Faculty Bibliography

In the last decade, healthcare systems have shifted their focus from increased volume of patients and procedures to improving patient outcomes and quality. While there are many societies and companies that have surrogate measures of excellence, these metrics are determined by those who do not directly participate and fully understand the best measurements of quality. In order to better assess quality and value, the Efficiency Quality Index (EQI) was created. The novel aspect of the EQI is the determination of metrics by the physicians who actually perform the procedures, in order to create an accurate and fair measurement of performance and outcomes. In this article, we describe how to create and implement the EQI, as well as outline its benefits.

Screening for lung cancer has changed substantially in the past decade since The National Lung Screening Trial. The resultant increased discovery of incidental pulmonary nodules has led to a growth in the number of lesions requiring tissue diagnosis. Bronchoscopy is one main modality used to sample lesions, but peripheral lesions remain challenging for bronchoscopic biopsy. Alternatives have included transthoracic biopsy or operative biopsy, which are more invasive and have a higher morbidity than bronchoscopy. In hopes of developing less invasive diagnostic techniques, technologies have come to assist the bronchoscopist in reaching the outer edges of the lung. Navigational bronchoscopy is able to virtually map the lung and direct the biopsy needle where the scope cannot reach. Robotic bronchoscopy platforms have been developed to provide stability and smaller optics to drive deeper into the bronchial tree. While these new systems have not yet proven better outcomes, they may reduce the need for invasive procedures and be valuable armamentarium in diagnosing and treating lung nodules, especially in the periphery.

Systems engineering is an interdisciplinary approach to creating, evaluating, and managing a complex process in order to increase reliability, cost-effectiveness, and quality. The operating room is a complex environment that requires human-human interaction, human-device interaction, planning, and coordination of scarce resources for the purpose of providing surgery to patients in a safe and efficient manner. The operating room is an important revenue generator, but it can also be responsible for unsustainable costs if not managed effectively. Reducing costs and increasing the efficiency of surgical cases is important for generating health care value. Efficiency efforts that aim for standardization of surgical protocols must be balanced by flexibility in the unpredictable operating room environment. This paper reviews systems engineering efforts to improve efficiency in the operating room including operating room scheduling, personnel factors, resource management, orthopedicspecific initiatives, and future innovations.

The use of telemedicine and telehealth services has grown exponentially over the past decade and has become increasingly relevant and necessary during the coronavirus 2019 (COVID-19) pandemic. There remains ample opportunity to electronically connect cardiothoracic surgeons with their patients during both preoperative and postoperative visits. In this review, we examine the various implementations of telemedicine within thoracic surgery and explore future applications in this quickly developing field.

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.

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.

BACKGROUND:Our objectives are to present our outcomes of robotic segmentectomy and our preferred technique for nodule localization using indocyanine green both bronchoscopically and intravenously. METHODS:This is a retrospective review of a consecutive series of patients scheduled for robotic segmentectomy from a single surgeon's prospectively collected database. RESULTS:Between January 2010 and October 2018, there were 245 consecutive patients who underwent planned robotic segmentectomy by one surgeon, of which 93 (38%) received indocyanine green via electromagnetic navigational bronchoscopy and all 245 received intravenous indocyanine green. Median time for navigational bronchoscopy was 9 minutes. Navigational bronchoscopy with indocyanine green correctly identified the lesion in 80 cases (86%). Our preferred technique is: 0.5 mL of 25 mg of indocyanine green diluted in 10 mL of saline given bronchoscopically, followed by a 0.5 mL saline flush, staying at least 4 mm from the pleural surface. The remaining 9.5 mL of indocyanine green is administered intravenously after pulmonary artery ligation. An R0 resection was achieved in all 245 patients, a median of 17 lymph nodes were resected, and the average length of stay was 3.1 days (range 1-21 days). Major morbidity occurred in 3 patients and there were no 30 or 90-day mortalities. CONCLUSIONS:Robotic segmentectomy is safe with excellent early clinical outcomes. In our series, electromagnetic navigational bronchoscopy and indocyanine green localization is efficient and effective at identifying the target lesion. Intravenous indocyanine green delineates the intersegmental plane.