Developing novel non-assistant help operation in dual-portal robotic-assisted thoracic surgery (neoDRATS).

Objective: To introduce and evaluate the non-assistant help operation in dual-portal robotic-assisted thoracic surgery (neoDRATS), a novel technique designed to eliminate the need for skilled assistants by using all 4 robotic arms independently during anatomical lung surgery. Methods: Patients were placed in the lateral decubitus position under general anesthesia with single-lung ventilation. The da Vinci Xi Surgical System was used, with specific configurations for right- and left-side operations. The neoDRATS technique used a 4-cm working port and a 1.8-cm secondary port, with detailed guidelines for optimal setup and robotic arm manipulation. Results: The neoDRATS approach demonstrated successful surgical outcomes without the need for a skilled assistant. The use of a 0° camera and careful placement of instruments minimized interference within the thoracic cavity. The technique provided smooth operability and minimized postoperative discomfort. Video demonstrations of right and left upper lobectomies are provided to illustrate the approach. Conclusions: NeoDRATS offers a practical, safe, and minimally invasive alternative to conventional multiportal and uniportal robotic-assisted thoracic surgeries. This technique simplifies the surgical process, particularly in settings with limited availability of skilled assistants, and represents a significant advancement in robotic thoracic surgery. Further refinement and clinical integration of neoDRATS are anticipated as robotic innovations continue to evolve.

Initial Experience of Single-Port Robotic Lobectomy for Large-Sized Non-Small Cell Lung Cancer: A Single-Center Retrospective Study.

Single-port robotic-assisted thoracic surgery (SP-RATS) lobectomy using the da Vinci Xi system has been performed by several pioneers. However, due to the severe collisions and the steep learning curve, this approach is not yet widely used. This study aimed to evaluate the feasibility of SP-RATS lobectomy for large-sized non-small cell lung cancer (NSCLC). As we believe that for large-sized tumors it is reasonable to make a slightly larger incision, we performed SP-RATS lobectomy for large-sized NSCLC (greater than 5 cm) through a single incision (6-8 cm). Eleven patients underwent SP-RATS lobectomy using the da Vinci Xi system at our institution from April 2022 to May 2024. The median tumor size on computed tomography and on pathology was 6.6 cm [interquartile range (IQR), 6.1-7.5 cm] and 6 cm [IQR, 5.1-7.1], respectively. The median total operative time was 198 min [IQR, 159-260 min], and the median postoperative length of stay was 4 days [IQR, 4-10 days], with no major postoperative complications (≥grade III on the Clavien-Dindo classification). Our approach may combine the benefits of single-port surgery with those of robotic surgery and is safe, feasible, and may promote better outcomes in patients with large-sized NSCLC.

1000 Robotic-assisted lobectomies for primary lung cancer: 16 years single center experience.

OBJECTIVE: This study aimed at describing our high-volume single center experience in robotic-assisted thoracic surgery (RATS) to evaluate short outcome and feasibility of the technique, the adequacy of oncological results, and the learning curve. METHODS: We retrospectively analyzed data from 1000 consecutive patients who underwent lobectomy and systematic lymphadenectomy for primary lung cancer using RATS approach between May 2007 and May 2023. RESULTS: Nine-hundred ninety-seven patients (99.7 %) underwent lobectomy, whereas 3 (0.03 %) patients bilobectomy. Conversion rate to open surgery was 3.7 %. Minor complications occurred in 213 (21.3 %) patients, major complications in 29 patients (2.9 %). The 30-day and 90-day operative mortality was 0 % and 0.1 %, respectively. The median number of N1 + N2 stations resected was 5 (range 0-9), with a median number of 17 of N1 + N2 lymph nodes resected (range 0-55). The oncological outcome was evaluated only on the subgroup of patients (n = 895) with non-small cell lung cancer. Pathological lymph node upstaging from cN0 to pN1/pN2 was evident in 147 patients (17.3 %): 9 % from cN0 to pN1 and 7.1 % from cN0 to pN2. With a median follow-up of 3.9, 5-year OS and DFS were respectively 89.3 % and 83.6 % for stage I, 74 % and 66.5 % for stage II, and 61 % and 36.4 % for stage IIIA. CONCLUSIONS: Better vision and excellent instrument maneuverability of the robotic surgical system allowed excellent results in terms of early, adequate oncological outcome comparable to open surgery literature data, and acceptable learning curve. ULTRAMINI ABSTRACT: 1000 consecutive patients who underwent lobectomy and systematic lymphadenectomy for primary lung cancer using RATS approach have been analyzed with the aim to describe our high-volume single center experience, and to evaluate short outcome and feasibility of the technique, the adequacy of oncological results, and the learning curve.

Subxiphoid Single-Port Robotic Thymectomy Using the Single-Port Robotic System versus VATS: A Multi-Institutional, Retrospective, and Propensity Score-Matched Study.

Subxiphoid thymectomy is a novel alternative to the transthoracic approach and sternotomy, with potential benefits, such as reduced postoperative pain and faster recovery. We previously reported the initial experience with subxiphoid single-port robotic-assisted thoracic surgery (SRATS) thymectomy using the single-port robotic system (SPS). However, the efficacy of this technique remains unknown. Thus, this study examined the multi-institutional experience with SRATS thymectomy and compared the perioperative outcomes of this technique to those of subxiphoid single-port video-assisted thoracic surgery (SVATS) thymectomy. The data of patients who underwent subxiphoid SRATS and SVATS thymectomy, performed by three thoracic surgeons at three institutions between September 2018 and May 2024, were retrospectively collected. In total, 110 patients were included, with 85 and 25 undergoing SRATS and SVATS thymectomy, respectively. After propensity score matching, 25 patients were included in each group. The SRATS group was associated with a lower conversion rate to multi-port surgery (0% vs. 20%, p = 0.05), shorter chest tube drainage duration (1.32 ± 0.75 vs. 2.00 ± 1.29 days, p = 0.003), and a shorter postoperative hospital stay (2.52 ± 1.00 vs. 5.08 ± 5.20 days, p = 0.003). Subxiphoid SRATS thymectomy using the SPS is feasible and is a good alternative to conventional thymectomy. Further studies are necessary to confirm its benefits.

Early adoption of robotic lung resection in an established video assisted thoracic surgery practice.

Background: Reported advantages to robotic thoracic surgery include shorter length of stay (LOS), improved lymphadenectomy, and decreased complications. It is uncertain if these benefits occur when introducing robotics into a well-established video-assisted thoracoscopy (VATS) practice. We compared the two approaches to investigate these advantages. Materials and methods: IRB approval was obtained for this project. Patients who underwent segmentectomy or lobectomy from May 2016-December 2018 were propensity-matched 2: 1 (VATS: robotic) and compared using weighted logistic regression with age, gender, Charlson Comorbidity Index, surgery type, stage, Exparel, and epidural as covariates. Complication rates, operation times, number of sampled lymph nodes, pain level, disposition, and LOS were compared using Wilcoxon rank-sum and with Rao-Scott Chi-squared tests. Results: 213 patients (142 VATS and 71 robot) were matched. Duration of robotic cases was longer than VATS (median 186 min (IQR 78) vs. 164 min (IQR 78.75); p < 0.001). Significantly more lymph nodes (median 11 (IQR 7.50) vs. 8 (IQR 7.00); p = 0.004) and stations were sampled (median 4 (IQR 2.00) vs. 3 (IQR 1.00); p < 0.001) with the robot. Interestingly, robotic resections had higher 72-hour pain scores (median 3 (IQR 3.25) vs. 2 (IQR 3.50); p = 0.04) and 48-hour opioid usage (median 37.50 morphine milligram equivalents (MME) (IQR 45.50) vs. 22.50 MME (IQR 37.50); p = 0.01). Morbidity, LOS, and disposition were similar (all p > 0.05). Conclusions: The robotic approach facilitates better lymph node sampling, even in an established VATS practice.

Comparison of early postoperative patient-reported outcomes after multiportal robotic-assisted thoracoscopic surgery and uniportal video-assisted thoracoscopic surgery for non-small cell lung cancer.

INTRODUCTION: We aimed to compare early postoperative patient-reported outcomes between multiportal robotic-assisted thoracoscopic surgery (M-RATS) and uniportal video-assisted thoracoscopic surgery (U-VATS) for non-small-cell lung cancer (NSCLC). MATERIALS AND METHODS: Symptom severity and functional status were measured using the Perioperative Symptom Assessment for Lung Surgery at pre-surgery, during postoperative hospitalisation, and within 4 weeks of discharge. A propensity score-matched (PSM) analysis of patients with NSCLC who were treated with M-RATS and U-VATS was performed. The symptom severity and daily functional status presented as proportion of moderate-to-severe scores on a 0-10-point scale, were compared using a generalised estimation equation model. RESULTS: We enrolled 762 patients with NSCLC from a prospective cohort (CN-PRO-Lung 3), including 151 and 611 who underwent M-RATS and U-VATS, respectively, before PSM analysis. After 1:1 PSM, two groups of 148 patients each were created. Pain severity (P = 0.019) and activity limitation (P = 0.001) during hospitalisation were higher in the M-RATS group. However, no significant differences existed post-discharge in pain (P = 0.383), cough (P = 0.677), shortness of breath (P = 0.526), disturbed sleep (P = 0.525), drowsiness (P = 0.304), fatigue (P = 0.153), distress (P = 0.893), walking difficulty (P = 0.242), or activity limitation (P = 0.513). M-RATS caused less intraoperative blood loss (P = 0.013), more stations of dissected lymph nodes (P = 0.001), more numbers of dissected lymph nodes (P = 0.001), and less tube drainage on the first postoperative day (P = 0.003) than U-VATS. CONCLUSION: M-RATS and U-VATS achieved comparable symptom burden and functional impairment after discharge. However, compared to U-VATS, M-RATS was associated with more severe pain and activity limitation in the short postoperative period. TRIAL REGISTRATION NUMBER: ChiCTR2000033016.

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 to 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. A complete RATS procedure was performed by 42% of fellows and 6% of residents. 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 h (for 73% of the fellows and residents), 10-20 h (17%), 20-30 h (8%) or >30 h (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 centres, trainees at high-volume centres 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 centre dependent. Opportunities increase with seniority and exposure; however, increasing availability of robotic devices, theoretical formation, and simulation courses will increase opportunities.

Perioperative outcomes of robotic versus video-assisted thoracoscopic surgery in non-small cell lung cancer patients after neoadjuvant chemoimmunotherapy.

Background: Limited data are available regarding perioperative outcomes in patients with non-small cell lung cancer (NSCLC) who undergo robotic-assisted thoracic surgery (RATS) after neoadjuvant chemoimmunotherapy. This study aimed to compare the perioperative outcomes of RATS and video-assisted thoracic surgery (VATS) in NSCLC patients after neoadjuvant chemoimmunotherapy. Methods: The study involved consecutive NSCLC patients treated with minimally invasive surgery (MIS) after neoadjuvant chemoimmunotherapy at a high-volume single center from September 2020 to October 2022. Short-term effects, including demographic, perioperative and pathological parameters, were compared between the RATS group and the VATS group. Results: A total of 119 patients were included in this study. Of these, 33 (27.7%) patients received RATS and 86 (72.3%) patients received VATS. Major pathological response (MPR) and pathological complete response (pCR) rates were comparable between the two groups. The RATS group had a higher number of dissected lymph nodes (21 vs. 18, P=0.03) and lymph node stations (7 vs. 6, P=0.004) compared with the VATS group but no differences were found in perioperative outcomes. Conclusions: These findings suggest that both RATS and VATS are safe and feasible options for NSCLC patients who have received neoadjuvant chemoimmunotherapy. Furthermore, RATS may offer advantages over VATS in patients who require a more extensive lymph node dissection.

Factors related to post-thoracotomy pain following robotic-assisted thoracic surgery.

BACKGROUND: Robotic-assisted thoracic surgery (RATS) is a minimally invasive procedure; however, some patients experience persistent postoperative pain. This study aimed to investigate factors related to postoperative pain following RATS. METHODS: The data of 145 patients with lung cancer, who underwent RATS with a four-port (one in the sixth intercostal space [ICS] and three in the eighth ICS) lobectomy or segmentectomy between May 2019 and December 2022, were retrospectively analyzed. Factors associated with analgesic use for at least 2 months following postoperative pain (PTP group) were analyzed. RESULTS: Patients who underwent preoperative pain control for any condition or chest wall resection were excluded. Among the 138 patients, 45 (32.6%) received analgesics for at least 2 months after surgery. Patient height and transverse length of the thorax correlated with PTP in the univariate analysis (non-PTP vs. PTP; height, 166 vs. 160 cm; p < .001; transverse length of the thorax, 270 vs. 260 mm, p = .016). In the multivariate analysis, height was correlated with PTP (p = .009; odds ratio, 0.907; 95% confidence interval, 0.843-0.976). Height correlated with the transverse length of the thorax (r = .407), anteroposterior length of the thorax (r = .294), and width of the eighth ICS in the middle axillary line (r = .210) using Pearson's correlation coefficients. When utilizing a 165-cm cutoff value for height to predict PTP using receiver operating characteristic curve analysis, the area under the curve was 0.69 (95% confidence interval, 0.601-0.779). CONCLUSION: Short stature is associated with a high risk of postoperative pain following RATS.

Outcomes and costs with the introduction of robotic-assisted thoracic surgery in public hospitals.

Robotic-assisted thoracic surgery (RATS) is an effective treatment of non-small cell lung cancer (NSCLC) but the effects of its implementation in university hospital networks has not been described. We analyzed the early clinical outcomes, estimated costs, and revenues associated with three robotic systems implemented in the Paris Public Hospital network. A retrospective study included patients who underwent RATS for NSCLC in 2019 and 2020. Ninety-day morbidity, mortality, hospital costs, and hospital revenues were described. Economic analyses were conducted either from the hospital center or from the French health insurance system perspectives. Cost drivers were tested using univariate and multivariable analyses. Sensitivity analyses were performed to assess uncertainty over in-hospital length of stay (LOS), number of robotic surgeries per year, investment cost, operating room occupancy time, maintenance cost, and commercial discount. The study included 188 patients (65.8 ± 9.3 years; Charlson 4.1 ± 1.4; stage I 76.6%). Median in-hospital LOS was 6 days [5-9.5], 90-day mortality was 1.6%. Mean hospital expenses and revenues were €12,732 ± 4914 and €11,983 ± 5708 per patient, respectively. In multivariable analysis, factors associated with hospital costs were body mass index, DLCO, major complications, and transfer to intensive care unit. Sensitivity analyses showed that in-hospital LOS (€11,802-€15,010) and commercial discounts on the list price (€11,458-€12,732) had an important impact on costs. During the first 2 years following the installation of three robotic systems in Paris Public Hospitals, the clinical outcomes of RATS for NSCLC have been satisfactory. Without commercial discount, hospital expenses would have exceeded hospital revenues.Clinical registration number CNIL, N°2221601, CERC-SFCTCV-2021-07-20-Num17_MOPI_robolution.

Results of an exploratory survey within ESTS membership in 2022 on current trend of robotic-assisted thoracic surgery and its training perspectives.

OBJECTIVES: Robotic-assisted thoracic surgery (RATS) is increasingly used in our specialty. We surveyed European Society of Thoracic Surgeons membership with the objective to determine current status of robotic thoracic surgery practice including training perspectives. METHODS: A survey of 17 questions was rolled out with 1 surgeon per unit responses considered as acceptable. RESULTS: A total of 174 responses were obtained; 56% (97) were board-certified thoracic surgeons; 28% (49) were unit heads. Most responses came from Italy (20); 22% (38) had no robot in their institutions, 31% (54) had limited access and only 17% (30) had full access including proctoring. Da Vinci Xi was the commonest system in 56% (96) centres, 25% (41) of them had dual console in all systems, whereas RATS simulator was available only in half (51.18% or 87). Video-assisted thoracic surgery (VATS) was the most commonly adopted surgical approach in 81% of centres (139), followed by thoracotomy in 67% (115) and RATS in 36% (62); 39% spent their training time on robotic simulator for training, 51% on robotic wet/dry lab, which being no significantly different to 46-59% who had training on VATS platform. There was indeed huge overlap between simulator models or varieties usage; 52% (90) reported of robotic surgery not a part of training curriculum with no plans to introduce it in future. Overall, 51.5% (89) responded of VATS experience being helpful in robotic training in view of familiarity with minimally invasive surgery anatomical views and dissection; 71% (124) reported that future thoracic surgeons should be proficient in both VATS and RATS. Half of the respondents found no difference in earlier chest drain removal with either approach (90), 35% (60) reported no difference in postoperative pain and 49% (84) found no difference in hospital stay; 52% (90) observed better lymph node harvest by RATS. CONCLUSIONS: Survey concluded on a positive response with at least 71% (123) surgeons recommending to adopt robotics in future.

Robotic Lobectomy Learning Curve Has Better Clinical Outcomes than Videothoracoscopic Lobectomy.

Introduction: The robotic-assisted (RATS) lobectomy learning curve is usually measured compared to an established videothoracoscopic (VATS) surgery program. The objective of our study is to compare the learning curves of both techniques. Methods: We performed an intention-to-treat analysis comparing the RATS vs. VATS lobectomies. Surgical time, conversions, complications, number of lymph nodes (LNs) and lymph node stations harvested, chest drainage duration, length of stay, readmissions, and 90-day mortality were compared between both groups. The learning curve was assessed using the CUSUM method. Results: RATS cases (30) and VATS cases (35) displayed no significant differences. The RATS learning curve was completed after 23 procedures while the VATS curve required 28 interventions. Complications appeared in four RATS procedures and in eight VATS patients. No differences in the number of LNs and harvested LN stations were reported. Four patients were readmitted in the RATS group, and eight in the VATS group. No 90-day postoperative mortality was observed in either group. The RATS group reported fewer chest tube days (3 (2-5) vs. 5 (4-5.8), p = 0.005) and hospital days (4 (3-6) vs. 5 (4-6), p = 0.023). Conclusions: The RATS curve appears shorter than the VATS curve. RATS lobectomies resulted in reduced chest tube duration and length of stay during the learning time period.

Clinical effectiveness of robotic-assisted compared to open or video-assisted lobectomy in Germany: a real-world data analysis.

OBJECTIVES: Despite robotic-assisted thoracic surgery (RATS) lobectomy being on the rise in Europe, the majority of lobectomies in Germany are still performed with an open or thoracoscopic [video-assisted thoracic surgery (VATS)] approach. Empirical evidence in favour of RATS lobectomy is inconsistent. This retrospective cohort study investigates the impact of RATS lobectomy compared with open thoracic surgery (OPEN) and VATS lobectomy on short-term outcomes in Germany using multicentre real-world data. METHODS: Anonymized routine data from Germany from 2018 to 2020 were retrospectively analysed. These data were provided by 61 German hospitals. Propensity score matching with subsequent generalized linear models was performed for statistical analysis. Additionally, in order to test the robustness of the results, multivariable regression analyses with cluster-robust standard errors were used. RESULTS: A total of 2498 patients with lobectomy were identified: in 1345 patients OPEN, in 983 VATS and 170 a RATS lobectomy was performed. RATS-compared to OPEN and VATS-reduced length of stay (LOS) by 28% or 4.2 days [confidence interval: 2.9; 5.4] and by 13% or 1.6 days [confidence interval: 0.2; 3.0], respectively. The risk of pneumonia was reduced by 5.3 percentage points in the RATS group compared to both OPEN and VATS (P = 0.07/0.01). RATS-compared to an open approach-reduces the risk of blood transfusions by 8.8 percentage points (P < 0.001) and LOS on the intensive care unit (P < 0.001). CONCLUSIONS: This study provides strong support that RATS lobectomy outperforms OPEN or VATS lobectomy in terms of hospital LOS, and short-term in-hospital postoperative complications in the real-world scenario in Germany.

Developing a Virtual Reality Simulation System for Preoperative Planning of Robotic-Assisted Thoracic Surgery.

Background. Robotic-assisted thoracic surgery (RATS) is now standard for lung cancer treatment, offering advantages over traditional methods. However, RATS's minimally invasive approach poses challenges like limited visibility and tactile feedback, affecting surgeons' navigation through com-plex anatomy. To enhance preoperative familiarization with patient-specific anatomy, we devel-oped a virtual reality (VR) surgical navigation system. Using head-mounted displays (HMDs), this system provides a comprehensive, interactive view of the patient's anatomy pre-surgery, aiming to improve preoperative simulation and intraoperative navigation. Methods. We integrated 3D data from preoperative CT scans into Perspectus VR Education software, displayed via HMDs for in-teractive 3D reconstruction of pulmonary structures. This detailed visualization aids in tailored preoperative resection simulations. During RATS, surgeons access these 3D images through Tile-ProTM multi-display for real-time guidance. Results. The VR system enabled precise visualization of pulmonary structures and lesion relations, enhancing surgical safety and accuracy. The HMDs offered true 3D interaction with patient data, facilitating surgical planning. Conclusions. VR sim-ulation with HMDs, akin to a robotic 3D viewer, offers a novel approach to developing robotic surgical skills. Integrated with routine imaging, it improves preoperative planning, safety, and accuracy of anatomical resections. This technology particularly aids in lesion identification in RATS, optimizing surgical outcomes.

Evaluation of the efficacy and safety of robot-assisted and video assisted thoracic surgery for early non-small cell lung cancer: A meta-analysis.

BACKGROUND: Radical resection of lung cancer and chemotherapy are the main methods for the treatment of early lung cancer, but surgical treatment is still the key and preferred method. OBJECTIVE: To evaluate the efficacy and safety of robotic-assisted thoracic surgery (RATS) and video assisted thoracic surgery (VATS) for non-small cell lung cancer (NSCLC). METHODS: The clinical cohort studies on the comparison of the effects of RATS and VATS in the treatment of NSCLC published in Web of Science, PubMed, The National Library of Medicine (NLM), China National Knowledge Infrastructure (CNKI) and Wanfang database from January 1, 2015 to December 31, 2022 were searched. Two researchers independently screened the literature, extracted the data, such as operation time, intraoperative conversion rate, intraoperative blood loss, number of lymph nodes dissected, and evaluated the quality of the included literature based on the Newcastle-Ottawa Scale (NOS). RevMan 5.3 software was used for Meat analysis. RESULTS: A total of 18 articles and 21,802 subjects were included. The results of the meta-analysis showed that the intraoperative blood loss of RATS was significantly less than that of VAS, and the difference was statistically significant [MD =-38.43 (95% CI: -57.71, -19.15, P< 0.001)]. Compared with VATS, the number of lymph nodes dissected in RATS was significantly higher [MD = 2.61 (95% CI: 0.47, 4.76, P= 0.02)]. The rate of conversion to thoracotomy in RATS was lower, and the difference was statistically significant [OR = 0.59 (95% CI: 0.50, 0.70, P< 0.001)]. There was no significant difference between RATS and VATS in operation time [MD =-9.34 (95% CI: -28.72, 10.04, P= 0.34)], postoperative thoracic drainage time [MD =-0.08 (95% CI: -0.42, 0.26, P= 0.64)], postoperative hospital stay [MD =-0.05 (95% CI: -0.19, 0.08, P= 0.42)], postoperative mortality [OR = 0.88 (95% CI: 0.56, 1.36, P= 0.56)] and postoperative complications [OR = 1.03 (95% CI: 0.93, 1.13, P= 0.57)]. CONCLUSION: Compared with VATS, the number of lymph nodes dissected in RATS was significantly more, and the removal of lesions and lymph nodes was more thorough and accurate. More flexible and precise operation avoids the injury of important blood vessels during operation, effectively reduces the amount of blood loss during operation, shortens the indwelling time of thoracic drainage tube, and is conducive to postoperative rehabilitation of patients.

Association of neighborhood socioeconomic disadvantage with use of minimally invasive resection for non-small cell lung cancer.

OBJECTIVE: Minimally invasive resection for non-small cell lung cancer has been linked to decreased postoperative morbidity. This work sought to characterize factors associated with receiving minimally invasive surgery for surgically resectable non-small cell lung cancer. METHODS: All adults undergoing lobectomy/sublobar resection for stage I non-small cell lung cancer were identified using the 2010-2020 National Cancer Database. Those undergoing thoracoscopic/robotic procedures comprised the minimally invasive resection cohort (others: open). Hospitals were stratified by minimally invasive resection procedure volume, with the top quartile considered high minimally invasive resection volume centers. Multivariable models were constructed to assess the independent association between the patients, diseases, and hospital factors and the likelihood of receiving minimally invasive resection. RESULTS: Of 217,762 patients, 112,304 (52%) underwent minimally invasive resection. The proportion of minimally invasive resection procedures increased from 27% in 2010 to 72% in 2020 (P < .001). After adjustment, several factors were independently associated with decreased odds of receiving minimally invasive resection, including lower quartiles of median neighborhood income (51st-75th percentile adjusted odds ratio, 0.92, 95% CI, 0.89-0.94; 26th-50th percentile adjusted odds ratio, 0.86, CI, 0.83-0.89; 0-25th percentile adjusted odds ratio, 0.78, CI, 0.75-0.81; reference: 76th-100th percentile income) and care at community hospitals (adjusted odds ratio, 0.70, CI, 0.68-0.71; reference: academic centers). Among patients receiving care at high minimally invasive resection volume centers, lowest income remained linked with reduced likelihood of undergoing minimally invasive resection from 2010 to 2015 (adjusted odds ratio, 0.85, CI, 0.77-0.94), but did not alter the odds of minimally invasive resection in later years (adjusted odds ratio, 1.01, CI, 0.87-1.16; reference: highest income). CONCLUSIONS: This study identified significant community income-based disparities in the likelihood of undergoing minimally invasive resection as definitive surgical treatment. Novel interventions are warranted to expand access to high-volume minimally invasive resection centers and ensure equitable access to minimally invasive surgery.

Assessment of Quality Outcomes and the Learning Curve for Robot-Assisted Anatomical Lung Resections.

Background: To determine the perioperative quality assessment results and learning curves for robot-assisted anatomical lung resection. Methods: We analyzed the data of the initial 400 patients who underwent lobectomies or segmentectomies by 1 surgeon from January 2020 to November 2021. The learning curve was analyzed using cumulative sum analysis. Results: The surgical experience was divided into an initial phase (1st-40th procedures), a transition phase (41st-131st procedures), and a proficient phase (132nd procedure onward). The operative time showed a conspicuously continuous improvement over the 400 consecutive patients. After the 120th procedure, there were significant improvements in the rate of persistent air leakage (11.7% versus 3.9%; P = .003), chest tube duration (3.92 ± 1.91 versus 2.99 ± 1.31, P = .00), and postoperative hospital stay (6.22 ± 2.02 versus 4.93 ± 1.44, P = .00). Conclusions: In conclusion, 40 patients were necessary to pass the learning curve, and technical proficiency with favorable perioperative outcomes was achieved after 120-130 patients.

Robotic-assisted wire saw resection of high-position rib tumors: a single-center experience.

Background: Rib tumors are typically curable through rib resection, associated with an excellent prognosis. Although transthoracic robotic first rib resection for thoracic outlet syndrome (TOS) has been previously documented, this paper presents our experience and technique in conducting robotic-assisted wire saw resections for high-position rib tumors. Methods: From January 2019 to May 2022, five patients diagnosed with high-position rib tumors underwent robotic-assisted wire saw resections. For our entire portal approach, we employed two 8-mm working ports, a 12-mm camera port, and a 12-mm assistant port. Data regarding the short-term and clinical long-term treatment effects were collected. Results: The median operation time was 124.2 minutes (range, 87-185 minutes), with no observed complications. The average intraoperative blood loss was 185 mL (range, 85-410 mL). Chest tubes were typically removed between 1 and 3 days post-operation. The average hospital stay post-surgery was 2.8 days, with a range of 2-5 days. We observed no relevant intraoperative or postoperative complications. No recurrence was reported during routine follow-ups 12 months post-surgery. Conclusions: Our findings indicate that the technique of robotic-assisted wire saw resection for high-position rib tumors is both feasible and reliable. This provides valuable insights for surgeons to consider robotic-assisted resection for high-position rib tumors.

Perioperative hypothermia in robotic-assisted thoracic surgery: Incidence, risk factors, and associations with postoperative outcomes.

OBJECTIVE: Inadvertent perioperative hypothermia has been associated with poor surgical outcomes. The purpose of this study was to evaluate the incidence and associated postoperative complications of inadvertent perioperative hypothermia in patients undergoing robotic-assisted thoracic surgery lung resections. METHODS: This was a single-center, retrospective cohort study evaluating all consecutive patients who underwent robotic-assisted thoracic surgery lung resection between January 1, 2021, and November 30, 2022. Temperatures were measured at 5 time points: preprocedure unit, anesthesia induction, 30 minutes postinduction, extubation, and recovery room arrival. Temperature changes were calculated at each interval. Adjusted and unadjusted comparison was performed between those who experienced varying levels of inadvertent perioperative hypothermia (Hypothermia I: <36 °C, Hypothermia II: <35.5 °C, and Hypothermia III: <35 °C) and those who did not. RESULTS: A total of 313 patients were included, and 201 (64.2%) lobectomies, 50 (16.0%) segmentectomies, and 62 (19.8%) wedge resections were performed. Across all patients, 291 (93.0%) had a temperature less than 36 °C, 195 (62.3%) had a temperature less than 35.5 °C, and 100 (31.9%) had a temperature less than 35.0 °C. Patients experienced significant temperature change at all intervals (P < .001), with the greatest loss occurring during the preprocedure interval (between leaving preprocedure unit and anesthesia induction). On adjusted analysis, patients who experienced inadvertent perioperative hypothermia less than 35.5 °C were older (odds ratio, 1.03; 95% CI, 1.01-1.05), had lower body mass index (odds ratio, 0.95; 95% CI, 0.87-0.98), and had increasing operative time (odds ratio, 1.00; 95% CI, 1.00-1.01). Patients who experienced inadvertent perioperative hypothermia had higher risk-adjusted rates of overall morbidity and infectious postoperative complications. CONCLUSIONS: The majority of patients undergoing robotic-assisted thoracic surgery lung resections experience some degree of inadvertent perioperative hypothermia and have associated increased rates of 30-day morbidity. Structured and interval-specific interventions should be implemented to decrease rates of inadvertent perioperative hypothermia and subsequent complications.