Cardiothoracic - Clinical Evidence

Abstract

BACKGROUND: We report our experience in starting a robotic program in thoracic surgery.

METHODS: We retrospectively reviewed our experience in starting a robotic program in general thoracic surgery on a consecutive series of patients.

RESULTS: 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.

CONCLUSIONS: 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.Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Abstract

BACKGROUND: Many general thoracic surgeons are learning robotic pulmonary resection.

METHODS: We retrospectively compared results of completely portal robot lobectomy with 4 arms (CPRL-4) against propensity-matched controls and results after technical changes to CPRL-4.

RESULTS: In 14 months, 168 patients underwent robotic pulmonary resection: 7 had metastatic pleural disease, 13 had conversion to open procedures, and 148 had completion robotically (106 lobectomies, 26 wedge resections, 16 segmentectomies). All patients underwent R0 resection and removal of all visible lymph nodes (median of 5 N2, 3 N1 nodal stations, 17 lymph nodes). The 106 patients who underwent CPRL-4 were compared with 318 propensity-matched patients who underwent lobectomy by rib- and nerve-sparing thoracotomy. The robotic group had reduced morbidity (27% vs 38%; P = .05), lower mortality (0% vs 3.1%; P = .11), improved mental quality of life (53 vs 40; P < .001), and shorter hospital stay (2.0 vs 4.0 days; P = .02). Results of CPRL-4 after technical modifications led to reductions in median operative time (3.7 vs 1.9 hours; P < .001) and conversion (12/62 vs 1/106; P < .001). Technical improvements were addition of fourth robotic arm for retraction, vessel loop to guide the stapler, tumor removal above the diaphragm, and carbon dioxide insufflation.

CONCLUSIONS: The newly refined CPRL-4 is safe and yields an R0 resection with complete lymph node removal. It has lower morbidity, mortality, shorter hospital stay, and better quality of life than rib- and nerve-sparing thoracotomy. Technical advances are possible to shorten and improve the operation.Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Abstract

We have developed a robotic video-assisted thoracoscopic technique (RVATS) for lung resection that could encourage broader use of minimally invasive lobectomy. During December 2006 to September 2010, RVATS was performed in 200 consecutive patients (90 women, 110 men) with the da Vinci Surgical System (Intuitive Surgical, Inc, Sunnyvale, CA). Pulmonary resection was performed through ports without the need for a utility incision. Data on patients' perioperative results were collected retrospectively. Robotic video-assisted pulmonary resection was accomplished in 197 of 200 patients. A total of 154 patients underwent lobectomy; 4 patients required bilobectomy, and 35 patients underwent segmentectomy. Three patients underwent a sleeve lobectomy, and 3 patients had an en-bloc resection with lobectomy. One patient received a left pneumonectomy. Three patients required conversion to a thoracotomy. The median operative time was 90 minutes. The median length of hospital stay was 3 days. 60-day mortality and morbidity was 2% and 26%, respectively. RVATS lung resection is technically feasible, safe, and results indicate the procedure is associated with reduced length of stay, low morbidity, and mortality. Copyright © 2011 Elsevier Inc. All rights reserved.

Abstract

BACKGROUND: Robotic mitral valve repair has been performed in Australia since 2004. The aim of this study was to perform a cost-analysis of robotic mitral valve repair (MVR) with direct comparison to conventional MVR surgery.

METHODS: All isolated MVRs performed within one metropolitan hospital network, between June 2005 and June 2008, were retrospectively compared. Ad hoc cost analysis was conducted.

RESULTS: There were 107 robotic and 40 conventional MVRs performed. The post-operative degrees of mitral regurgitation were comparable. Total operating time was 18% longer in robotic compared to conventional (239 min vs. 202 min, p<0.001, 95% CI: 11-27%). In robotic, Intensive Care Unit stay was reduced by 19% (p=0.002, 37 h vs. 45 h), and length of hospital stay was reduced by 26% (p<0.001, 6.47 days vs. 8.76 days). Mean hospital cost, without including capital costs, was not significantly increased (AUD$18,503 vs. AUD$17,880 p=0.176, 95% CI: -282 to 1,530).

CONCLUSIONS: Robotic mitral repair can be performed with similar immediate repair success rates as conventional surgery with a shorter recovery time, but a slightly longer operative time. There is no significant increase in cost over conventional surgery. Crown Copyright (c) 2010. Published by Elsevier B.V. All rights reserved.

Abstract

OBJECTIVES: Robotic mitral valve repair is the least invasive approach to mitral valve repair, yet there are few data comparing its outcomes with those of conventional approaches. Therefore, we compared outcomes of robotic mitral valve repair with those of complete sternotomy, partial sternotomy, and right mini-anterolateral thoracotomy.

METHODS: From January 2006 to January 2009, 759 patients with degenerative mitral valve disease and posterior leaflet prolapse underwent primary isolated mitral valve surgery by complete sternotomy (n = 114), partial sternotomy (n = 270), right mini-anterolateral thoracotomy (n = 114), or a robotic approach (n = 261). Outcomes were compared on an intent-to-treat basis using propensity-score matching.

RESULTS: : Mitral valve repair was achieved in all patients except 1 patient in the complete sternotomy group. In matched groups, median cardiopulmonary bypass time was 42 minutes longer for robotic than complete sternotomy, 39 minutes longer than partial sternotomy, and 11 minutes longer than right mini-anterolateral thoracotomy (P < .0001); median myocardial ischemic time was 26 minutes longer than complete sternotomy and partial sternotomy, and 16 minutes longer than right mini-anterolateral thoracotomy (P < .0001). Quality of mitral valve repair was similar among matched groups (P = .6, .2, and .1, respectively). There were no in-hospital deaths. Neurologic, pulmonary, and renal complications were similar among groups (P > .1). The robotic group had the lowest occurrences of atrial fibrillation and pleural effusion, contributing to the shortest hospital stay (median 4.2 days), 1.0, 1.6, and 0.9 days shorter than for complete sternotomy, partial sternotomy, and right mini-anterolateral thoracotomy (all P < .001), respectively.

CONCLUSIONS: Robotic repair of posterior mitral valve leaflet prolapse is as safe and effective as conventional approaches. Technical complexity and longer operative times for robotic repair are compensated for by lesser invasiveness and shorter hospital stay. Copyright © 2011 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.