Faculty Bibliography

Virtual reality and augmented reality technologies have evolved with a growing presence in both clinical care and surgical training.

BACKGROUND:Minimally invasive techniques are increasingly being used in pulmonary segmentectomy and combined subsegmentectomy. However, there are no reports as yet on robotic combined anatomic subsegmentectomy(CAS). Herein, we describe related clinical data and operative techniques and present our early results METHODS: Clinical data on patients undergoing robotic CAS were retrospectively reviewed. A combined subsegmentectomy was defined as the resection of ≥2 subsegments that involved ≥2 adjacent segments. Patients subjected to completely portal robotic CAS were enrolled in this study. RESULTS:Between May 2015 and January 2018, a single surgeon performed completely portal robotic CAS for 16 patients. In the CAS-treated patients, most of the lesions (75%) were located in the right upper lobe, and none required conversion to thoracotomy. Median operative time was 175 min (range, 75-294 min) and mean postoperative hospital stay was 4 days (range, 2-11 days). Although one patient experienced a prolonged air leak, the other 15 recovered uneventfully. Within a median follow-up period of 15 months, there were no deaths or tumor recurrences. CONCLUSIONS:Completely portal robotic CAS is a safe and effective procedure in a select subset of patients, proving quite suitable for smaller (<2 cm) multi-segment lung cancers, particularly lesions of right upper lobe. A robotics approach facilitates complex and challenging CAS, the disadvantage being lengthy operative times during early acquisition of skills.

BACKGROUND:Robotic segmentectomy has been suggested as a safe and effective management for early lung cancer and benign lung diseases. However, no large case series have documented the learning curve for this technically demanding procedure. METHODS:We conducted a retrospective study for robotic segmentectomy performed by the same surgeon between June 2015 and November 2017. The learning curve was initially analyzed using the cumulative sum (CUSUM) method to assess changes in the total operative times across the case sequence. Subsequently, an in-depth learning curve was generated using the risk-adjusted cumulative sum (RA-CUSUM) method, which considered perioperative risk factors and surgical failure. RESULTS:This study included 104 cases, and 87 were malignant. The median operative time was 145 min (interquartile range, IQR: 120-180 min) and the median blood loss was 100 ml (IQR: 50-100 ml). The median length of stay was 4 d (IQR: 3-5 d). Based on the CUSUM and RA-CUSUM analyses, the learning curve could be divided into 3 different phases: phase I, the initial learning period (1st-21st operation); phase II, the consolidation period (22nd-46th operation); and phase III, the experienced period (47th-104th operation). The operative time and intraoperative blood loss tended to decrease after the initial learning phase. Other perioperative outcomes were not significantly different among the three phases. CONCLUSIONS:The learning curve of robotic segmentectomy consisted of three phases. The technical competency for assuring feasible perioperative outcomes was achieved in phase II at the 40th operation.

BACKGROUND:Prolonged operating room turnover time erodes patient and employee satisfaction and value. METHODS:Lean and value stream mapping was applied to three operating room teams at an academic health center in New York City and a solution called Performance Improvement Team (PIT Crew) was piloted. RESULTS:Overall, 10% of operating room turnover steps were considered non-valued and were eliminated and 25% of previously sequential steps were performed synchronously. Seven institutional dogmas were eliminated, and three hospital policies were changed. After 35 pilot turnovers, median operating room turnover time improved from 37 minutes (range 26-167) in historical matched controls to 14 minutes (range 10-45, p<0.0001) for the PIT Crew. Cost of the PIT Crew was $1,298 daily and estimated return on investment was $19,500 per day. CONCLUSIONS:Lean and value stream mapping identifies non-valued steps in operating room turnover and affords opportunities for efficiency. Once institutional rules and dogma are changed, culture and workflow improve and turnover time significantly improves. This process adds cost but is profitable. Scalability and sustainability is under further study, as is the "halo effect" on the culture in other non-PIT Crew operating rooms.

The appropriate implementation of new technology, root cause analysis of "imperfect" outcomes and the continuous reappraisal of postgraduate training are needed to improve the care of tomorrow's patients. Healthcare delivery remains one of the most expensive sectors in the United States and the application of new and expensive technology that is necessary for the advancement of this complex specialty must be aligned with providing the best care for our patients. There are a several pathways to innovation; one is partnering with industry and the other is the investigational laboratory. Innovation and the funding thereof come from both the public and the private sector. The majority of new trials that are likely to impact cardiothoracic surgery are industry sponsored trials to meet the requirements necessary for regulatory approval. Cost considerations are paramount when considering integration of innovative technology and treatments into a clinical cardiothoracic surgical practice. The value of any new innovation is determined by the quality divided by the cost, and lean initiatives maximize this equation. The importance and implications of conflict of interest (COI) has been a concern for physicians particularly when new technology or procedures are being incorporated into clinical practice and full disclosures by medical professionals and others involved are essential. Our "societies" and "associations" provide a platform for presentation and peer-reviewed discussion of new procedures, innovations, and trials, etc. and provide a venue for the sharing of knowledge on the highest quality patient care through education and research.

We are honored to have been invited to write this piece entitled, "How to get the most out of your trainees in robotic thoracic surgery". Perhaps a better question is "How can we optimally coach and inspire each resident and/or fellow to maximize their value and potential as people, physicians and surgeons during the span of their career?". As surgeons, we must recognize some of the subtle differences in alignment between ourselves and our trainees, appreciate the value of the trainee within our profession, understand that there is variability to the coaching style that each trainee best responds to, and acknowledge that the success of the people we train-which may be our only true legacy-depends on how we engage and inspire them.