Faculty Bibliography

Minimally invasive esophagectomy with intrathoracic dissection and anastomosis is increasingly performed. Our objectives are to report our operative technique, early results and lessons learned. This is a retrospective review of 85 consecutive patients who were scheduled for minimally invasive Ivor Lewis esophagectomy (laparoscopic or robotic abdominal and robotic chest) for esophageal cancer. Between 4/2011 and 3/2015, 85 (74 men, median age: 63) patients underwent robotic Ivor Lewis esophageal resection. In all, 64 patients (75%) had preoperative chemoradiotherapy, 99% had esophageal cancer, and 99% had an R0 resection. There were no abdominal or thoracic conversions for bleeding. There was 1 abdominal conversion for the inability to completely staple the gastric conduit. The mean operative time was 6 hours, median blood loss was 35ml (no intraoperative transfusions), median number of resected lymph nodes was 22, and median length of stay was 8 days. Conduit complications (anastomotic leak or conduit ischemia) occurred in 6 patients. The 30 and 90-day mortality were 3/85 (3.5%) and 9/85 (10.6%), respectively. Initial poor results led to protocol changes via root cause analysis: longer rehabilitation before surgery, liver biopsy in patients with history of suspected cirrhosis, and refinements to conduit preparation and anastomotic technique. Robotic Ivor Lewis esophagectomy for cancer provides an R0 resection with excellent lymph node resection. Our preferred port placement and operative techniques are described. Disappointingly high thoracic conduit problems and 30 and 90-day mortality led to lessons learned and implementation of change which are shared.

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.

Adenomatoid tumor is an uncommon benign neoplasm of mesothelial differentiation that distinctively arises in and around the genital organs. In rare instances, it has been described in extragenital locations. There have been only two reports documenting its occurrence in the anterior mediastinum, and no reports documenting its occurrence in the posterior mediastinum. We report the first case of posterior mediastinal adenomatoid tumor. A 37-year-old Caucasian woman presented with symptoms of bronchitis. Imaging studies identified a 2.0 cm posterior mediastinal mass abutting the T9 vertebral body, clinically and radiologically most consistent with schwannoma. Histologic sections revealed a lesion composed of epithelioid cells arranged in cords and luminal profiles embedded in a fibrotic to loose stroma and surrounded by a fibrous pseudocapsule. Lesional cells showed vacuolated eosinophilic cytoplasm and peripherally displaced nuclei with prominent nucleoli. There was focal cytologic atypia but no mitotic figures or necrosis was identified. The lesional cells expressed cytokeratin, calretinin, and nuclear WT1 but were negative for PAX8, TTF1, p53, chromogranin, CD31, and CD34, and Ki67 showed <2% proliferation rate, diagnostic of adenomatoid tumor. Three years after resection, the patient is in good health without tumor recurrence. Thus, our encounter effectively expands the differential diagnosis of posterior mediastinal neoplastic entities.

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.

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: 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 was to evaluate our results after the implementation of lean (the elimination of wasteful parts of a process). METHODS: After meetings with our anesthesiologists, we standardized our "in the operating room-to-skin incision protocols" before pulmonary lobectomy. Patients were divided into consecutive cohorts of 300 lobectomy patients. Several protocols were slowly adopted and outcomes were evaluated. RESULTS: One surgeon performed 2,206 pulmonary lobectomies, of which 84% were for cancer. Protocols for lateral decubitus positioning changed over time. We eliminated axillary rolls, arm boards, and beanbags. Monitoring devices were slowly eliminated. Central catheters decreased from 75% to 0% of patients, epidurals from 84% to 3%, arterial catheters from 93% to 4%, and finally, Foley catheters were reduced from 99% to 11% (p