Faculty Bibliography

BACKGROUND:Our objective is to show our process to standardize and decrease the time to place and teach double-lumen endotracheal tube (DLETT) intubation. METHODS:Review of a prospective database of patients who underwent lobectomy or segmentectomy by one surgeon. A systematic approach was instituted starting in 2009. A monitor in the room displayed the bronchoscopic view as anesthesia residents were taught how to drive a bronchoscope. The bronchial side was placed above the carina, a bronchoscope went into the desired side and the double-lumen tube slid over it. A head towel protected the ears, face and hair and the DLETT was anchored so that re-bronching after turning was eliminated. All other non-valued steps were eliminated. RESULTS:There were 2,940 patients. Pulmonary lobectomy was performed in 2,421 patients and segmentectomy in 566. Patients were divided into 9 cohorts of 350 consecutive patients except for the last cohort. Median time for DLETT placement decreased from 13 minutes from 1/1997-2/2001 to a median 45 seconds from 6/2016-5/2017 (p<0.001). Anesthesia residents, present for 76% of the operations were able to place the tube independently 80% of the time. There were no airway perforations. CONCLUSIONS:DLETT placement can be standardized and taught efficiently. Factors that may lead to this are: eliminating non-valued steps (process of lean), engaging anesthesiologists and surgeons to teach team standardization, improved tracheal-bronchial anatomy and bronchoscopy skills in residents and displaying the intubation and bronchoscopy on a monitor.

The objectives of this study are to review the complicated and often confusing technical changes required when converting from the Si robotic system to the Xi when performing pulmonary lobectomy and segmentectomy. We reviewed a prospective database of a consecutive series of patients who intended to undergo robotic lobectomy or segmentectomy by one surgeon. There were 101 lobectomies and 25 segmentectomies performed on the Si robot in 2015-2016, and 95 lobectomies and 28 segmentectomies in 2016 on the Xi robot. The two groups were similar for age, height, weight, pulmonary function, anatomic resections, and co-morbidities. Technical differences in robotic arm numbering, port placement, and instrumentation are shown below. Median docking time was shorter with the Xi robot [7.5 (95% CI 6-8) versus 10 (95% CI 9-12) min, p = 0.003] as was operation duration [114 (95% CI 104-123) versus 119 (95% CI 116-126) min, p = 0.041] and skin closure to room exit [12 (95% CI 10-24) versus 13 (95% CI 12-15) min, p = 0.081]. Anesthesiologists expressed greater comfort with the Xi system, because the patient's head was not covered by the robot. Outcomes for Si and Xi operations such as median blood loss (20 cc versus 20 cc), transfusion rate (0 versus 0), major complication rate (3.2 versus 3.3%), and the 30- and 90-day mortality were no different (one 30-day death in the Si group). The technical changes that are required for robotic Si-to-Xi conversion are shown. The Xi system may offer improved operational efficiency.

Aorto-pulmonary paraganglioma is an exceptionally rare condition, and its diagnosis and treatment are a challenge for the general thoracic surgeon. We describe the case of a 35 years old man who was incidentally diagnosed with a visceral mediastinal mass, deeply encased in the aorto-pulmonary window. To our knowledge this is the first case of its kind to be successfully treated with the adoption of a minimally invasive technique. We conclude that the dissection was made easier by the robotic instrumentation and by the camera system, and a minimally invasive approach would have been more difficult by traditional thoracoscopy.

OBJECTIVE:Our objective is to report the world's largest series with the longest follow-up of robotic lobectomy for non-small cell lung cancer (NSCLC). METHODS:This was a multi-institutional retrospective review of a consecutive series of patients from 4 institutions' prospective robotic databases. RESULTS:There were 1339 patients (men 55%, median age 68 years). The median operative time was 136 minutes, median number of lymph nodes was 13 (5 N2 stations and 1 N1), median blood loss was 50 cc, and 4 (0.005%) patients received intraoperative transfusions. Conversions occurred in 116 patients (9%) and for bleeding in 24 (2%). Median length of stay was 3 days. Major morbidity occurred in 8%. The 30-day and 90-day operative mortality was 0.2% and 0.5%, respectively. Follow-up was complete in 99% of patients with a median follow-up of 30 months (range 1-154 months). The 5-year stage-specific survival was: 83% for the 672 patients with stage IA NSCLC, 77% for the 281 patients with stage IB, 68% for the 118 patients with stage IIA, 70% for 99 patients with IIB, 62% for 143 patients with stage IIIA (122 had N2 disease, 73%), and 31% for 8 patients with stage IIIB (none had N3 disease). The cumulative incidence of metastatic NSCLC was 15% (128 patients, 95% confidence interval, 13%-18%). The cumulative incidence of local recurrence in the ipsilateral operated chest was 3% only (26 patients, 95% confidence interval, 2%-5%). CONCLUSIONS:The oncologic results of robotic lobectomy for NSCLC are promising, especially for patients with pathologic N2 disease. However, further follow-up and studies are needed.

BACKGROUND:Our objective is to compare the clinical to the pathologic stage in patients with non-small cell lung cancer (NSCLC). METHODS:Review of a prospective database from one surgeon. Patients had NSCLC, chest tomography (CT) and most had positron emissions tomography (PET). Those with suggested N1, N2, central tumors and/or tumors > 5 cm underwent mediastinoscopy and/or endobronchial ultrasound and, if N2 negative, underwent resection with complete thoracic lymphadenectomy. RESULTS:(p=0.034); of N2 disease included African American race (p=0.020) and large tumor size (p=0.047). CONCLUSIONS:Despite advancements in CT, PET and minimally invasive nodal biopsy, there remains significant NSCLC mis-staging, especially for N2 disease. Improved, targeted N2 lymph node biopsy may improve pre-resection staging.

INTRODUCTION/BACKGROUND:Robotic lobectomy is an increasingly common surgical approach for anatomic lung resection. Over the last decade, robotic lobectomy has shown to be safe, with oncologic efficacy similar to lobectomy via thoracotomy or video-assisted thoracoscopic surgery (VATS). Comparative analysis between these modalities is an active area of investigation. While initially expensive, the costs of a robotic platform decrease as the number of operations performed increases, length of stay is shortened, and postoperative morbidity is reduced. Moreover, the added cost has value which is defined over long periods of time. Areas covered: The clinical technique and optimal conduct of lobectomy is explained in granular detail for all five types of lobectomies. The advantages and disadvantages of a robotic platform are analyzed, including a review of the recent literature. Expert commentary: The number of robotic pulmonary resections performed has tripled in the past two years. Anticipated developments in robotic surgery include improvements in robotic training, continued refinement of robotic instrumentation, and additional adjunctive technologies. The overall costs of robotic surgery will decrease, in part, due to increasing competition as additional companies enter the market.