Effectiveness of Robotic Lobectomy—Outcome and Learning Curve in a High Volume Center

Abstract

Background Robotic surgery has been developed as a sophisticated tool to expand possibilities in minimal invasive surgery. The learning curve for this method is short in various surgical fields; however, limited data exist on the learning curve in robotic thoracic surgery.

Methods This study analyzes a single center experience of robotic lobectomies using a prospectively kept database. Perioperative data and outcome of patients during the learning curve were compared with patients operated with increased institutional experience. The learning curve was defined as the initial 20 lobectomies.

Results Sixty-four robotic lobectomies were performed between January 2014 and February 2017. Indications, preoperative lung functions, comorbidities, patient age, and tumor stage were comparable between patients operated during the learning curve and thereafter. The mean operative time could be significantly reduced after the learning curve (286 ± 86 vs. 211 ± 62 minutes; p = 0.0003). The conversion rate dropped from 4 of 20 (20%) during the learning curve to 2 of 44 (4.5%, p = 0.07) thereafter. Chest tube duration (4.3 ± 2.9 vs. 3.8 ± 2.1 days) and hospital stay (8.3 ± 3.4 vs. 7.9 ± 4.5 days) were not different in the two phases. The number of resected lymph nodes increased from 11.2 ± 6.8 to 13.9 ± 6.5 (p = 0.0797). Lymph node upstaging was achieved in 8 (12.9%) cases. Ninety-day mortality was 0%, and 2-year overall survival was 83%.

Conclusions Robotic thoracic surgery can be safely performed and trained with low complication rates and contributes to the extension of minimal invasive thoracic surgery. The initial learning curve in our experience is overcome after 20 cases. However, to become proficient in more advanced procedures and to further reduce operative time, additional training is required. Prospective studies are required to clearly determine the role of robotic surgery in comparison to the video-assisted thoracoscopic surgery (VATS) procedures.

Keywords

learning curve - robotic lobectomy - lymph node upstaging - lung cancer

• References

• 1 Lewis RJ, Caccavale RJ, Sisler GE, Mackenzie JW. One hundred consecutive patients undergoing video-assisted thoracic operations. Ann Thorac Surg 1992; 54 (03) 421-426
• 2 Puri V, Patel A, Majumder K. , et al. Intraoperative conversion from video-assisted thoracoscopic surgery lobectomy to open thoracotomy: a study of causes and implications. J Thorac Cardiovasc Surg 2015; 149 (01) 55-61 , 62.e1
• 3 Smith DE, Dietrich A, Nicolas M, Da Lozzo A, Beveraggi E. Conversion during thoracoscopic lobectomy: related factors and learning curve impact. Updates Surg 2015; 67 (04) 427-432
• 4 Toker A, Özyurtkan MO, Kaba E, Ayalp K, Demirhan Ö, Uyumaz E. Robotic anatomic lung resections: the initial experience and description of learning in 102 cases. Surg Endosc 2016; 30 (02) 676-683
• 5 De Leyn P, Dooms C, Kuzdzal J. , et al. Revised ESTS guidelines for preoperative mediastinal lymph node staging for non-small-cell lung cancer. Eur J Cardiothorac Surg 2014; 45 (05) 787-798
• 6 Cerfolio RJ, Bryant AS. Robotic-assisted pulmonary resection - right upper lobectomy. Ann Cardiothorac Surg 2012; 1 (01) 77-85
• 7 Baste JM, Riviera C, Nouhaud FX, Rinieri P, Melki J, Peillon C. Implementation of a robotic video-assisted thoracic surgical program [in French]. Rev Mal Respir 2016; 33 (03) 207-217
• 8 Howington JA, Blum MG, Chang AC, Balekian AA, Murthy SC. Treatment of stage I and II non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013; 143 (5 Suppl): e278S-313S
• 9 Kent M, Wang T, Whyte R, Curran T, Flores R, Gangadharan S. Open, video-assisted thoracic surgery, and robotic lobectomy: review of a national database. Ann Thorac Surg 2014; 97 (01) 236-242 , discussion 242–244
• 10 Cerfolio RJ, Bryant AS, Minnich DJ. Starting a robotic program in general thoracic surgery: why, how, and lessons learned. Ann Thorac Surg 2011; 91 (06) 1729-1736 , discussion 1736–1737
• 11 Bedetti B, Bertolaccini L, Solli P, Scarci M. Learning curve and established phase for uniportal VATS lobectomies: the Papworth experience. J Thorac Dis 2017; 9 (01) 138-142
• 12 Meyer M, Gharagozloo F, Tempesta B, Margolis M, Strother E, Christenson D. The learning curve of robotic lobectomy. Int J Med Robot 2012; 8 (04) 448-452
• 13 Veronesi G, Agoglia BG, Melfi F. , et al. Experience with robotic lobectomy for lung cancer. Innovations (Phila) 2011; 6 (06) 355-360
• 14 Park HS, Detterbeck FC, Boffa DJ, Kim AW. Impact of hospital volume of thoracoscopic lobectomy on primary lung cancer outcomes. Ann Thorac Surg 2012; 93 (02) 372-379
• 15 Tchouta LN, Park HS, Boffa DJ, Blasberg JD, Detterbeck FC, Kim AW. Hospital volume and outcomes of robot-assisted lobectomies. Chest 2017; 151 (02) 329-339
• 16 Okyere S, Attia R, Toufektzian L, Routledge T. Is the learning curve for video-assisted thoracoscopic lobectomy affected by prior experience in open lobectomy?. Interact Cardiovasc Thorac Surg 2015; 21 (01) 108-112
• 17 Konge L, Petersen RH, Hansen HJ, Ringsted C. No extensive experience in open procedures is needed to learn lobectomy by video-assisted thoracic surgery. Interact Cardiovasc Thorac Surg 2012; 15 (06) 961-965
• 18 Boffa DJ, Kosinski AS, Paul S, Mitchell JD, Onaitis M. Lymph node evaluation by open or video-assisted approaches in 11,500 anatomic lung cancer resections. Ann Thorac Surg 2012; 94 (02) 347-353 , discussion 353
• 19 Licht PB, Jørgensen OD, Ladegaard L, Jakobsen E. A national study of nodal upstaging after thoracoscopic versus open lobectomy for clinical stage I lung cancer. Ann Thorac Surg 2013; 96 (03) 943-949 , discussion 949–950
• 20 Martin JT, Durbin EB, Chen L. , et al. Nodal upstaging during lung cancer resection is associated with surgical approach. Ann Thorac Surg 2016; 101 (01) 238-244 , discussion 44–45
• 21 Merritt RE, Hoang CD, Shrager JB. Lymph node evaluation achieved by open lobectomy compared with thoracoscopic lobectomy for N0 lung cancer. Ann Thorac Surg 2013; 96 (04) 1171-1177
• 22 Medbery RL, Gillespie TW, Liu Y. , et al. Nodal upstaging is more common with thoracotomy than with vats during lobectomy for early-stage lung cancer: an analysis from the national cancer data base. J Thorac Oncol 2016; 11 (02) 222-233
• 23 Wilson JL, Louie BE, Cerfolio RJ. , et al. The prevalence of nodal upstaging during robotic lung resection in early stage non-small cell lung cancer. Ann Thorac Surg 2014; 97 (06) 1901-1906 , discussion 1906–1907
• 24 Decaluwé H, Stanzi A, Dooms C. , et al; Leuven Lung Cancer Group. Central tumour location should be considered when comparing N1 upstaging between thoracoscopic and open surgery for clinical stage I non-small-cell lung cancer. Eur J Cardiothorac Surg 2016; 50 (01) 110-117
• 25 Decaluwe H, Petersen RH, Brunelli A. , et al. Multicentric evaluation of the impact of central tumor location when comparing n1 upstaging between video assisted thoracoscopic surgery (vats) and open surgery for clinical stage I non-small cell lung cancer. Eur J Cardiothorac Surg 2017; DOI: 10.1093/ejcts/ezx338. . [Epub ahead of print]