisted vs video-assisted and traditional open thoracic surgery for lung cancer: A systematic review and network meta-analysis

BACKGROUND

The superiority of robot-assisted thoracic surgery (RATS) over video-assisted thoracic surgery (VATS) and thoracotomy remains controversial for lung cancer.

METHODS

A network meta-analysis (NMA) and pairwise meta-analysis (PMA) were performed to evaluate the perioperative outcomes using five databases.

RESULTS

Thirty-two studies involving 6593 patients were included for analysis. The NMA showed that RATS had similar operative time, conversion rate to thoracotomy, number of lymph node, postoperative morbidity, and length of hospital stay with VATS, except for lower 30-day mortality. Compared with thoracotomy, longer operative time and shorter hospital stay were observed in RATS, but no significant difference was observed in number of lymph node, postoperative morbidity, and 30-day mortality in both NMA and PMA. In lobectomy/segmentectomy subgroup, all outcomes, except for operative time of RATS vs VATS and number of lymph node, were similar with overall analyses.

CONCLUSIONS

RATS had comparable perioperative outcomes with VATS and open surgery.

[Robotics in thoracic surgery]

The number of interventions using robot-assisted thoracic surgery (RATS) is increasing in Germany, following the previous international development. Robot-assisted surgery provides some technical advantages and can overcome existing limitations of video-assisted thoracic surgery (VATS), especially in the case of extended resections, thus enabling the proportion of minimally invasive operations to be further increased. The safety of the procedure, even in extended resections, has repeatedly been demonstrated but whether there are clinically relevant benefits from RATS is currently the subject of scientific discussions. In addition, a further technical evolution of the RATS can be postulated by the upcoming market introduction of new robotic systems.

[Robot-assisted Lobectomy under Port-only Mode with Artificial Pneumothorax]

背景与目的

达芬奇机器人手术操作系统目前在胸外科得到了广泛的应用，国内不同中心采用的建立通道方式及操作流程，不同辅助操作孔多采用小切口的方式。

方法

基于大量临床实践的基础上，我们在实践中总结国内、外经验，并结合国人体型特点，对机器人辅助肺叶切除术的切口及操作流程进行了改进并实践出一套更加简化易行的手术方法。

结果

全孔道（port-only）人工气胸下机器人辅助肺叶切除术在术中解剖安全性，止血效果和伤口美观性方面，都有进一步的提升。

结论

本研究对全孔道人工气胸机器人辅助肺叶切除的流程加以优化，以期为肺癌患者更好地服务。