Faculty Bibliography

Lymph node dissection (LND) along the left recurrent laryngeal nerve (RLN) is a technically challenging part of esophageal cancer surgery, especially after chemoradiotherapy (CRT). Robotic surgery holds promise to increase its safety and feasibility. The aim of this study was to describe a single thoracoscopic surgeon's experience related to the transition from video-assisted esophagectomy (VATE) to robotic esophagectomy (RE)-with a special focus on the safety of left RLN LND. Patients who underwent minimally invasive esophagectomy and RLN dissection following CRT were dichotomized according to the use of robotic surgery (robotic esophagectomy [RE] versus video-assisted thoracoscopic esophagectomy [VATE]). The following parameters were determined: (1) number of dissected nodes, (2) rates of RLN palsy, (3) rates of perioperative complications, and (4) learning curve. Learning curve analysis was performed using the 10-patient moving average (MA) for operation times and with the cumulative sum (CUSUM) method for left RLN LND (target failure rate: 15%). The RE and VATE groups consisted of 39 and 67 patients, respectively. The intraoperative identification of the left RLN was more common in the RE group (97.4%) than in the VATE group (68.7%; P < 0.001). Postoperative left RLN palsy was significantly more frequent in the VATE group (26.9%) than in the RE group (10.3%; P = 0.042), with a higher rate of pneumonia in the former (16.4% versus 2.6%; P = 0.03). The MA chart revealed a downward trend followed by a flattening of the RE operation time at operation number 17 and 29, respectively. CUSUM analysis showed that the left RLN palsy rate decreased to the target rate after 12 operations. We conclude that at least 12 cases are required for a surgeon with prior experience in VATE to safely accomplish left RLN LND through a robotic approach.

BACKGROUND:Intraoperative catastrophes during robotic anatomical pulmonary resections are potentially devastating events. The present study aimed to assess the incidence, management, and outcomes of these intraoperative catastrophes for patients with primary lung cancers. METHODS:This was a retrospective, multiinstitutional study that evaluated patients who underwent robotic anatomical pulmonary resections. Intraoperative catastrophes were defined as events necessitating emergency thoracotomy or requiring an additional unplanned major surgical procedure. Standardized data forms were collected from each institution, with questions on intraoperative management strategies of catastrophic events. RESULTS:Overall, 1810 patients underwent robotic anatomical pulmonary resections, including 1566 (86.5%) lobectomies. Thirty-five patients (1.9%) experienced an intraoperative catastrophe. These patients were found to have significantly higher clinical TNM stage (P = .031) and lower forced expiratory volume in 1 second (81% vs 90%; P = .004). A higher proportion of patients who had a catastrophic event underwent preoperative radiotherapy (8.6% vs 2.3%; P = .048), and the surgical procedures performed differed significantly compared with noncatastrophic patients. Patients in the catastrophic group had higher perioperative mortality (5.7% vs 0.5%; P = .018), longer operative duration (195 minutes vs 170 minutes; P = .020), and higher estimated blood loss (225 mL vs 50 mL; P < .001). The most common catastrophic event was intraoperative hemorrhage from the pulmonary artery, followed by injury to the airway, pulmonary vein, and liver. Detailed management strategies were discussed. CONCLUSIONS:The incidence of catastrophic events during robotic anatomical pulmonary resections was low, and the most common complication was pulmonary arterial injury. Awareness of potential intraoperative catastrophes and their management strategies are critical to improving clinical outcomes.

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.