Robotic Lung Resection Research Articles

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.

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. 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. 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. 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 open-thoracotomy-view approach using vertical port placement and confronting monitor setting.

Robotic lung resections (RLRs) are conventionally performed using look-up views of the thorax from the caudal side. To conduct RLR with views similar to those in open thoracotomy, we adopted a vertical port placement and confronting upside-down monitor setting, which we called robotic 'open-thoracotomy-view approach'. We herein present our experience of this procedure. We retrospectively reviewed 58 patients who underwent RLR (43 with lobectomy; 15 with segmentectomy) with 3-arm open-thoracotomy-view approach using the da Vinci Surgical System between February 2019 and October 2020. The patient cart was rolled in from the left cranial side of the patient regardless of the side to be operated on. Robotic ports were vertically placed along the axillary line, and 2 confronting monitors and 2 assistants were positioned on each side of the patient. The right-side monitor, which was set up for the left-side assistant to view, projected the upside-down image of the console surgeon's view. All procedures were safely performed. The median duration of surgery and console operation was 215 and 164 min, respectively. Emergency conversion into thoracotomy and severe morbidities did not occur, and the median postoperative hospitalization duration was 3 days. In all procedures, the console surgeon and 2 assistants had direct 'bird-eye' views of the cranially located intrathoracic structures and instrument tips, which are sometimes undetectable with the conventional look-up view. The open-thoracotomy-view approach setting is a possible option for RLR. It offers natural thoracotomy views and can circumvent some of the known limitations of the conventional procedure.

Activity-Based Cost Analysis of Robotic Anatomic Lung Resection During Program Implementation

BackgroundWhile robotic-assisted lung resection has seen a significant rise in adoption, concerns remain regarding initial programmatic outcomes and potential increased costs. We present our initial outcomes and cost analysis since initiation of a robotic lung resection program. MethodsPatients undergoing either video-assisted thoracoscopic lobectomy or segmentectomy (VATS) or robotic-assisted lobectomy or segmentectomy (RALS) between August of 2014 and January of 2017 underwent retrospective review. Patients underwent 1:1 propensity matching based on preoperative characteristics. Perioperative and 30-day outcomes were compared between groups. Detailed activity-based costing analysis was performed on individual patient encounters taking into effect direct and indirect controllable costs, including robotic operative supplies. ResultsThere were no differences in 30-day mortality between RALS (n = 74) and VATS (n = 74) groups (0% vs 1.4%; P = 1). RALS patients had a decreased median length of stay (4 days vs 7 days; P < .001) and decreased median chest tube duration (3 days vs 5 days, P < .001). Total direct costs, including direct supply costs, were not significantly different between RALS and VATS ($6621 vs $6483; P = .784). Median total operating costs and total unit support costs, which are closely correlated to length of stay, were lower in the RALS group. Overall median controllable costs were significantly different between RALS and VATS ($16,352 vs $21,154; P = .025). ConclusionsA potentially cost-advantageous robotic-assisted pulmonary resection program can be initiated within the context of an existing minimally invasive thoracic surgery program while maintaining good clinical outcomes when compared with traditional VATS. Process-of-care changes associated with RALS may account for decreased costs in this setting.

Robotic right upper lobectomy: Twelve steps.

Robotic right upper lobectomy: Twelve steps.

Robot-assisted lobectomy versus completely portal robotic lobectomy: What is the difference?

Background This study aims to compare robot-assisted lobectomy versus completely portal robotic lobectomy. Methods Between January 2014 and December 2019, a total of 41 patients (10 males, 31 females; median age 62 years; range, 50 to 68 years) underwent robotic anatomical pulmonary resection in our institution were retrospectively analyzed. The patients were consecutively divided into two groups: the first 20 (48.8%) patients underwent pulmonary resection by robot-assisted lobectomy technique, while the next 21 (51.2%) patients underwent pulmonary resection by completely portal robotic lobectomy with four arms. Data including age, sex, diagnosis, surgery type and duration, rate of conversion to open surgery, and length of stay of the patients were recorded. The operation time, docking time, console time, and closure duration for each patient were also noted. Results There was no statistically significant difference in age, sex, comorbidities, complications, length of hospital stay, adequate lymph node staging, or tumor size and side between the two groups (p>0.05). However, the mean console and operation times were statistically significantly shorter in the patients receiving completely portal robotic lobectomy with four arms (p=0.001). Conclusion The advantage of completely portal robotic lobectomy with four arms is relative, although it significantly shortens the operation time. Based on our experiences, this technique may be preferred in case of inadequate lung deflation, as carbon dioxide insufflation allows sufficient workspace for robotic lung resection.

Techniques for robotic lung resection

Background: Minimally invasive approaches to anatomic lung resections including lobectomy and segmentectomy are becoming more pervasive. The robotic-assisted approach is the newest of minimally invasive techniques and includes advantages in terms of mechanics and optics. Here, general considerations and steps to robotic-assisted anatomic lung resections are presented.

Advanced robotic resections in lung cancer

: Locally advanced tumors require multiple strategies for safe resection. Use of a robotic platform offers several advantages that assist the surgeon with successful minimally invasive resection of complex pathology. This paper discusses technical considerations for robotic lung resections requiring resection in post-treatment field, sleeve bronchoplasty, chest wall resection, or pneumonectomy. With these strategies, the benefits of minimally invasive surgery can be conferred to patients with locally advanced disease who may otherwise require an open approach.

The association of robotic lobectomy volume and nodal upstaging in non-small cell lung cancer.

Robotic lung resection for lung cancer has gained popularity over the last 10 years. As with many surgical techniques, there are improvements in outcomes associated with increased operative volume. We sought to investigate lymph-node harvest and upstaging rates for robotic lobectomies performed at hospitals with varying robotic experience. The National Cancer Data Base was queried for patients with early stage non-small cell lung cancer who received lobectomy between 2010 and 2015. Hospitals were stratified into volume categories based on the number of robotic resections performed, as a proxy for robotic experience: low at ≤ 12, low-middle 13-26, middle-high 27-52, and high volume at greaterthanor equal to 53. Lymph-node counts and nodal upstaging were compared among these volume categories. 8360 robotic lobectomies were performed. Mean lymph-node counts were forlow, low-middle, middle-high, and high-volume robotic lobectomies were 9.8, 11.4, 12.9, and 12.6, respectively (P < 0.001),whilenodal-upstaging rates were10.3%, 10.2%, 12.8%, and 13.4%, respectively (P < 0.001). Compared to low-volume hospitals, on multivariable analysis,high-volume robotic centers had increased nodal harvest (P < 0.001) and nodal-upstaging rates (P < 0.001). Robotic lobectomies performed at high-volume hospitals have greater lymph-node harvest and upstaging than low-volume hospitals.

Defining the learning curve of robotic thoracic surgery: what does it take?

Controversy exists as to what constitutes a learning curve to achieve competency, and how the initial learning period of robotic thoracic surgery should be approached. We conducted a systematic review of the literature published prior to December 2018 using PubMed/MEDLINE for studies of surgeons adopting the robotic approach for anatomic lung resection or thymectomy. Changes in operating room time and outcomes based on number of cases performed, type of procedure, and existing proficiency with video-assisted thoracoscopic surgery (VATS) were examined. Twelve observational studies were analyzed, including nine studies on robotic lung resection and three studies on thymectomy. All studies showed a reduction in operative time withan increasing number of cases performed. A steep learning curve was described for thymectomy, with a decrease in operating room time in the first 15 cases and a plateau after 15-20 cases. For anatomic lung resection, the number of cases to achieve a plateau in operative time ranged between 15-20 cases and 40-60 cases. All but two studies had at least some VATS experience. Six studies reported on experience of over one hundred cases and showed continued gradual improvements in operating room time. The learning curve for robotic thoracic surgery appears to be rapid with most studies indicating the steepest improvement in operating time occurring in the initial 15-20 cases for thymectomy and 20-40 cases for anatomic lung resection. Existing data can guide a standardized robotic curriculum for rapid adaptation, and aid credentialing and quality monitoring for robotic thoracic surgery programs.

Comparative study of anatomic lung resection by robotic vs. video-assisted thoracoscopic surgery.

Comparative studies of robotic lung resection are limited. Our study aims to compare short-term and long-term outcomes of anatomic lung resection by robotic or video-assisted thoracoscopic surgery (VATS) from a single surgeon experienced in both approaches. A retrospective analysis of consecutive anatomic lung resections by robot or VATS was performed to compare perioperative characteristics and long-term survival. From December 2010 to June 2015, 61 patients underwent robotic surgery, and 105 patients underwent VATS. Patient demographics were similar except that the VATS group had higher percentage of diabetic patients (robotic 14.75% vs. VATS 30.48%, P=0.0258) and a slightly lower percentage of patients with previous cancer history (robotic 57.38% vs. VATS 40.95%, P=0.0409). The robotic group had a higher rate of prolonged air leak ≥7 d (robotic 14.75% vs. VATS 3.81%; P=0.0161), and a modestly longer length of hospital stay (robotic median of 4.0 days vs. VATS median of 3.0 days, P=0.0123). Other postoperative complications, mortality, nodal upstaging and conversion rate were similar. Disease-free survival was not different. The robotic group appeared to have slightly better overall survival, however, this observation was confounded by a lower percentage of diabetic patients in this group. Further analysis has demonstrated that in non-diabetic patients who underwent either surgery, the overall survival remained similar. The same observation was also made in diabetic patients. Robotic anatomic lung resection appears to be associated with a higher rate of prolonged air leak (≥7 d), and resulting slightly longer length of hospital stay than VATS. Within the same follow-up period, both the disease-free survival and the overall survival are similar.

Pain control using liposomal bupivacaine versus bupivacaine for robotic assisted thoracic surgery

Background Despite a trend towards minimally invasive thoracic surgeries over thoracotomies, patients can still experience significant post-operative pain. Literature on the use of liposomal bupivacaine in patients undergoing robotic surgeries is lacking. Objective To compare pain control via intercostal nerve block with liposomal bupivacaine to bupivacaine for patients undergoing robotic assisted thoracic surgery. Setting A455 bed community hospital. Methods This was a prospective observational study with a historical control group of 96 patients who underwent robotic lung resection. Patients in the control group received bupivacaine, while the intervention group received liposomal bupivacaine. Main outcome measure Average pain scores 24, 48, and 72h after surgery. Results There were no significant differences in average pain scores between groups. The frequency of ketorolac use on the first post-operative day was lower for those who received liposomal bupivacaine. There were no significant differences in opioid requirements, length of stay, or rate of complications. Conclusions There was no significant difference in post-operative pain control between patients receiving liposomal bupivacaine and bupivacaine for robotic assisted surgery.

Credentialing for robotic lobectomy: what is the learning curve? A retrospective analysis of 272 consecutive cases by a single surgeon.

Credentialing processes for surgeons seeking robotic thoracic surgical privileges are not evidence-based, and the learning curve has not been reported. The goal of this study is to review our experience with robotic lobectomies and provide evidence for the development of a more uniform credentialing process. We performed a retrospective review of the first 272 consecutive robotic lobectomies performed between 2011 and 2017 by a single surgeon with prior video-assisted thoracoscopic (VATS) experience. Primary outcomes were operative duration, blood loss, chest tube duration, length of hospital stay, intraoperative complication, and conversion to thoracotomy. The patients were subdivided by surgical date into two cohorts of 120 consecutive patients to compare differences in outcomes, thereby illustrating the learning curve. Between 2011 and 2017, 272 patients (median age 67.5years) underwent a robotic lobectomy by a single surgeon. The majority of patients (157/272) had early stage (T1N0) adenocarcinoma. For the entire cohort, median operative time was 160min (83-317min). The median blood loss was 75mL (10-4000mL). Median chest tube duration was 2days (1-23days) and median hospital stay was 3days (1-25days). Intraoperative complications occurred in seven patients. Only six patients required conversion to thoracotomy. Using multivariable logistic regression, it was found that the age, gender, and stage do not factor into conversion to thoracotomy, but BMI was found to be a significant covariate (p 0.043). As the surgeon performs more surgeries, there is a significantly shorter operative time (p < 0.001), decreased blood loss (p < 0.001), and shorter hospital stay (p < 0.014). When the first 120 and last 120 surgeries were compared, there was significantly less blood loss (234.6 vs 78.69cc, p < 0.001), shorter operative time (181.9 vs 147.4min, p < 0.001), shorter tube duration (3.49 vs 3.11 days, p 0.007), and shorter length of stay (4.03 vs 3.48 days, p < 0.001), respectively. More intraoperative complications were observed during the first 120 surgeries (6/120) compared to the last 120 surgeries (0/120; Fischer exact p = 0.029). Regression model plots did not show any apparent and significant change points, but rather a steady improvement. The more cases the surgeon does, the better is the outcome in terms of operative duration, blood loss, post-operative length of stay and intraoperative complications. The learning curve for robotic surgery for a surgeon with prior VATS experience is that of a continuous improvement with experience instead of a particular change point. Since most thoracic surgeons who perform robotic-assisted surgery have already gotten past their VATS learning curves, they no longer have a definable learning curve for robotic surgery. Hence, if a surgeon is already proficient and credentialed to perform VATS lung resections, he or she is no longer faced with a significant learning curve for robotic lung resections, and should be credentialed to do so once he or she has undergone the appropriate training with the equipment and technology.

Different techniques in robotic lung resection

We read with great interest the article of Jin and co-authors describing a left lower lung lobectomy performed with robotic technique (1). The robotic approach for surgical treatment of lung cancer was first introduced in 2002 (2). The initial spread of this technique has been slow because many limitations were emphasized, such as the spatial footprint of the apparatus, the complexity in installing the robot’s arms into the patient’s chest and the increased duration of surgery; operating at a distance from the patient was also considered a source of anxiety by many surgeons. As a result, time was needed to gain confidence with the new apparatus and change the surgeons’ mentality for accepting the new procedure.

Four arm robotic-assisted pulmonary resection-right upper lobectomy: how to do it.

Numerous published articles have shown the safety and efficacy of robotic lung resection, including lobectomy. Several techniques have been described by different authors to perform a robot assisted lung lobectomy. We adopted four arms robotic procedure. We usually perform three ports (10-15 mm) and an anterior 3 to 4 cm utility incision. This technique allows to safely proceed with an anterior to posterior approach to the hilum. In this study, we present in clear and sequential steps, the procedure to perform a right upper lobectomy for early stage lung cancer. We also supply a high-quality video, operative tips and a preference cards.

Four arms robotic-assisted pulmonary resection-left lower lobectomy: how to do it.

Numerous published articles have shown the safety and efficacy of robotic lung resection, including lobectomy. The robotic approach offers similar survival rate to the open and video-assisted thoracoscopic surgery methods. Potential advantages provided by robotic technology, such as three-dimensional (3D) high-quality camera, wristed tools and ergonomic ease that seems to overcome certain video-assisted thoracic surgery (VATS) limits have been widely described. Several techniques have been developed by different surgeons to perform a robotic lobectomy. In this study, we present our technique for performing a four-arm robotic lobectomy for the treatment of early stage lung cancer. This is shown in clear, sequential steps. We also provide an instrument preference card, some operative tips and a high-quality video.

Preface for robotic lung resections.

In the past decade, robotic thoracic surgery for atomic lung resections became the most recent minimally invasive technique. The studies have shown its feasibility and safety.

New stapling devices in robotic surgery.

Minimally invasive thoracic surgery is rapidly diffusing worldwide. Robotic anatomic pulmonary resection is gaining popularity and acceptance in the thoracic community for the reported feasibility, safety, and good outcomes. The last available robotic system, da Vinci Xi System, added new technical improvements on robotic device allowing best performances in robotic lung resection. We report our initial experience in the use of EndoWrist Stapler during robotic anatomic surgery for lung cancer.

Catastrophes and complicated intraoperative events during robotic lung resection.

Intraoperative complications and catastrophes are an accepted and perhaps inevitable aspect of all surgeries. Anatomic pulmonary resection puts in close proximity the tracheal-bronchial tree, pulmonary vasculature, heart and great vessels within the small volume area of the chest. Fortunately, major complications and catastrophes are uncommon regardless of surgical approach. Pulmonary arterial injury is the most frequently reported. Most injuries necessitate a thoracotomy for definitive management though novel techniques are emerging for minimally invasive management. This section focuses on intraoperative pulmonary artery and vein injuries, major airway injuries and transections, injuries to major abdominal organs and effects of carbon dioxide insufflation during robotic pulmonary resection.

Robotic lung resections: video-assisted thoracic surgery based approach.

Advances in technology cause major developments in minimally invasive thoracic surgery practice. The expected benefits of minimally invasive pulmonary surgery are clear and mostly as follows; shorter hospital stay, fast recovery, less pain, and decreased morbidity and mortality. Robotic surgery with improved visualization and instrumental technical capabilities has become an attractive tool for surgeons who are performing lung resections. However, robotic surgery still seems far away from standardization even in the basic fundamental which is "the best approach for docking". In this article, we would like to share our experience in robotic surgery with video-assisted thoracic surgery (VATS) based or in other terms "robotic-assisted" approach, and discuss its advantages and disadvantages. We speculate that, especially at early experience, VATS based approach or "robotic-assisted approach" may provide a smooth start up with the support of the experienced table surgeon.

Long-term survival of early-stage non-small cell lung cancer patients who underwent robotic procedure: a propensity score-matched study.

BackgroundIn the past decade, many researchers focused on to robot-assisted surgery. However, on long-term outcomes for patients with early-stage non–small cell lung cancer (NSCLC), whether the robotic procedure is superior to video-assisted thoracic surgery (VATS) and thoracotomy is unclear. Nonetheless, in the article titled “Long-term survival based on the surgical approach to lobectomy for clinical stage I non–small cell lung cancer: comparison of robotic, video assisted thoracic surgery, and thoracotomy lobectomy” by Yang et al. that was recently published in Annals of Surgery, the authors provided convincing evidence that the robotic procedure results in similar long-term survival as compared with VATS and thoracotomy. Minimally invasive procedures typically result in shorter lengths of hospital stay, and the robotic procedure in particular results in superior lymph node assessment.Main bodyOur propensity score-matched study generated high-quality data. Based on our findings, we see promise in expanding patient access to robotic lung resections. In this study, propensity score matching minimized the bias involved between groups. Nevertheless, due to its retrospective nature, bias may still exist. Currently, the concept of rapid rehabilitation is widely accepted, and it is very difficult to set up a randomized controlled trial to compare robotic, VATS, and thoracotomy procedures for the treatment of NSCLC. Therefore, to overcome this limitation and to minimize bias, the best approach is to use a registry and prospectively collected, propensity score-matched data.ConclusionsRobotic lung resections result in similar long-term survival as compared with VATS and thoracotomy. Robot-assisted and VATS procedures are associated with short lengths of hospital stay, and the robotic procedure in particular results in superior lymph node assessment. Considering the alarming increase in the incidence of lung cancer in China, a nationwide database of prospectively collected data available for clinical research would be especially important.