William R. Wrightson, MD, Chief Robotic Thoracic Surgery, Robley Rex VA Medical Center, Louisville, KY 40206
Ethical Statement:
i) The author(s) has no conflict of interest or disclosures
ii) The study involves human participants
iii) Informed consent is not applicable
Abstract:
Introduction: We report on our initial experience shifting from video assisted thoracic surgery (VATS) to the Da Vinci Si® robotic system in robotic thoracic surgery (RTS) at a VA medical center.
Methods: Retrospective review of 40 consecutive thoracic robotic cases at a single institution and thoracic surgeon. We report on operative time, estimated blood loss, length of stay (LOS) and lymph nodes sampled. This data was compared to video assisted thoracic surgery (VATS) cases completed prior to starting the robotic program.
Results: There were 40 robotic cases completed. Robotic docking and console times were 7.7 and 87.6 minutes respectively. Total OR time was higher in RTS lobectomy 205 minutes, versus wedge resections 94 minutes, however there was not a large difference in VATS versus RTS in terms of overall OR time. The average LOS was 2.3 days versus 6.3 days for RTS and VATS respectively. Oral opioid usage was significantly less with 71.0 mg versus 24.5 mg in VATS versus RTS. There were more LN harvested with RTS (4.4) versus VATS (1.3) (p<0.001).
Conclusion: RTS is an effective platform for thoracic surgical procedures. In our hands it has resulted in a shorter LOS, less perioperative pain and improved lymph node sampling.
Background
Minimally invasive surgery has gained increasing acceptance in thoracic surgery. However, open thoracotomy remains utilized in over 50% of lobectomy cases ([1]). Successful robotic thoracic surgery (RTS) was first reported in 2002 ([2]), and since that time RTS lobectomy has increased from 3.4% of lobectomy in 2010 to 17% in 2015 ([3]).
Robotic enhanced surgery improves thoracic access by simulating the open environment thru augmented 3D visualization and wristed intrathoracic instrument movements. In thoracic surgery, the robotic platform provides a perfect blend of vision, mechanical dexterity and computer precision. Reported advantages of the RTS include; better optics and visualization; more complete lymph node dissection; shorter length of stays (LOS) and decreases postoperative pain. While these benefits are enticing, there are limitations to robotic surgery such as reduced access, high facility investment and disposable costs. These implications remain a considerable hurdle however the advantages narrow the gap between RTS and other surgical platforms.
A variety of studies have compared open, VATS and RTS finding noninferiority for any of the approaches ([4], [5], [6]). The surgical technique used to complete the resection is only part of the equation. Surgeon experience and comfort, oncologic utility, patient outcomes as well as patient perceived value will determine the overall significance of RTS. We report our initial experience with the DaVinci Si® (Intuitive Surgical) robot system in thoracic surgical procedures and its impact on patient care and flow thru a veteran hospital system.
Methods
This is a retrospective review of a quality data base at a single institution and single operative surgeon. Cases include the first 40 consecutive robotic cases from October 2018 thru June 2019. This is compared to 40 consecutive VATS cases done prior to initiating the robotics program. Robotic cases moved thru a progression of minimal step low risk cases (Level 1), multistep moderate risk procedures (Level 2) and multistep complex cases(Level 3). Cases include wedge resection (level 1), thymectomy and diaphragmatic hernia repair (Level 2), lobectomy with lymph node dissection (level 3) (Table 1). We report on basic measures of both VATS and RTS including OR time, estimated operative blood loss (EBL), length of stay (LOS), oral opioid use and number of lymph nodes (LN) harvested.
Results
There were 40 robotic cases completed with 2 conversions to open in an 8 month period. Conversions were secondary to bleeding from the superior segmental branch of the pulmonary artery and the second due to a non-robotic stapler misfire. There were no major complications and no deaths.
Cases included wedge resections, thymectomy, and lobectomy (Table 2). The average LOS was 2.3 days versus 6.3 days for RTS and VATS respectively (table 3). Length of stay for lobectomy was 2.7 days(CI 95% 2.3-3.1) compared to wedge resection 1.7 days (CI 95%, 1.5-1.6). Extended hospital stays were related to complications of prolonged air leak (4), atrial fibrillation (1).
Robotic docking and console times were 7.7 and 87.6 minutes respectively (Table 4). Total OR time was higher in lobectomy 205 minutes, (CI 95% 186-224) versus wedge resections 94 minutes (CI 95% 86-101) for RTS. Average OR time was similar with a nonsignificant difference favoring RTS (143 versus 130 minutes respectively). There was a significant difference in terms of LOS, postoperative oral opioid use, and total LN sampled (p<0.001).
Intraoperative blood loss was 98.6 ml (CI 95%, 77.7-119.4) versus 92.5 ml (CI 95%, 66.8-118.2). This difference is more pronounced when examining the second 20 cases with 72.7 ml (CI 95% 54.1-91.3) blood loss in the RTS group (Table 3).
te
rms of LOS, OR time, EBL and opioid use.
Discussion
RTS has greatly impacted the management of thoracic patients at our institution. While we are still early in our program development, RTS seems to offer advantages not seen in VATS including more complete LN dissection, a shorter LOS, and better pain control.
Implementation of the robotic platform evolved from simple wedge resections (Level 1) to more lobectomy with mediastinal lymph node dissection (Level 3). As we progressed, we added a more lymph node dissection to the wedge resection. An important benefit, complete standardized lymph node dissection for each case greatly facilitated the anatomic resection. Greater exposure of hilar vessels and bronchi facilitated subsequent transection by the bedside assistant.
Preliminary concerns regarding the robotic system was that the da Vinci Siâ did not have vascular stapling capability relegating that responsibility to the bedside assistant or surgical resident. We discovered that the exposure of the pulmonary arterial branches were more complete and better visualized than with open thoracotomy or VATS. In turn, guiding a non-surgeon or resident around major pulmonary arterial branches was easier and more comfortable that expected. We experienced one minor vascular injury early in the series related to a difficult dissection. I attribute this to inexperience with exposure and incomplete lymph node dissection.
In our hands VATS has always seemed to limit the effective capture of some elusive and troublesome nodes. This is especially true of station 7 on the right and left, and intrabronchial nodes around the upper lobes (10 and 11). With the robotic approach, the nodal dissection becomes the preparatory step to the indicated procedure, clearing the way for safe application of the stapler and division of the vessels. Certainly many surgeons can do an excellent LN dissection via VATS, however we believe, the robot affords a more precise approach, finer dissection and effortless removal of nodal stations.
Studies have questioned if VATS produces equivalent nodal dissection compared to open lobectomy. For example, Licht et all showed that nodal upstaging was lower after VATS compared to open lobectomy for clinical stage I NSCLC ([7]). The rate of nodal upstaging for robotic resection appears to be superior to VATS and similar to thoracotomy based on some reports ([8]).
OR times were slightly lower in RTS versus VATS lobectomy procedures in our experience, however as we advanced to more complex Level 3 cases the time increased to 204 minutes. Robotic energy, that extra time required to implement the robot, did not contribute significantly to the procedure with docking averaging 7 minutes. Cerfolio et al report a progressive decrease in operative time with more experience. In their paper, OR time decreased from 195 min in the first 100 cases to 144 minutes in cases 201-300 ([9]). We saw a rise in OR time from 129 to 145 minutes likely suggesting the increased case complexity was responsible for the increased times. Undoubtedly, there is a learning curve associated with robotic surgery and comparing to historical VATS procedures in an established program will be biased.
Intraoperative blood loss was higher in our initial experience. Much of this was related to implementing use of standard bipolar instrumentation. It is recommended to utilize a Maryland style bipolar dissector in RTS cases as the energy device. The dissector allows for grasping and dissecting of tissue and temperate coagulation to free lymph nodes and vessels with less thermal spread. Learning the correct application of energy and jaw positioning can be difficult to master, especially if one has not utilized this routinely in their practice. Knowing the specifications of your particular energy generator and the optimal settings are an advantage that took us several cases to master. Nelson et al report their initial experience with blood loss of 100 ml RTS versus 150 for VATS ([10]). This is consistent with our results of 93 ml in the robotic cases.
We are seeing a shorter length of stay after robotic cases. There is likely some confirmation bias related to the process and the use of an enhanced recovery after surgery (ERAS) program, non the less it has resulted in a statistically significant decrease in LOS. National averages of length of stay for VATS lobectomy vary but have been reported from 4-7 days([11], [12]). Our average LOS was just over 2 days. Longer stays were related to prolonged air leak (PAL) or pre-existing comorbid factors. We did not see a significant difference in the rate of PAL between VATS or robotic cases.
The remote center function of the robot is the point on the trocar that has near 0 movement. It is the fulcrum point that is placed appropriately, minimizes the traction injuries on the rib space and may result in decreased postoperative pain. While in theory this functions as advertised, variation in the width of the rib space and thickness of the chest wall can impact the surrounding tissue damage and injury from motion on the trocar and robotic arms. This has improved with better port placement in particular the most posterior port. Recent studies reported similar perioperative pain comparing VATS, RTS and open thoracotomy ([13], 10)
Post operatively our patients utilized 70% less oral opioid compared to historical VATS controls. We no longer use patient controlled analgesia (PCA) and had limited use of IV breakthrough pain management. There were 7 patients that required breakthrough IV pain meds with an average usage of 2.2 mg morphine sulfate (95% CI, 1.3-3.1). There has been a conscious effort in our facility to improve postoperative pain management. This included a more comprehensive non-narcotic pain regimen utilizing IV acetaminophen, ketorolac and gabapentin. In addition, we get improved nerve blocks intraoperatively (both with the robot and VATS) that also assists in this process. Some of this improvement may be subjective in both the conscientious delivery of oral opioids from nursing staff and a perceived improvement in pain control from the patient. Kwon et. al. report that minimally invasive approaches decrease acute and chronic pain, however more RTS patients believed the specific approach affected their perceived pain ([14]).
Establishing a streamlined system for management of the robotic patient (and by extension the thoracic patient) including specialized teams in the operating room, and enhanced recovery protocols in the post-operative period provide a comprehensive surgical management platform. In our early experience we could not demonstrate inferiority in the robotic platform using some basic measures. We saw more judicious use of pain medications, improving intraoperative blood loss, more precise LN dissection and a decreased LOS. We believe the robotic platform contributes to this value, but it is not likely the exclusive reason.
References
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