The primary objective of this study was to evaluate our experience using a completely portal (no access incision) robotic pulmonary lobectomy or segmentectomy.
This was a retrospective review of a ...consecutive series of patients.
From February 2010 until October 2013, 862 robotic operations were performed by 1 surgeon. Of these, 394 were for a planned anatomic pulmonary resection, comprising robotic lobectomy in 282, robotic segmentectomy in 71, and conversions to open in 41 (10 for bleeding, 1 patient required transfusion; and no conversions for bleeding in the last 100 patients). Indications were malignancy in 88%. A median of 17 lymph nodes were removed. Median hospital stay was 2 days. Approximate financial data yielded: median hospital charges, $32,000 per patient (total, $12.6 million); collections, 23.7%; direct costs, $13,800 per patient; and $4,750 profit per patient (total, $1.6 million). Major morbidity occurred in 9.6%. The 30-day operative mortality was 0.25%, and 90-day mortality was 0.5%. Patients reported a median pain score of 2/10 at their 3-week postoperative clinic visit.
Robotic lobectomy for cancer offers outstanding results, with excellent lymph node removal and minimal morbidity, mortality, and pain. Despite its costs, it is profitable for the hospital system. Disadvantages include capital costs, the learning curve for the team, and the lack of lung palpation. Robotic surgery is an important tool in the armamentarium for the thoracic surgeon, but its precise role is still evolving.
Both robotic pulmonary operations and anatomic segmentectomy are being increasingly performed. The largest published series of anatomic robotic segmentectomy comprises 35 patients, and the specific ...details of port placement are poorly understood.
This is a review of a consecutive series of patients from a single surgeon's prospective database. All patients in the study were scheduled to undergo robotic anatomic segmentectomy.
Between February 2010 and December 2014, 100 patients went to the operating room for a planned pulmonary segmentectomy. A robotic approach was chosen for all. Seven patients underwent conversion to robotic lobectomy, and the remaining 93 patients had an anatomic robotic segmentectomy. There were no conversions to thoracotomy. Indications for resection were lung cancer in 79 patients, metastatic lesions in 10 patients, fungal infections in 4 patients, and other conditions in 7 patients. The median age was 69 years, and 50 patients were men. The median blood loss was 20 mL (range, 10-120 mL), the median number of lymph nodes removed was 19, the median operative time was 1.28 hours (88 minutes), the median length of stay was 3 days, and major morbidity occurred in 2 patients (pneumonia in both). All had undergone R0 resection. There were no 30- or 90-day mortalities. Of the 79 patients with lung cancer, the median follow-up was 30 months, and 3 patients (3.4%) had recurrence in the operated lobe. Overall survival was 95% at 30 months.
Completely portal robotic anatomic segmentectomy is safe and effective and offers outstanding intraoperative 30-day and 90-day results. The recurrence rate is approximately 3% at 2.5 years.
We report our experience in starting a robotic program in thoracic surgery.
We retrospectively reviewed our experience in starting a robotic program in general thoracic surgery on a consecutive ...series of patients.
Between February 2009 and September 2010, 150 patients underwent robotic operations. Types of procedures were lobectomy in 62, thymectomy in 30, and benign esophageal procedures in 6. No thymectomy or esophageal procedures required conversion. One conversion was needed for suspected bleeding for a mediastinal mass. Twelve patients were converted for lobectomy (none for bleeding, 1 in the last 24). Median operative time for robotic thymectomy was 119 minutes, and median length of stay was 1 day. The median time for robotic lobectomy was 185 minutes, and median length of stay was 2 days. There were no operative deaths. Morbidity occurred in 23 patients (15%). All patients with cancer had R0 resections and resection of all visible mediastinal and hilar lymph nodes.
Robotic surgery is safe and oncologically sound. It requires training of the entire operating room team. The learning curve is steep, involving port placement, availability of the proper instrumentation, use of the correct robotic arms, and proper patient positioning. The robot provides an ideal surgical approach for thymectomy and other mediastinal tumors. Its advantage over thoracoscopy for pulmonary resection is unproven; however, we believe complete thoracic lymph node dissection and teaching is easier. Importantly, defined credentialing for surgeons and cost analysis studies are needed.
Our objective is to report our incidence, results, and technique for the control of major vascular injuries during minimally invasive robotic thoracic surgery.
This is a consecutive series of ...patients who underwent a planned robotic thoracic operation by one surgeon.
Between February 2009 and September 2015, 1,304 consecutive patients underwent a robotic operation (lobectomy, n = 502; segmentectomy, n = 130; mediastinal resection, n = 115; Ivor Lewis, n = 103; thymectomy, n = 97; and others, n = 357) by one surgeon. Conversion to thoracotomy occurred in 61 patients (4.7%) and in 14 patients (1.1%) for bleeding (pulmonary artery, n = 13). The incidence of major vascular injury during anatomic pulmonary resection was 2.4% (15 of 632). Of these, 13 patients required thoracotomy performed in a nonurgent manner while the injury was displayed on a monitor, 2 had the vessel repaired minimally invasively, 2 required blood transfusion (0.15%), and 1 patient had 30-day mortality (0.16%). Techniques used to minimize morbidity include having a sponge available during vessel dissection and stapling, applying immediate pressure, delaying the opening until the bleeding is controlled without external pressure, and ensuring there is no bleeding while the chest is opened.
Major vascular injuries can be safely managed during minimally invasive robotic surgery. Our evolving technique features initial packing of the bleeding for several minutes, maintaining calmness to provide time to prepare for thoracotomy, and reexamination of the injured vessel. If repair is not possible minimally invasively, the vessel is repacked and a nonhurried, elective thoracotomy is performed while the injury is displayed on a monitor to ensure active bleeding is not occurring.
Our objective was to determine the incidence and optimal management of chylothorax after pulmonary resection with complete thoracic mediastinal lymph node dissection (MLND).
This is a retrospective ...review of patients who underwent pulmonary resection with MLND.
Between January 2000 and December 2012, 2,838 patients underwent pulmonary resection with MLND by one surgeon (RJC). Forty-one (1.4%) of these patients experienced a chylothorax. Univariate analysis showed that lobectomy (p<0.001), a robotic approach (p=0.03), right-sided operations (p<0.001), and pathologic N2 disease (p=0.007) were significantly associated with the development of chylothorax. Multivariate analysis showed that lobectomy (p=0.011), a robotic approach (p=0.032), and pathologic N2 disease (p=0.027) remained predictors. All patients were initially treated with cessation of oral intake and 200 μg subcutaneous somatostatin every 8 hours. If after 48 hours the chest tube output was less than 450 mL/day and the effluent was clear, patients was given a medium-chain triglyceride (MCT) diet and were observed for 48 hours in the hospital. If the chest tube output remained below 450 mL/day, the chest tube was removed, they were discharged home with directions to continue the MCT diet and to return in 2 weeks. Patients were instructed to consume a high-fat meal 24 hours before their clinic appointment. If the patient's chest roentgenogram was clear at that time, they were considered "treated." This approach was successful in 37 (90%) patients. The 4 patients in whom the initial treatment was unsuccessful underwent reoperation with pleurodesis and duct ligation.
Chylothorax after pulmonary resection and MLND occurred in 1.4% of patients. Its incidence was higher in those with pathologic N2 disease and those who underwent robotic resection. Nonoperative therapy is almost always effective.
Robotic lobectomy can be taught while maintaining quality patient outcomes Cerfolio, Robert J., MD, MBA, FACS, FCCP; Cichos, Kyle H., BS; Wei, Benjamin, MD ...
Journal of thoracic and cardiovascular surgery/The Journal of thoracic and cardiovascular surgery/The journal of thoracic and cardiovascular surgery,
10/2016, Letnik:
152, Številka:
4
Journal Article
Recenzirano
Odprti dostop
Abstract Objective The objective is to report our outcomes of teaching and performing minimally invasive robotic lobectomy. Methods Robotic lobectomy was divided into 19 specific sequential technical ...maneuvers. The number of steps residents could perform in a set period of time was recorded. Video review by the attending surgeon and coaching were used to improve what residents could safely perform. Outcomes compared were percentage of maneuvers that general surgical or cardiothoracic residents (fellows) completed, operative times, and Society of Thoracic Surgeons–defined metrics of patient outcomes. Results There were 520 consecutive robotic lobectomies over 5 years. The various maneuvers completed by general surgical residents (N = 35) and cardiothoracic residents (N = 7) increased over time, for example, steps 1 to 5 increased 20% and 70% compared with 80% and 90% ( P < .001), step 8 increased 0% and 50% compared with 90% and 100% ( P < .0001), and step 19 increased 30% and 50% compared with 90% and 100% ( P = .001), respectively. Operative outcomes, including intraoperative blood loss, median number of lymph nodes, median length of stay, major morbidity, and 30-day and 90-day mortality, were no different. Operative time initially increased and then decreased over time. Conversion to thoracotomy (15% to 2.5%, P = .042) and major vascular injury (3% to 0%, P = .018) decreased. Conclusions Robotic lobectomy can be safely taught to residents without compromising patient outcomes by dividing it into a series of surgical maneuvers. Recording outcomes for each step and using video review and coaching techniques may help increase the percent of maneuvers residents can complete in a set time.
The American College of Surgery Oncology Group Z0030 study was a prospective randomized study that showed that mediastinal lymph node sampling (MLNS) offered similar results to mediastinal lymph node ...dissection (MLND) in patients with non-small cell lung cancer (NSCLC). However, that study only randomized patients after thorough samplings that were negative on frozen section in several N2 and N1 nodal stations. The purpose of this study was to evaluate the effect of MLND to the more common practice of ruling out N2 disease preoperatively and then resection without sending lymph nodes for frozen section.
This is a retrospective study of patients clinically staged as N0 with NSCLC. The incidence of pathologic N2 disease reported by the Society of Thoracic Surgeons (STS) database was considered to represent MLNS and it was compared with our patients who underwent complete MLND.
Between January 2002 and December 2009, 1,358 patients clinically staged as N0 underwent lobectomy or segmentectomy and MLND (not MLNS). Our incidence of pathologic N2 disease in 1,107 patients who underwent lobectomy was 10.6% compared with 9.4% in the 24,896 STS lobectomy patients (p=0.196). Our incidence of pathologic N2 disease in 251 patients who underwent segmentectomy was 13.0% compared with 5.3% in the 2,150 STS segmentectomy patients (p<0.001).
When complete MLND is performed in patients during pulmonary resection who are clinically node negative (have benign N2 nodes after selective endobronchial or esophageal ultrasound or mediastinoscopy) without using intraoperative frozen section of N2 or N1, more patients are pathologically staged with N2 disease; thus, more are considered for adjuvant chemotherapy. The impact on survival in these patients is unproven.
To prospectively assess the incidence of non-imaged malignant nodules in patients who undergo thoracotomy for metastasectomy with bimanual lung palpation.
This is a prospective cohort study of ...patients who underwent open metastasectomy by thoracotomy. All patients had metastatic lung lesions, underwent 64-slice helical computed tomographic (CT) scan with intravenous contrast using 5-mm collimated cuts, and most had integrated PET (positron emission tomography)-CT. Unsuspected malignant pulmonary nodules that were palpated and removed, and that were not imaged preoperatively, were recorded.
From January 2006 to March 2010, 152 patients underwent metastasectomy by rib-sparing, nerve-sparing thoracotomy by 1 surgeon. Fifty-one (34%) patients had 57 pulmonary nodules that were not imaged preoperatively and 32 of the 57 (56%) nodules were malignant. Thirty patients had non-imaged malignant nodules that were palpated and removed. There were 15 malignant nodules that were in different lobes than the imaged nodules. The 3 most commonly missed malignant nodules occurred in patients with colorectal cancer, renal cell, and sarcoma.
Metastasectomy by thoracotomy, which affords bimanual palpation of the entire lung, discovers ipsilateral non-imaged malignant pulmonary metastases in 1 of 5 patients who had at least 1 imaged metastatic pulmonary lesion. This is true despite preoperative, fine cut chest CT scan with contrast, and integrated 18F-fluorodeoxyglucose-PET-CT scanning. The clinical significance of these non-imaged, resected malignant nodules is unknown, nor is the added morbidity of resecting benign nodules.
Objective Minimally invasive esophagectomy with intra-thoracic dissection and anastomosis is increasingly performed. Our objectives are to report our operative technique, early results and lessons ...learned. Methods This is a retrospective review of 85 consecutive patients who were scheduled for minimally invasive Ivor Lewis esophagectomy (laparoscopic or robotic abdominal and robotic chest) for esophageal cancer. Methods Between 4/2011 and 3/2015, 85 (74 men, median age 63) patients underwent robotic Ivor Lewis esophageal resection. Sixty-four patients (75%) had preoperative chemo-radiotherapy, 99% had esophageal cancer and 99% had an R0 resection. There were no abdominal or thoracic conversions for bleeding. There was one abdominal conversion for the inability to completely staple the gastric conduit. The mean operative time was 6 hours, median blood loss was 35 ml (no intra-operative transfusions), median number of resected lymph nodes was 22 and median length of stay was 8 days. Conduit complications (anastomotic leak or conduit ischemia) occurred in 6 patients. The 30-day and 90-day mortality were 3/85 (3.5%) and 9/85 (10.6%), respectively. Initial poor results led to protocol changes via root cause analysis: longer rehabilitation prior to surgery, liver biopsy in patients with history of suspected cirrhosis, and refinements to conduit preparation and anastomotic technique. Conclusion Robotic Ivor Lewis esophagectomy for cancer provides an R0 resection with excellent lymph node resection. Our preferred port placement and operative techniques are described. Disappointingly high thoracic conduit problems and 30 and 90-day mortality led to lessons learned and implementation of change which are shared. Ultra-miniabstract A review of 85 consecutive patients undergoing robotic Ivor Lewis esophagectomy shows our preferred technique and early results. Root cause analysis led to protocol changes that were implemented in order to improve our 30 and 90-day mortality and other outcomes.
Previous publications suggest that mediastinoscopy only obtains a biopsy of lymph node tissue in about 50% of patients; however, those data included results from nonthoracic surgeons.
A retrospective ...cohort study was performed using a database of a consecutive series of patients who underwent mediastinoscopy or video mediastinoscopy by general thoracic surgeons only.
Between January 1997 and September 2013, 1,970 patients underwent mediastinoscopy (video mediastinoscopy in the last 243). The indications were staging for known or suspected lung cancer in 68.5%. Morbidity occurred in 25 patients (1.3%). Significant bleeding occurred in 5 patients (0.25%): 2 patients required sternotomy, and bleeding in the other 3 was controlled with packing alone. No patients required transfusion. There were no 30-day operative deaths. Median operative time was 18 minutes, and 96.1% of operations were performed as outpatient procedures. Lymph node tissue was obtained from all patients, and biopsy specimens from at least two mediastinal stations were obtained for 98% who had non-small cell lung cancer. The false-negative rate for N2 lymph nodes that were accessible by mediastinoscopy was 8.2% when lymph nodes dissected at the time of pulmonary resection were used as the reference standard.
In the hands of general thoracic surgeons mediastinoscopy provides lymph node tissue from multiple stations essentially 100% of the time; has minimal morbidity and essentially no deaths; and is a short outpatient procedure. Specialty-specific data (and not national databases) should be used when the efficacy of mediastinoscopy is compared with endobronchial ultrasound.
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