Faculty Bibliography

Robotic-assisted pulmonary lobectomy can be considered for patients fit for conventional lobectomy. Contraindications include prohibitive lung function or medical comorbidities, multistation N2, gross N2 disease, or evidence of N3 disease. Team training, familiarity with equipment, troubleshooting, and preparation are critical for successful robotic lobectomy. Similar to video-assisted thoracoscopic surgery (VATS) lobectomy, robotic lobectomy is associated with decreased blood loss, blood transfusion, air leak, chest tube duration, duration of stay, and mortality compared with thoracotomy. Robotic lobectomy offers many of the same benefits in perioperative morbidity and mortality, and the advantages of optics, dexterity, and surgeon ergonomics compared with VATS lobectomy.

OBJECTIVES: Robotic thoracic operations are increasing, and new robotic systems are imminent. A definition of what constitutes a robotic thoracic operation and a nomenclature to detail the technique used is needed to accurately compare outcomes. METHODS: The American Association of Thoracic Surgeons Guideline Committee appointed an expert consensus writing committee to construct definitions and nomenclature for robotic thoracic surgery. A PubMed search was generated and after vetting and review of the literature a consensus statement was reached. RESULTS: The proposed definition is: "A robotic thoracic operation is a minimally invasive surgical procedure that does not spread, lift or remove any part of the chest or abdominal wall and is characterized by: the surgeon and the assistant's vision of the operative field is via a monitor only and the patient's tissue is manipulated by robotic instruments that follow a slave like mimic of human hands or thoughts via a computerized system." In addition, a flexible nomenclature is proposed that should be applicable to current and future robotic systems that details the number of robotic arms used, the types of ports and/or incisions made, the use of insufflation, and the operation performed. CONCLUSIONS: The American Association of Thoracic Surgeons writing committee proposes a definition and nomenclature for robotic thoracic surgery. Definitions are needed to ensure that future studies accurately compare results and outcomes and nomenclatures allow surgeons and scientists from diverse countries and cultures to use the same language to allow accurate communication.

OBJECTIVES: To identify the associations of lymph node metastases (pN+), number of positive nodes, and pN subclassification with cancer, treatment, patient, geographic, and institutional variables, and to recommend extent of lymphadenectomy needed to accurately detect pN+ for esophageal cancer. SUMMARY BACKGROUND DATA: Limited data and traditional analytic techniques have precluded identifying intricate associations of pN+ with other cancer, treatment, and patient characteristics. METHODS: Data on 5806 esophagectomy patients from the Worldwide Esophageal Cancer Collaboration were analyzed by Random Forest machine learning techniques. RESULTS: pN+, number of positive nodes, and pN subclassification were associated with increasing depth of cancer invasion (pT), increasing cancer length, decreasing cancer differentiation (G), and more regional lymph nodes resected. Lymphadenectomy necessary to accurately detect pN+ is 60 for shorter, well-differentiated cancers (<2.5 cm) and 20 for longer, poorly differentiated ones. CONCLUSIONS: In esophageal cancer, pN+, increasing number of positive nodes, and increasing pN classification are associated with deeper invading, longer, and poorly differentiated cancers. Consequently, if the goal of lymphadenectomy is to accurately define pN+ status of such cancers, few nodes need to be removed. Conversely, superficial, shorter, and well-differentiated cancers require a more extensive lymphadenectomy to accurately define pN+ status.

Robotic thymectomy is an increasingly used modality. Patients who are candidates for traditional, open thymectomy are typically also candidates for robotic thymectomy, with the exception of patients with invasion of great vessels. Knowledge of and training on the robotic platform is critical for success. Patient and port positioning is described. Critical steps during robotic thymectomy include attention to careful division of the thymus off the innominate vein, and complete retrieval of bilateral superior horns of the gland. Robotic thymectomy may be performed with excellent perioperative and long-term outcomes for both neoplastic and non-neoplastic indications.

Robotic esophagectomy is an increasingly used modality. Patients who are candidates for traditional, open esophagectomy are typically also candidates for robotic esophagectomy. Knowledge of and training on the robotic platform is critical for success. Patient and port positioning is described. Either a hand-sewn or stapled intrathoracic anastomosis may be performed. Minimally invasive esophagectomy (MIE) appears to be associated with decreased respiratory complications versus open esophagectomy. Robotic esophagectomy may be performed with excellent perioperative outcomes, though long-term oncologic data regarding the operation are not yet available.