Robotic Segmentectomy Research Articles

Uncommon anatomical variation of the origin of the right upper pulmonary vein detected by 3D reconstruction prior to robotic segmentectomy

Uncommon anatomical variation of the origin of the right upper pulmonary vein detected by 3D reconstruction prior to robotic segmentectomy

Early outcomes of robotic versus video-thoracoscopic anatomical segmentectomy: a propensity score-matched real-world study.

Minimally invasive anatomic segmentectomy for the resection of pulmonary nodules has significantly increased in the last years. Nevertheless, there is limited evidence on the safety and feasibility of robotic segmentectomy compared to video-assisted thoracic surgery. This study aimed to compare the real-world early outcomes of robotic and video-thoracoscopic in anatomic segmentectomy. Single centre cohort study including all consecutive patients undergoing segmentectomy by either robotic or video-thoracoscopic from June 2018 to November 2023. Propensity score case matching analysis generated two matched groups undergoing robotic or video-thoracoscopic segmentectomy. Short-term outcomes were analysed and compared between groups. 204 patients (75 robotic and 129 video-thoracoscopic patients) were included. After matching, 146 patients (73 cases in each group) were compared. One 30-day death was observed in the robotic group (P = 1). Two conversions to thoracotomy occurred in the robotic, and none in the video-thoracoscopic group (P = 0.5). Surgical time was longer in the robotic group (P = 0.091). There were no significant differences between robotic and video-thoracoscopic groups in postoperative complications (13.7% vs 15.1%, P = 1), cardiopulmonary complications (6.8% vs 6.8%, P = 1), major complications (4.1% vs 4.1%, P = 1), prolonged air leak (4.1% vs 5.5%, P = 1), arrythmia (1.4% vs 0%, P = 1) and reoperation (2.7% vs 2.7%, P = 1). Median length of stay was 3 days (IQR, 2-3 days) in the robotic group vs 3 days (IQR, 2.5-4 days) in the video-thoracoscopic group (P = 0.212). Robotic segmentectomy is a safe and feasible alternative to video-thoracoscopy, as no significant differences in early postoperative outcomes were found between the two techniques.

The process and safety of removing chest tubes 4 to 12 hours after robotic pulmonary lobectomy and segmentectomy

ObjectiveChest tubes cause pain and morbidity. MethodsThis is a quality initiative study and review of patients who underwent robotic pulmonary resection by 1 surgeon (R.J.C.). The goal was to remove chest tubes within 4 to 12 hours after robotic segmentectomy and lobectomy. Primary outcome was removal without the need for reinsertion, thoracentesis, or any morbidity due to early removal of the chest tube. Secondary outcomes were symptomatic pneumothorax, pleural effusion, chylothorax, subcutaneous emphysema, and chest tube reinsertion or thoracentesis within 60 days of surgery. ResultsBetween January 2018 and December 2022, 590 patients underwent robotic lobectomy or segmentectomy. Chest tubes were removed within 4 to 12 hours postoperatively in 63.5% of patients (375/590). In 2022, this was achieved in 91% after lobectomy (119/128) and 94% after segmentectomy (75/80). There were significantly more chest tubes removed within 4 to 12 hours postoperatively from 2020 to 2022 than pre-2020 (P < .001). Forty patients (6.8%) were discharged home on postoperative day 1 with a chest tube. Sixteen patients (2.7%) had post–chest tube removal increasing pneumothorax and subcutaneous emphysema; none required tube reinsertion. There was no 30-day or 90-day mortality. Twelve patients (2%) had an outpatient thoracentesis for effusion within 60 days. Twenty patients (3.3%) were readmitted, none seemingly related to effusions. Nonsmokers (P = .04) and segmentectomy (P = .001) were associated with chest tube removal within 4 to 12 hours of surgery. ConclusionsChest tubes can be safely removed within 4 to 12 hours after robotic segmentectomy and lobectomy. Factors associated with successful early chest tube removal are nonsmoking, segmentectomy, and team members becoming comfortable with the process.

Video Presentation: Robotic Left Superior (S6) Segmentectomy and Bronchial Sleeve Resection

Recent guidelines advocate parenchymal preserving surgery, including bronchial sleeve lobectomy for low-grade neuroendocrine tumours. Segmentectomy and bronchoplasty may further improve parenchymal preservation, whilst respecting oncological principles. Robotic-assisted thoracic surgery (RATS) bronchial sleeve lobectomy has been shown to be safe and effective. This paper reports the second-in-man robotic segmentectomy with sleeve bronchoplasty.

Robotic pulmonary segmentectomy, initial experience in the Czech Republic.

The initiation of lung cancer screening in Czechia and diagnosis in earlier stages has been reflected by an increasing demand for anatomical lung segmentectomy. The purpose of this study was to describe early results of the first robotic-assisted thoracoscopic segmentectomies performed in the country. Our institution has performed 151 robotic anatomical lung resections since the initiation of the screening program in August 2020, which enabled us to attain the status of a proctoring and case observation centre. The robotic segmentectomy program was initiated after completing 70 robotic lobectomies. We performed a retrospective analysis of the results of our first 20 patients indicated for robotic segmentectomy. Median age of the patients was 60, with 11 females and 7 males. The most common indications included primary lung malignancy (n=13), pulmonary metastasis (n=2) and benign lesions (n=3). We performed 11 simple segmentectomies, 6 complex (S2, S3, S1a+2, S10 on the right) and one right S6 segmentectomy with bronchoplasty. The mean number of harvested lymph nodes for NSCLC was 20, the mean blood loss was 25 mL (from 10 mL to 100 mL), and the mean operative time was 200 minutes. All resection margins were tumour-free. There was no conversion to thoracotomy. Two patients were excluded as they required conversion to robotic lobectomy given that their lesions were localized close to the intersegmental plane. One complication (recurrent laryngeal nerve paralysis) occurred in 1 patient. Mean chest tube duration was 1.9 days and length of stay 3.9 days. Our experience suggests that implementation of the robotic segmentectomy program after completion of the robotic learning curve provides promising outcomes. Robotic technology and preoperative planning facilitate this technically demanding procedure especially when bronchoplasty is required.

Robotic left apicoposterior bisegmentectomy for non–small cell lung cancer

Robotic left apicoposterior bisegmentectomy for non–small cell lung cancer

Robotic segmentectomy for early-stage lung cancer.

Lobectomies have long been the gold standard for surgical treatment of early-stage non-small cell lung cancer (NSCLC), with segmentectomies limited to instances of benign disease or as an alternative in patients where lung preservation is indicated. However, a recently published randomized control trial has demonstrated the superiority of segmentectomy over lobectomy in terms of overall survival for early-stage lung cancer. Segmentectomy could thus be considered a standard procedure for small-sized peripheral NSCLC. While segmentectomy via video-assisted thoracic surgery (VATS) is the most widespread approach, development in video instrumentation and thoracic robotic surgery is rapidly gaining interest. Indeed, robotic surgery pioneers boast the advantages in three-dimensional view, improved magnification, ergonomics, dexterity, safety, and ease of surgery with this technology. This review aims to outline robotic-assisted segmentectomy indications, preoperative evaluation, and the operative conduct for the different lung segments from a single surgeon console. There are many ways to perform segmentectomies and therefore this review describes generalized approaches that can be tailored based on experience.

Defining the learning curve of robotic portal segmentectomy in small pulmonary lesions: a prospective observational study.

Although robotic segmentectomy has been applied for the treatment of small pulmonary lesions for many years, studies on the learning curve of robotic segmentectomy are quite limited. Thus, we aim to investigate the learning curve of robotic portal segmentectomy with 4 arms (RPS-4) using prospectively collected data in patients with small pulmonary lesions. One hundred consecutive patients with small pulmonary lesions who underwent RPS-4 between June 2018 and April 2021 were included in the study. Da Vinci Si/Xi systems were used to perform RPS-4. The mean operative time, console time, and docking time for the entire cohort were 119.2 ± 41.6, 85.0 ± 39.6, and 6.6 ± 2.8min, respectively. The learning curve of RPS-4 can be divided into three different phases: 1-37 cases (learning phase), 38-78 cases (plateau phase), and > 78 cases (mastery phase). Moreover, 64 cases were required to ensure acceptable surgical outcomes. The total operative time (P < 0.001), console time (P < 0.001), blood loss (P < 0.001), and chest tube duration (P = 0.014) were reduced as experience increased. In conclusion, the learning curve of RPS-4 could be divided into three phases. 37 cases were required to pass the learning phase, and 78 cases were needed to truly master this technique.

Robotic upper lobe segmentectomy: technical pearls

: Minimally invasive approaches to segmentectomy have grown in popularity as sublobar resection has been increasingly offered as a parenchyma-sparing alternative to lobectomy for amenable lesions. Both video-assisted thoracic surgery and robotic surgery offer advantages over traditional thoracotomy, with fewer complications, shortened hospital stay, and less pain. While segmentectomy has been traditionally performed by video-assisted thoracic surgery, the robotic approach represents a growing subset of minimally invasive sublobar resections. Patient selection for robotic segmentectomy involves a standard preoperative evaluation including pulmonary function tests, cardiac evaluation, and complete staging. Preoperative axial imaging is essential in choosing patients with lesions amenable to segmentectomy, and evaluating the segmental anatomy. Safe robotic segmentectomy centers around thorough knowledge of the segmental vascular and bronchial anatomy and its variants, and preoperative imaging can help the surgeon anticipate variant anatomy intraoperatively. The operative technique generally involves a mediastinal lymph node dissection with frozen section of the N1 nodes and conversion to lobectomy if positive. The segmental resection then proceeds depending on the individual segment to be resected, but generally involves dissection and division of the vessels and bronchus, followed by division of the parenchyma along the intersegmental plane. For most patients, postoperative recovery is short and uncomplicated, with most patients being discharged on the first or second postoperative day.

2022 Canadian Surgery Forum Sept. 15–17, 202201. Operative classification of ventral abdominal hernias: new and practical classification02. Watchful waiting for large primary splenic cysts03. Transversus abdominis plane (TAP) blocks with and without dexamethasone in colorectal surgery04. What factors determine publication of resident research day projects?05. Characterization of near-infrared imaging and indocyanine green use amongst general surgeons06. Variation in opioid prescribing

# 01. Operative classification of ventral abdominal hernias: new and practical classification {#article-title-2} Ventral hernias of the abdomen are defined as a noninguinal, nonhiatal defect in the fascia of the abdominal wall. Unfortunately, there is not currently a universal classification system

Trends in segmentectomy for the treatment of stage 1A non-small cell lung cancers: Does the robot have an impact?

ObjectivesLobectomy may unnecessarily resect healthy lung parenchyma in Stage 1A non-small cell lung cancers (NSCLC). Segmentectomies may provide a lung-sparing option. VATS segmentectomies can be technically challenging; robotics may have features that provide advantages in performing segmentectomies. We describe the association of the robot on national trends in segmentectomies. MethodsThe National Cancer Database (2010–2017) was queried for patients with Stage 1A NSCLC who underwent lobectomies and segmentectomies. The proportion of segmentectomies vs. lobectomies and the proportion of robotic vs. VATS segmentectomies was calculated annually. ResultsThe proportion of segmentectomies increased compared to lobectomies for all surgical approaches but remained constant for minimally-invasive approaches. The proportion of robotic segmentectomies increased over the years compared to VATS segmentectomies.Descriptive statistics are reported as numbers and proportions. Trends in the proportions of lobectomies and segmentectomies were compared using Chi-squared test for categorical variables and unpaired t-test for independent means. A p-value of <0.05 was considered statistically significant. Statistical analysis was performed using SPSS Statistics Software version 24 (IBM Corp, Armonk, NY). ConclusionsWe demonstrate an increasing trend and proportion of robotic segmentectomies being performed in comparison to VATS segmentectomies. The robotic platform may facilitate the performance of more segmentectomies for early-stage NSCLC.Statistical Analysis

Robotic segmentectomy: is the game really worth the candle?

Robotic segmentectomy: is the game really worth the candle?

Robotic segmentectomy using a lung base-flip approach.

Robotic segmentectomy using a lung base-flip approach.

Comment on "The Unbearable Lightness of Difference Between Statistical and Clinical Significance".

We are glad to see that the short-term results of our RVlob trial comparing robotic-assisted lobectomy and video-assisted lobectomy recently published on Annals of Surgery1 have aroused wide discussion. We deeply appreciate the comment from Bertolaccini et al, which reminds us to prudently interpret the statistical significance. Regarding one of our primary endpoints, the extent of lymph nodes (LNs) dissection, Bertolaccini et al pointed out that the reported difference of one more LN dissected by robotic-assisted lobectomy was not clinically significant. Indeed, we are fully aware of the gap between statistical and clinical significance and regard the survival benefit as the most solid evidence. As mentioned in the Discussion section of our original article, the correlation between an improved number of LNs and long-term survival is insignificant according to some published retrospective studies.2,3 However, beneficial effects of more LNs dissected on proper staging and prognosis may be shielded by the limited sample size. Furthermore, consensus on the optimal number of resected LNs in lung cancer surgery is still lacking. The threshold values vary from 8 to 12 in different studies.4–6 Ultimately, since no surrogate endpoints can perform as well as the overall survival, we expect the further follow-up of our RVlob trial to demonstrate a convincing argument for the controversy. When it comes to the comparison of direct and indirect costs, heterogeneity between countries, and medical systems should never be neglected. According to a review written by Jacobs and Fassbender,7 there is a wide variation among the measurements and analyses of indirect costs. In our study, we have defined the indirect cost as the overhead costs and amortization of surgical equipment,1 which is inconsistent with the definition provided by Bertolaccini et al. We will appreciate if they could specify the reference for the “widely used guidelines for the economic evaluation of healthcare interventions” so that we could reflect on the suitability of our definition. Despite the different reimbursement conditions of various medical systems, the current high cost of robotic surgery remains a common issue worldwide. No matter how much of the robotic surgery fee is reimbursed by the public health service, breakthrough in technical barriers, and innovative inventions will undoubtedly improve the feasibility of the robot-assisted surgery. As we have mentioned in a previous letter8 discussing a propensity score-matched study of robotic segmentectomy,9 the continued debate on robotic surgery will urge us to provide more convincing evidence. Fortunately, we have already stepped out to provide the perioperative results of a prospective randomized-controlled trial rather than a retrospective comparative study. Meanwhile, prudent reflection on methodology and statistical analysis should always be promoted when evaluating new treatments, just as the letter from Bertolaccini et al.

Introduction and Implementation of Robotic Liver Resection in a High Volume HPB Center

Background: Robotic surgery is the new field of implementation of minimally invasive surgery and it could potentially offer some advantages in case of difficult liver resections (postero-superior segments). The aim of this study is to analyse our initial series of robotic hepatectomy. Materials and Methods: Clinico-patological data as well intra-operative and post-operative outcomes of all patients submitted to robotic hepatectomy between January 2017 and June 2021 were prospectively recorded in a dedicated database and analysed. Results: A total of 111 consecutive patients underwent robotic hepatectomy during the study period. 48 of patients were women (mean age 67 yo), mean BMI was 26,05 (range 19-40) and ASA class of 3. Mean size of resected lesion was 29,387 mm (range 9-72). Indications for resection were metastatic tumours (56,76 %), HCC (22,5%), cholangiocarcinoma (5,4%), gallbladder cancer (9,9%) and 6 cases of symptomatic benign lesions.30,6% of lesions (34 patients) were located in postero-superior segments. Robotic bisegmentectomy was performed in 14 patients. Robotic segmentectomy was performed in 12 patients, while in the other patients single or multiple parenchimal sparing atypical resections were performed. Mean operative time was 187,612 min. (range 60-390), and mean estimated blood loss was 130, 135 ml (range 10-1100). Mean length of hospital stay was 6 days (range 3-21). There were no postoperative deaths. Conclusions: Our initial experience with robotic liver resection demonstrated that with a good selection of patients robotic hepatectomy can be introduced safely especially in high specialized centres with excellents results also for lesions located in postero-superior segments.

Robotic segmentectomy S7 + S8 with the use of indocyanine green (ICG): technical details

Robotic segmentectomy S7 + S8 with the use of indocyanine green (ICG): technical details

Midterm survival of imaging-assisted robotic lung segmentectomy for non-small-cell lung cancer.

OBJECTIVESOur goal was to report our midterm results using imaging-assisted modalities with robotic segmentectomies for non-small-cell lung cancer (NSCLC).METHODSThis was a retrospective study of all robotic segmentectomies, with confirmed NSCLC, performed at our general and thoracic surgery unit in the Rouen University Hospital (France), from January 2012 through December 2019. Benign and metastatic lesions were excluded. Data were extracted from the EPITHOR French nationwide database.RESULTSA total of 121 robotic segmentectomies were performed for 118 patients with a median age of 65 (interquartile range: 60, 69) years. The majority had clinical stage T1aN0M0 (71.9%) or T1bN0M0 (13.2%). The mean (standard deviation) number of resected segments was 1.93 (1.09) with 80.2% imaging-assisted segmentectomies. Oriented (according to tumour location) or systematic lymphadenectomy or sampling was performed for 72.7%, 23.1% and 4.1% of patients. The postoperative course was uneventful for 94 patients (77.7%), whereas 34 complications occurred for 27 patients (22.3%), including 2 patients (1.7%) with Clavien-Dindo ≥III complications. The mean thoracic drainage duration was 4.12 days, and the median hospital stay was 4 days (interquartile range: 3, 5) after the operation. The 2-year survival rate was 93.9% (95% confidence interval: 86.4–97.8%). Excluding stage IV (n = 3) and stage 0 tumours (n = 6), the 2-year survival rate was 95.7% (95% confidence interval: 88.4–98.8%) compared to an expected survival rate of 94.0% according to stage-specific survival rates found in a large external reference cohort.CONCLUSIONSImaging-guided robotic-assisted thoracic surgery segmentectomy seems to be useful and oncological with good midterm results, especially for patients with early-stage NSCLC.

Robotic right-S2 segmentectomy in a 59-years-old smoking woman, affected by a 14 mm PET-positive nodule of the right upper lobe, LDCT-screening detected

Robotic right-S2 segmentectomy in a 59-years-old smoking woman, affected by a 14 mm PET-positive nodule of the right upper lobe, LDCT-screening detected

Overview of the outcomes of robotic segmentectomy and lobectomy.

Segmentectomy has gained popularity in the latest years as a valid alternative to lobectomy. Initially reserved to patient unfit for lobar lung resection, this procedure is now offered also in selected patient with <2 cm peripheral lung cancer confined to an anatomic segment with no nodal involvement on preoperative evaluation. The introduction of screening with low-dose CT chest scan allowed the identification of lung cancer at early stages, making possible to schedule a more conservative lung surgery. A major improvement came also from minimally invasive surgery (MIS), reducing complication rate with comparable survival rates when compared to open surgery. However, due to long learning curve and uncomfortable instruments handling of video-assisted thoracoscopy, many surgeons still prefer to perform segmentectomies through a thoracotomy and thus increasing perioperative morbidity and leading to post-thoracotomy syndrome due to rib-spreading. Robotic assisted thoracic surgery (RATS) can avoid this throwback, combining the handling of open surgery with lesser invasiveness of thoracoscopy. Although literature has given strong evidences in favour of robotic lobectomies, data are still limited regarding segmentectomies performed with this technique. Moreover, no results are still available from the two ongoing randomized controlled trials comparing segmentectomy to lobectomy and so the latter represent the oncologically proper procedure for lung cancer along with lymph-node dissection. In this review we analyse the literature currently available on outcomes of lobar and sublobar anatomical resection performed by RATS, with a brief mention of the existing surgical techniques of port positioning and the costs of this procedure.

Discharging Patients by Postoperative Day One After Robotic Anatomic Pulmonary Resection

BackgroundOur objective is to assess the feasibility and safety of discharging patients by postoperative day one (POD1) after robotic segmentectomy and lobectomy, and to describe outcomes for patients. MethodsA retrospective analysis was made of a prospectively collected database of a quality improvement initiative by a single surgeon. Factors associated with discharge by POD1 were evaluated using a multivariate logistic regression model. ResultsFrom January 2018 to July 2020, of 253 patients who underwent robotic anatomic pulmonary resection, 134 (53%) were discharged by POD1, 67% after segmentectomy and 41% after lobectomy. Discharge by POD1 improved with experience and was achieved in 97% of patients after segmentectomy and 68% after lobectomy in the final quartile. Thirty-one patients (12%) were discharged home with a chest tube, including 7 (2.8%) on POD1. On multivariate analysis, never smokers and segmentectomy were associated with discharge by POD1. Conversely, decreased baseline performance status and perioperative complications were associated with discharge after POD1. There were 10 minor morbidities (4%), 6 major morbidities (2.4%), and no 30- or 90-day mortality. There were 4 readmissions (1.6%), of which 1 (0.4%) was after POD1 discharge. Patient satisfaction remained high throughout the study period. ConclusionsWith experience and communication, select patients can be discharged home on POD1 after robotic segmentectomy and lobectomy with excellent outcomes and high satisfaction. Discharge by POD1 was associated with never smokers and segmentectomy, and inversely associated with decreased baseline performance status and perioperative complications.