Maintaining safe lung cancer surgery during the COVID-19 pandemic in a global city.

BACKGROUND: SARS-CoV-2 has challenged health service provision worldwide. This work evaluates safe surgical pathways and standard operating procedures implemented in the high volume, global city of London during the first wave of SARS-CoV-2 infection. We also assess the safety of minimally invasive surgery(MIS) for anatomical lung resection. METHODS: This multicentre cohort study was conducted across all London thoracic surgical units, covering a catchment area of approximately 14.8 Million. A Pan-London Collaborative was created for data sharing and dissemination of protocols. All patients undergoing anatomical lung resection 1st March-1st June 2020 were included. Primary outcomes were SARS-CoV-2 infection, access to minimally invasive surgery, post-operative complication, length of intensive care and hospital stay (LOS), and death during follow up. FINDINGS: 352 patients underwent anatomical lung resection with a median age of 69 (IQR: 35-86) years. Self-isolation and pre-operative screening were implemented following the UK national lockdown. Pre-operative SARS-CoV-2 swabs were performed in 63.1% and CT imaging in 54.8%. 61.7% of cases were performed minimally invasively (MIS), compared to 59.9% pre pandemic. Median LOS was 6 days with a 30-day survival of 98.3% (comparable to a median LOS of 6 days and 30-day survival of 98.4% pre-pandemic). Significant complications developed in 7.3% of patients (Clavien-Dindo Grade 3-4) and 12 there were re-admissions(3.4%). Seven patients(2.0%) were diagnosed with SARS-CoV-2 infection, two of whom died (28.5%). INTERPRETATION: SARS-CoV-2 infection significantly increases morbidity and mortality in patients undergoing elective anatomical pulmonary resection. However, surgery can be safely undertaken via open and MIS approaches at the peak of a viral pandemic if precautionary measures are implemented. High volume surgery should continue during further viral peaks to minimise health service burden and potential harm to cancer patients. FUNDING: This work did not receive funding.

Training in robotic thoracic surgery-the European way.

The increasing demand for robot-assisted thoracic surgery (RATS) in Europe requires a structured and standardized training module. Until now, Intuitive Surgical Inc. (Sunnyvale, CA, USA) has delivered the only available robotic surgery platform. Although the training program that is organized by Intuitive is divided in an initial and an advanced course, the success of the training depends on many external factors. Until now the training focused on experienced thoracic surgeons. The aim of this article is to offer a stepwise training module, which can be adopted by experienced open (thoracotomy) surgeons or video-assisted thoracic (VATS) surgeons but is primarily meant for thoracic surgery fellows and residents, as it is our sincere opinion that we should focus on training for this type of surgery as early in their careers as possible. In order to maintain surgical technique and minimize the chance of complications, on-going training and certification of the surgeons and the team is deemed necessary.

Resource implications of robotic thoracic surgery: what are the wider issues?

The benefits of minimally invasive thoracic surgery are well documented when compared to the use of standard thoracotomy. Much controversy exists, however, regarding the resource implications when using robot-assisted thoracic surgery (RATS), especially when compared to video-assisted thoracoscopic surgery (VATS). Much of the costs attributed to a particular approach center around the frequency and severity of the complications that may arise. Little exists in the literature to appropriately compare and contrast the complication rate following either of the minimally invasive approaches. There is a suggestion that many conventional open surgeons are more readily persuaded to adopt a minimally invasive approach through the use of the robotic platform, therefore reducing the complication-related costs of standard thoracotomy by an increase in minimally invasive resection rates. Further gains may be made in the ability to perform more complex minimally invasive procedures via a RATS approach without recourse to open conversion when compared to VATS. As opportunities and competition increase in the commercial market place, it is reasonable to assume costs will fall and further savings will be made.

Right robotic-assisted thoracoscopic lower lobectomy.

The right lower lobectomy is considered one of the easier resection operations performed by an open technique. The posterior approach for the video-assisted thoracoscopic surgery (VATS) version of this is similar, as instruments and staplers pass up the fissure. When moving to the robotic platform with the camera and instruments entering from caudal ports, the equal view of the lobe, fissure and both hila allow for a more balanced operation. This article aims to discuss the technology of robotic-assisted surgery and the optimal surgical techniques to enable precise and safe resection of the lower lobe.

Sequential robotic-assisted lung resection with a subxiphoid utility incision.

For the past two years, the authors have used a subxiphoid utility incision for robot-assisted lobectomies. This approach prevents unnecessary rib pressure, offers a good angle of approach to the hilum, and allows specimen retrieval with minimal resistance. Robot-assisted lung resection is an established technique that facilitates postoperative recovery by minimizing operative trauma and postoperative pain. We believe the subxiphoid utility incision further enhances recovery and facilitates early repeat surgery. We present two cases of staged sequential robot-assisted anatomical lung resection using the same subxiphoid utility incision on each occasion.

Outcomes from the Delphi process of the Thoracic Robotic Curriculum Development Committee.

OBJECTIVES: As the adoption of robotic procedures becomes more widespread, additional risk related to the learning curve can be expected. This article reports the results of a Delphi process to define procedures to optimize robotic training of thoracic surgeons and to promote safe performance of established robotic interventions as, for example, lung cancer and thymoma surgery. METHODS: In June 2016, a working panel was spontaneously created by members of the European Society of Thoracic Surgeons (ESTS) and European Association for Cardio-Thoracic Surgery (EACTS) with a specialist interest in robotic thoracic surgery and/or surgical training. An e-consensus-finding exercise using the Delphi methodology was applied requiring 80% agreement to reach consensus on each question. Repeated iterations of anonymous voting continued over 3 rounds. RESULTS: Agreement was reached on many points: a standardized robotic training curriculum for robotic thoracic surgery should be divided into clearly defined sections as a staged learning pathway; the basic robotic curriculum should include a baseline evaluation, an e-learning module, a simulation-based training (including virtual reality simulation, Dry lab and Wet lab) and a robotic theatre (bedside) observation. Advanced robotic training should include e-learning on index procedures (right upper lobe) with video demonstration, access to video library of robotic procedures, simulation training, modular console training to index procedure, transition to full-procedure training with a proctor and final evaluation of the submitted video to certified independent examiners. CONCLUSIONS: Agreement was reached on a large number of questions to optimize and standardize training and education of thoracic surgeons in robotic activity. The production of the content of the learning material is ongoing.

Unusual presentation of mucoepidermoid carcinoma with recurrent pulmonary embolism.

Mucoepidermoid carcinoma is a rare type of tumor of bronchial glands. We describe an unusual presentation of mucoepidermoid carcinoma in a 19-year-old man with atypical pneumonia, deep vein thromboses and recurrent pulmonary embolism, which, to the best of our knowledge has not previously been reported.