International Society for Minimally Invasive Cardiothoracic Surgery

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Fissure Diving Correlating Clinical Outcomes And Objective Performance Metric To Fissure Grade During Robotic Lobectomy
Narica Clarke1, John Lazar2, Mallory Shields3, Allan Fong4
1The MedStar Health—Georgetown/Washington Hospital Center Residency Program in General Surgery, Washington, DC, USA, 2Ascension Medical Group, Nashville, TN, USA, 3Intuitive Surgical, Seattle, WA, USA, 4The MedStar Health—Georgetown/Washington Hospital Center, Washington, DC, USA

BACKGROUND:It has been shown that surgeon performance correlates with better outcomes, but robotic lobectomy (RL) is known as one of the most heterogeneous and difficult operations to master. Specifically, fissure dissection can be extremely nuanced due to its anatomical variance. However, there are currently no standardized techniques to evaluate performance during robotic fissure dissection. Recent technological advances allow surgeon researchers to use objective data streams directly from the robot called objective performance indicators (OPIs) to quantify surgeon movements. This feasibility study aims to correlate fissure grade to OPIs and clinical outcomes.
METHODS:The fissure dissections of 16 RL’s performed by a single surgeon for stage I lung cancer were graded with the Craig and Walker classification (grade 1-4), with grade 1 the least severe and grade 4 the most. Videos were segmented into functional surgical steps by a professional annotator, and OPIs were calculated for each task. OPIs associated with energy and camera use and instrument movement were compared to fissure grade using the Kruskal - Wallis H - test. Average console time and staple load were analyzed and compared to fissure grade.
RESULTS:Comparing fissure grade to OPIs and associated with energy and camera use and instrument movement, no statistical significance was found. However, there was an evident correlation between higher fissure grade and increased energy and camera use and instrument movement. The same trend was also observed comparing fissure grade to clinical outcomes. While not statistically significant (p =0.071), higher fissure grades (grade 1-3) trended towards increasing console time (93.30, 160.64 and 194.33 minutes, respectively). Increasing fissure grades 1-3 directly correlated to increased staple fires and was statistically significant (p = 0.04) with average staple fires (5.67, 7.18 and 10.67 respectively). Length of stay was significant between grades 1 and 3 (2.67 days [1-4] and 3.67 [3-5], p <0.05).
CONCLUSIONS:This is the first known study examining fissure dissection during robotic lobectomy by applying a grading system to OPIs and post operative outcomes. The results, while not all statistically significant, uncover a trend differentiating objective characteristics of surgical movements and post-surgical outcomes, thus providing an initial objective insight into surgical performance. Future studies will concentrate on isolating specific OPIs and tasks to individual outcomes.


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