Faculty Bibliography

OBJECTIVE:Robot-assisted lobectomy is the fastest growing technique for pulmonary lobectomy, but the diversity of approaches has led to apprehension about port placement among learning surgeons. The aim of this study was to survey high-volume thoracic surgeons who perform robot-assisted lobectomy to understand and consolidate common themes of port placement. METHODS:An electronic online survey was created, and the link was emailed to the 100 highest volume robotic thoracic surgeons in the United States. The survey included an interactive graphical interface, which allowed each respondent to mark the preferential robotic port placement in the chest wall for each of the 5 pulmonary lobectomies. Results were analyzed individually and in aggregate. A heat map was generated to show trends. RESULTS:insufflation. Exact locations for each robotic port were reported by 60% of the surveyed surgeons and the results varied; however, most surgeons generally used the seventh to ninth interspaces for the camera and instruments. The use of multiple different interspace levels was common. Ninety-four percent of respondents used an additional nonrobotic assistant port. CONCLUSIONS:There is not a universal port strategy for robot-assisted lobectomy. However, placement of the camera and robotic ports low in the seventh to ninth interspaces is the most common approach. There are some nuances of stapling port strategies and sequence of port placement, which are identified.

During minimally invasive pulmonary resection, it is often difficult to localize pulmonary nodules that are small (<2 cm), low-density/subsolid on imaging, or deep to the visceral pleura. The use of near-infrared fluorescence (NIF) imaging for localizing pulmonary nodules using indocyanine green (ICG) contrast is an emerging technology that is increasingly utilized during pulmonary resection. When administered via electromagnetic navigational bronchoscopy (ENB), ICG can accurately localize pulmonary nodules. When injected intravenously (IV), ICG can also help delineate the intersegmental plane. Research is ongoing regarding the utility of ICG for identification of the sentinel lymph node in lung cancer.

Virtual reality and augmented reality technologies have evolved with a growing presence in both clinical care and surgical training.

We are honored to have been invited to write this piece entitled, "How to get the most out of your trainees in robotic thoracic surgery". Perhaps a better question is "How can we optimally coach and inspire each resident and/or fellow to maximize their value and potential as people, physicians and surgeons during the span of their career?". As surgeons, we must recognize some of the subtle differences in alignment between ourselves and our trainees, appreciate the value of the trainee within our profession, understand that there is variability to the coaching style that each trainee best responds to, and acknowledge that the success of the people we train-which may be our only true legacy-depends on how we engage and inspire them.

BACKGROUND:Our objectives are to present our outcomes of robotic segmentectomy and our preferred technique for nodule localization using indocyanine green both bronchoscopically and intravenously. METHODS:This is a retrospective review of a consecutive series of patients scheduled for robotic segmentectomy from a single surgeon's prospectively collected database. RESULTS:Between January 2010 and October 2018, there were 245 consecutive patients who underwent planned robotic segmentectomy by one surgeon, of which 93 (38%) received indocyanine green via electromagnetic navigational bronchoscopy and all 245 received intravenous indocyanine green. Median time for navigational bronchoscopy was 9 minutes. Navigational bronchoscopy with indocyanine green correctly identified the lesion in 80 cases (86%). Our preferred technique is: 0.5 mL of 25 mg of indocyanine green diluted in 10 mL of saline given bronchoscopically, followed by a 0.5 mL saline flush, staying at least 4 mm from the pleural surface. The remaining 9.5 mL of indocyanine green is administered intravenously after pulmonary artery ligation. An R0 resection was achieved in all 245 patients, a median of 17 lymph nodes were resected, and the average length of stay was 3.1 days (range 1-21 days). Major morbidity occurred in 3 patients and there were no 30 or 90-day mortalities. CONCLUSIONS:Robotic segmentectomy is safe with excellent early clinical outcomes. In our series, electromagnetic navigational bronchoscopy and indocyanine green localization is efficient and effective at identifying the target lesion. Intravenous indocyanine green delineates the intersegmental plane.

BACKGROUND:Prolonged operating room turnover time erodes patient and employee satisfaction and value. METHODS:Lean and value stream mapping was applied to three operating room teams at an academic health center in New York City and a solution called Performance Improvement Team (PIT Crew) was piloted. RESULTS:Overall, 10% of operating room turnover steps were considered non-valued and were eliminated and 25% of previously sequential steps were performed synchronously. Seven institutional dogmas were eliminated, and three hospital policies were changed. After 35 pilot turnovers, median operating room turnover time improved from 37 minutes (range 26-167) in historical matched controls to 14 minutes (range 10-45, p<0.0001) for the PIT Crew. Cost of the PIT Crew was $1,298 daily and estimated return on investment was $19,500 per day. CONCLUSIONS:Lean and value stream mapping identifies non-valued steps in operating room turnover and affords opportunities for efficiency. Once institutional rules and dogma are changed, culture and workflow improve and turnover time significantly improves. This process adds cost but is profitable. Scalability and sustainability is under further study, as is the "halo effect" on the culture in other non-PIT Crew operating rooms.

BACKGROUND:Minimally invasive techniques are increasingly being used in pulmonary segmentectomy and combined subsegmentectomy. However, there are no reports as yet on robotic combined anatomic subsegmentectomy(CAS). Herein, we describe related clinical data and operative techniques and present our early results METHODS: Clinical data on patients undergoing robotic CAS were retrospectively reviewed. A combined subsegmentectomy was defined as the resection of ≥2 subsegments that involved ≥2 adjacent segments. Patients subjected to completely portal robotic CAS were enrolled in this study. RESULTS:Between May 2015 and January 2018, a single surgeon performed completely portal robotic CAS for 16 patients. In the CAS-treated patients, most of the lesions (75%) were located in the right upper lobe, and none required conversion to thoracotomy. Median operative time was 175 min (range, 75-294 min) and mean postoperative hospital stay was 4 days (range, 2-11 days). Although one patient experienced a prolonged air leak, the other 15 recovered uneventfully. Within a median follow-up period of 15 months, there were no deaths or tumor recurrences. CONCLUSIONS:Completely portal robotic CAS is a safe and effective procedure in a select subset of patients, proving quite suitable for smaller (<2 cm) multi-segment lung cancers, particularly lesions of right upper lobe. A robotics approach facilitates complex and challenging CAS, the disadvantage being lengthy operative times during early acquisition of skills.