Faculty Bibliography

OBJECTIVE: The objective is to report our outcomes of teaching and performing minimally invasive robotic lobectomy. METHODS: Robotic lobectomy was divided into 19 specific sequential technical maneuvers. The number of steps residents could perform in a set period of time was recorded. Video review by the attending surgeon and coaching were used to improve what residents could safely perform. Outcomes compared were percentage of maneuvers that general surgical or cardiothoracic residents (fellows) completed, operative times, and Society of Thoracic Surgeons-defined metrics of patient outcomes. RESULTS: There were 520 consecutive robotic lobectomies over 5 years. The various maneuvers completed by general surgical residents (N = 35) and cardiothoracic residents (N = 7) increased over time, for example, steps 1 to 5 increased 20% and 70% compared with 80% and 90% (P < .001), step 8 increased 0% and 50% compared with 90% and 100% (P < .0001), and step 19 increased 30% and 50% compared with 90% and 100% (P = .001), respectively. Operative outcomes, including intraoperative blood loss, median number of lymph nodes, median length of stay, major morbidity, and 30-day and 90-day mortality, were no different. Operative time initially increased and then decreased over time. Conversion to thoracotomy (15% to 2.5%, P = .042) and major vascular injury (3% to 0%, P = .018) decreased. CONCLUSIONS: Robotic lobectomy can be safely taught to residents without compromising patient outcomes by dividing it into a series of surgical maneuvers. Recording outcomes for each step and using video review and coaching techniques may help increase the percent of maneuvers residents can complete in a set time.

To address uncertainty of whether pathologic stage groupings after neoadjuvant therapy (ypTNM) for esophageal cancer share prognostic implications with pathologic groupings after esophagectomy alone (pTNM), we report data-simple descriptions of patient characteristics, cancer categories, and non-risk-adjusted survival-for pathologically staged cancers after neoadjuvant therapy from the Worldwide Esophageal Cancer Collaboration (WECC). Thirty-three institutions from six continents submitted data using variables with standard definitions: demographics, comorbidities, clinical cancer categories, and all-cause mortality from first management decision. Of 7,773 pathologically staged neoadjuvant patients, 2,045 had squamous cell carcinoma, 5,686 adenocarcinoma, 31 adenosquamous carcinoma, and 11 undifferentiated carcinoma. Patients were older (61 years) men (83%) with normal (40%) or overweight (35%) body mass index, 0-1 Eastern Cooperative Oncology Group performance status (96%), and a history of smoking (69%). Cancers were ypT0 (20%), ypT1 (13%), ypT2 (18%), ypT3 (44%), ypN0 (55%), ypM0 (94%), and G2-G3 (72%); most involved the distal esophagus (80%). Non-risk-adjusted survival for yp categories was unequally depressed, more for earlier categories than later, compared with equivalent categories from prior WECC data for esophagectomy-alone patients. Thus, survival of patients with ypT0-2N0M0 cancers was intermediate and similar regardless of ypT; survival for ypN+ cancers was poor. Because prognoses for ypTNM and pTNM categories are dissimilar, prognostication should be based on separate ypTNM categories and groupings. These data will be the basis for the 8th edition cancer staging manuals following risk adjustment for patient, cancer, and treatment characteristics and should direct 9th edition data collection.

BACKGROUND: Data from selected centers show that robotic lobectomy is safe and effective and has 30-day mortality comparable to that of video-assisted thoracoscopic surgery (VATS). However, widespread adoption of robotic lobectomy is controversial. We used The Society of Thoracic Surgeons General Thoracic Surgery (STS-GTS) Database to evaluate quality metrics for these 2 minimally invasive lobectomy techniques. METHODS: A database query for primary clinical stage I or stage II non-small cell lung cancer (NSCLC) at high-volume centers from 2009 to 2013 identified 1,220 robotic lobectomies and 12,378 VATS procedures. Quality metrics evaluated included operative morbidity, 30-day mortality, and nodal upstaging, defined as cN0 to pN1. Multivariable logistic regression was used to evaluate nodal upstaging. RESULTS: Patients undergoing robotic lobectomy were older, less active, and less likely to be an ever smoker and had higher body mass index (BMI) (all p < 0.05). They were also more likely to have coronary heart disease or hypertension (all p < 0.001) and to have had preoperative mediastinal staging (p < 0.0001). Robotic lobectomy operative times were longer (median 186 versus 173 minutes; p < 0.001); all other operative measurements were similar. All postoperative outcomes were similar, including complications and 30-day mortality (robotic lobectomy, 0.6% versus VATS, 0.8%; p = 0.4). Median length of stay was 4 days for both, but a higher proportion of patients undergoing robotic lobectomy had hospital stays less than 4 days (48% versus 39%; p < 0.001). Nodal upstaging overall was similar (p = 0.6) but with trends favoring VATS in the cT1b group and robotic lobectomy in the cT2a group. CONCLUSIONS: Patients undergoing robotic lobectomy had more comorbidities and robotic lobectomy operative times were longer, but quality outcome measures, including complications, hospital stay, 30-day mortality, and nodal upstaging, suggest that robotic lobectomy and VATS are equivalent.

BACKGROUND: Our objective is to report our incidence, results, and technique for the control of major vascular injuries during minimally invasive robotic thoracic surgery. METHODS: This is a consecutive series of patients who underwent a planned robotic thoracic operation by one surgeon. RESULTS: Between February 2009 and September 2015, 1,304 consecutive patients underwent a robotic operation (lobectomy, n = 502; segmentectomy, n = 130; mediastinal resection, n = 115; Ivor Lewis, n = 103; thymectomy, n = 97; and others, n = 357) by one surgeon. Conversion to thoracotomy occurred in 61 patients (4.7%) and in 14 patients (1.1%) for bleeding (pulmonary artery, n = 13). The incidence of major vascular injury during anatomic pulmonary resection was 2.4% (15 of 632). Of these, 13 patients required thoracotomy performed in a nonurgent manner while the injury was displayed on a monitor, 2 had the vessel repaired minimally invasively, 2 required blood transfusion (0.15%), and 1 patient had 30-day mortality (0.16%). Techniques used to minimize morbidity include having a sponge available during vessel dissection and stapling, applying immediate pressure, delaying the opening until the bleeding is controlled without external pressure, and ensuring there is no bleeding while the chest is opened. CONCLUSIONS: Major vascular injuries can be safely managed during minimally invasive robotic surgery. Our evolving technique features initial packing of the bleeding for several minutes, maintaining calmness to provide time to prepare for thoracotomy, and reexamination of the injured vessel. If repair is not possible minimally invasively, the vessel is repacked and a nonhurried, elective thoracotomy is performed while the injury is displayed on a monitor to ensure active bleeding is not occurring.

Robotic-assisted pulmonary lobectomy can be considered for patients able to tolerate conventional lobectomy. Contraindications to resection via thoracotomy apply to patients undergoing robotic lobectomy. Team training, familiarity with equipment, troubleshooting, and preparation are critical for successful robotic lobectomy. Robotic lobectomy is associated with decreased rates of blood loss, blood transfusion, air leak, chest tube duration, length of stay, and mortality compared with thoracotomy. Robotic lobectomy offers many of the same benefits in perioperative morbidity and mortality, and additional advantages in optics, dexterity, and surgeon ergonomics as video-assisted thoracic lobectomy. Long-term oncologic efficacy and cost implications remain areas of study.

BACKGROUND: Both robotic pulmonary operations and anatomic segmentectomy are being increasingly performed. The largest published series of anatomic robotic segmentectomy comprises 35 patients, and the specific details of port placement are poorly understood. METHODS: This is a review of a consecutive series of patients from a single surgeon's prospective database. All patients in the study were scheduled to undergo robotic anatomic segmentectomy. RESULTS: Between February 2010 and December 2014, 100 patients went to the operating room for a planned pulmonary segmentectomy. A robotic approach was chosen for all. Seven patients underwent conversion to robotic lobectomy, and the remaining 93 patients had an anatomic robotic segmentectomy. There were no conversions to thoracotomy. Indications for resection were lung cancer in 79 patients, metastatic lesions in 10 patients, fungal infections in 4 patients, and other conditions in 7 patients. The median age was 69 years, and 50 patients were men. The median blood loss was 20 mL (range, 10-120 mL), the median number of lymph nodes removed was 19, the median operative time was 1.28 hours (88 minutes), the median length of stay was 3 days, and major morbidity occurred in 2 patients (pneumonia in both). All had undergone R0 resection. There were no 30- or 90-day mortalities. Of the 79 patients with lung cancer, the median follow-up was 30 months, and 3 patients (3.4%) had recurrence in the operated lobe. Overall survival was 95% at 30 months. CONCLUSIONS: Completely portal robotic anatomic segmentectomy is safe and effective and offers outstanding intraoperative 30-day and 90-day results. The recurrence rate is approximately 3% at 2.5 years.