Robotic-assisted thoracic surgery training in France: a nation-wide survey from young surgeons.

OBJECTIVES: Evaluate theoretical and practical training of thoracic surgeons-in-training in robotic-assisted thoracic surgery (RATS) in France. METHODS: A survey was distributed to thoracic surgeons-in-training in France from November 2022-February 2023. RESULTS: We recruited 101 thoracic surgeons-in-training (77% response rate). Over half had access to a surgical robotics system at their current institution. Most (74%) considered robotic surgery training essential, 90% had attended a robotic procedure. Only 18% had performed a complete thoracic robotic procedure as the main operator. 42% of fellows and 6% of residents had performed a complete RATS procedure. Of the remaining surgeons, 23% had performed part of a robotic procedure. Theoretical courses and simulation are well developed; 72% of residents and 91% of fellows had undergone simulation training in the operating room, at training facilities, or during congress amounting to < 10 hours (for 73% of the fellows and residents), 10-20 hours (17%), 20-30 hours (8%), or > 30 hours (3%). Access to RATS was ≥1 day/week in 71% of thoracic departments with robotic access. Fellows spent a median of 2 (IQR 1-3) semesters in departments performing robotic surgery. Compared with low-volume centers, trainees at high-volume centers performed significantly more complete robotic procedures (47% vs 13%; p = 0.001), as did fellows compared with residents. CONCLUSIONS: Few young surgeons perform complete thoracic robotic procedures during practical training, and access remains center dependent. Opportunities increase with seniority and exposure; however, increasing availability of robotic devices, theoretical formation, and simulation courses will increase opportunities.

Is the Epithor conversion score reliable in robotic-assisted surgery anatomical lung resection?

OBJECTIVES: Despite an improvement in surgical abilities, the need for an intraoperative switch from a minimally invasive procedure towards an open surgery (conversion) still remains. To anticipate this risk, the Epithor conversion score (ECS) has been described for video-assisted thoracoscopic surgery (VATS). Our objective was to determine if this score, developed for VATS, is applicable in robotic-assisted thoracoscopic surgery (RATS). METHODS: This was a retrospective monocentric study from January 2006 to June 2022, and data were obtained from the EPITHOR database. Patients included were those who underwent anatomic lung resection either by VATS or RATS. The ECS was calculated for all patients studied. Discrimination and calibration of the test were measured by the area under the curve and Hosmer-Lemeshow test. RESULTS: A total of 1685 were included. There were 183/1299 conversions in the VATS group (14.1%) and 27/386 conversions in the RATS group (6.9%). Patients in the RATS group had fewer antiplatelet therapy and peripheral arterial disease. There were more segmentectomies in the VATS group. As for test discrimination, the area under the curve was 0.66 [0.56-0.78] in the RATS group and 0.64 [0.60-0.69] in the VATS group. Regarding the calibration, the Hosmer-Lemeshow test was not significant for both groups but more positive (better calibrated) for the VATS group (P = 0.12) compared to the RATS group (P = 0.08). CONCLUSIONS: The ECS seems applicable for patients operated with RATS, with a correct discrimination but a lower calibration performance for patients operated with VATS. A new score could be developed to specifically anticipate conversion in patients operated on by RATS.

Benignant and malignant epidemiology among surgical resections for suspicious solitary lung cancer without preoperative tissue diagnosis.

OBJECTIVES: The aim of this study was to describe the epidemiology of patients undergoing diagnostic and/or curative surgical pulmonary resections for lung opacities suspected of being localized primary lung cancers without preoperative tissue confirmation. METHODS: We performed a single-centre retrospective study of a prospectively implemented institutional database of all patients who underwent pulmonary resection between January 2010 and December 2020. Patients were selected when surgery complied with the Fleischner society guidelines. We performed a multivariable logistic regression to determine the preoperative variables associated with malignancy. RESULTS: Among 1392 patients, 213 (15.3%) had a final diagnosis of benignancy. We quantified futile parenchymal resections in 29 (2.1%) patients defined by an anatomical resection of >2 lung segments for benign lesions that did not modified the clinical management. Compared with patients with malignancies, patients with benignancies were younger (57.5 vs 63.9 years, P < 0.001), had lower preoperative risk profile (thoracoscore 0.4 vs 2.1, P < 0.001), had a higher proportion of wedge resection (50.7% vs 12.2%, P < 0.01) and experienced a lower burden of postoperative complication (Clavien-Dindo IV or V, 0.4% vs 5.6%, P < 0.001). Preoperative independent variables associated with malignancy were (adjusted odd ratio [95% confident interval]) age 1.02 [1.00; 1.04], smoking (year-pack) 1.005 (1.00; 1.01), history of cardiovascular disease 2.06 [1.30; 3.30], history of controlled cancer 2.74 [1.30; 6.88] and clinical N involvement 4.20 [1.11; 37.44]. CONCLUSIONS: Futile parenchymal lung resection for suspicious opacities without preoperative tissue diagnosis is rare (2.1%) while surgery for benign lesions represented 15.3% and has a satisfactory safety profile with very low postoperative morbi-mortality.