Does Experience Impact Robotic Lobectomy Proficiency?

Evaluating proficiency in performing robotic lobectomy varies largely based on the outcome measured, researchers recently found.

“Recent studies show the minimally invasive approaches are now the dominant approach for early stage lung cancers [when performing pulmonary lobectomy],” said Andrew F. Feczko, MD, of the Swedish Medical Center in Seattle, who presented his team’s findings at the Southern Thoracic Surgical Association’s 65th Annual Meeting & Exhibition.

“We sought to describe the effects of prior operative experience on the outcome and development of proficiency during transition to robotic lobectomy.”

For their study, researchers compared different outcomes based on lobectomy experience by using cumulative sum (CUSUM) analysis. They queried the STS General Thoracic Database to collect data on surgeons who performed robotic lobectomies on patients with clinical stage I and stage II non-small cell lung cancer between 2009 and 2016. Surgeons were classified as “de novo” (DNS), open to robot (ORS), or VATS to robot (VRS) and measured operative time, blood transfusion, mortality, and major morbidity. Proficiency was defined as 20 consecutive cases without reaching an unacceptable cumulative rate of negative outcomes. There were 4,475 cases eligible for inclusion, with a median of 41 per surgeon (DNS, 15; ORS, 21; and VRS, 29).

According to the study abstract, the overall major morbidity rate was 18%; target rate was 10%, and the unacceptable rate was 15%. Initial and sustained proficiency was attained in 40% of DNS, 67% of ORS, and 69% of VRS. By the 20th case, rates were 93% for DNS, 100% for ORS, and 86% for VRS. ORS maintained 100% by case 50, and VRS increased to 92%, but DNS went down to 89%.

Thirty-day mortality rates started out at 93% for DNS, 95% for ORS, and 86% for VRS. VRS showed the most improvement by 20 cases, going up to 97%, while DNS and ORS maintained their proficiency rates. After 50 cases, all three groups achieved 100% proficiency.

Overall transfusion rate was 3.5%. Target rate was 5% and 10% was considered unacceptable. DNS had the highest initial proficiency rate (93%); both ORS and VRS had 90% proficiency. After 20 cases, DNS had 100% proficiency. VRS improved by slightly more and achieved 97%, while ORS was at 95%. All three groups achieved 100% proficiency after 50 cases.

The operative target time was 250 minutes; initially, 40% of DNS, 14% of ORS, and 21% of VRS achieved proficiency. After 20 cases, proficiency for the same groups increased to 47%, 29%, and 21%, respectively. After 50 cases, 100% of DNS reached proficiency, compared to 57% of ORS and 67% of VRS.

While presenting the findings, Feczko said 30-day mortality rates for DNS, ORS, and VRS were all 1% (P = 0.92). DNS and ORS both had 3% transfusion rates, while VRS was 4.5% (P = 0.16). ORS had the highest major morbidity rates (12%), followed by DNS (11%) and VRS (10%) (P = 0.26). DNS had the lowest operation duration at 247 minutes. ORS operations took 256 minutes, and for VRS, it was 277 minutes (P < 0.001).

The study had several limitations, including that it relied on STS database information, which is not universal. The researchers also did not know the prior experience for the DNS surgeons. Additionally, they were limited to CUSUM interpretation.

“ORS lagged behind in achieving operating time proficiency, suggesting the need for focused mentorship,” the authors concluded in their abstract. “Sustained operative time proficiency should be a key goal to improve resource utilization.”

Based on the findings, Feczko said, robotic lobectomy can safely be performed by almost all surgeons after reaching 20 cumulative cases.