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International Society For Minimally Invasive Cardiothoracic Surgery

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Robot-assisted Anatomic Pulmonary Resection Can Be Performed Without An Active Bedside Assistant
Anuj S. Shah, Duc T. Nguyen, Ray Chihara, Edward Y. Chan, Edward A. Graviss, Min P. Kim.
Houston Methodist Hospital, Houston, TX, USA.

BACKGROUND: A major benefit of robotic-assisted surgery is the ability to perform complex operations without an active assistant, which contrasts with video-assisted thoracoscopic (VATS) or an open surgery where exposure or visualization with the camera is typically performed by an active assistant. We sought to determine the safety of performing robotic-assisted anatomic pulmonary resection without an active assistant.
METHODS: We performed a retrospective analysis of a single surgeon's experience in adopting robot-assisted thoracic surgery, specifically anatomic pulmonary resection, using the Da Vinci Xi system from 2016-2020. We trained scrub technicians to perform passive assistance; once the surgeon felt comfortable, we no longer had an active bedside assistant during pulmonary resection. We evaluated the conversion rate, estimated blood loss, length of stay, major postoperative complications, and mortality between cases with or without active bedside assistant.
RESULTS: 164 anatomic pulmonary resections were performed out of 773 thoracic robot-assisted cases during the period. The median age of anatomic pulmonary resection patients was 70 years, predominately female (59%) undergoing lobectomy (89%). Overall, the conversion to open or VATS rate was 2.4% (n=4), median EBL was 45 cc, the median length of stay was three days, the major postoperative complication rate was 14 %, and there was no mortality. First 20 months, there was an active bedside assistant (n=60) while there was no active bedside assistant after that time (n=104). Between these two time periods, there were significantly fewer conversions (6.7% vs. 0%, p=0.02), less EBL (55 cc vs. 25 cc, p=0.003), less length of stay (3.5 days vs. 2 days, p<0.001) during the time without active bedside assistant. There was no significant difference in major postoperative complications (12% vs. 15%, p=0.51) or mortality (0% vs. 0%) with or without bedside assistant.
CONCLUSIONS: Robot-assisted anatomic pulmonary resection can be performed safely without an active bedside assistant with passive assistance being performed by a surgical technician. The significant improvement in outcomes is likely due to overcoming the initial learning curve of using the technology rather than not having a bedside assistant. Autonomy during anatomic pulmonary resection is a significant benefit of robot-assisted pulmonary resection compared to the open or VATS approach.

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