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Standardizing Robotic Lobectomy: Feasibility and Safety in 128 Consecutive Lobectomies Within a Single Healthcare System

Lazar, John F. MD; Spier, Laurence N. MD; Hartman, Alan R. MD; Lazzaro, Richard S. MD

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: March/April 2017 - Volume 12 - Issue 2 - p 77–81
doi: 10.1097/IMI.0000000000000352
Original Articles

Objective Single-surgeon cohorts assessing robotically assisted video-assisted thoracic (RA-VATS) lobectomy have reported good outcomes, but there are little data regarding multiple surgeons applying a standard technique in separate hospitals. The purpose of this study was to show how a standardized robotic technique is both safe and reproducible between surgeons and institutions.

Methods From July 1, 2012, to October 1, 2013, patients undergoing RA-VATS lobectomy for both benign and malignant disease were identified from a prospectively collected database of two thoracic surgeons from different hospitals within the same healthcare system and retrospectively analyzed. Each surgeon employed an identical “rule of 10” completely port-based approach through all 128 cases. The primary end points of the study were in-hospital and 30-day mortality. Secondary end points were differences in morbidity and perioperative outcomes between the two surgeons based on their “rule of 10” technique.

Results A total of 128 cases were performed with 121 lobectomies, 3 bilobectomies, and 4 pneumonectomies for both malignant and benign disease. Each surgeon had 64 cases without a single in-hospital or 30-day mortality. Overall morbidity was 16.4%. Each surgeon had one readmission and take back to operating room (a washout and a mechanical pleurodesis). The most common complication was prolonged air leak (38.1%, 8/21 patients). There was no statistical difference in length of stay, complications, severity of illness, and clinical staging between the two surgeons. There was a significant difference in resected lymph nodes (11.79 vs 14.45, P = 0.0086). Compared with published national meta-analysis on RA-VAT lobectomies, there was a significantly reduced length of stay (4.2 vs 6 days, P = 0.0436) and bleeding (0.8 vs 1.8%, P = 0.0003). Nodal upstaging from cN0 to pN1 was 8% and cN0 to pN2 was 2% for an overall nodal upstaging of 10% for stage I nonsmall cell lung cancer.

Conclusions By standardizing how a robotic lobectomy is performed, we were able to show that RA-VATS lobectomy is safe and may allow for the expansion of minimally invasive lobectomy to surgeons who otherwise have failed to adopt traditional VATS. When compared with the most recent national meta-analysis, we had reduced morbidity, mortality, bleeding, and length of stay. Robotic nodal upstaging for stage I nonsmall lung cancer was consistent with larger multicenter study. We hope that these results will help lead to the standardization robotic lobectomy and a larger multisurgeon/institutional study that could pave the way for greater adoption of minimally invasive lobectomy.

From the *Division of Thoracic Surgery, PinnacleHealth CardioVascular Institute, Harrisburg, PA USA; †Division of Cardiothoracic Surgery, Northwell Health, Manhasset, NY USA; and ‡Division of Cardiothoracic Surgery, Lenox Hill Hospital/Northwell Health, New York, NY USA.

Accepted for publication February 16, 2017.

Presented at the 52nd Annual Scientific Meeting of the Eastern Cardiothoracic Surgical Society, October 8–11, 2014, Palm Beach, FL USA.

Disclosures: John F. Lazar, MD, is on the speaker's bureau of Myriad Genetics, Salt Lake City, UT USA; Laurence N. Spier, MD, and Richard S. Lazzaro, MD, are consultants for Intuitive Surgical, Sunnyvale, CA USA; and Alan R. Hartman, MD, declares no conflict of interest.

Address correspondence and reprint requests to Richard S. Lazzaro, MD, Lenox Hill Hospital/Northwell Health, 130 E 77th Street, New York, NY 10075 USA. E-mail:

©2017 by the International Society for Minimally Invasive Cardiothoracic Surgery