6-year Pulmonary Lobectomy Analysis Comparing Robotic to Thoracotomy and VATS: Impact to a State University Cardiothoracic Training Program

OBJECTIVE: Current understanding of robotic lobectomy is largely from established thoracic surgical programs, often single-surgeon experience and does not involve trainees. Our objective is to assess the effect that a new robotic lobectomy program might have on a state university cardiothoracic (CT) training program to patient care, CT training, and the institution. METHODS: Our IRB-approved, prospectively maintained database and query of anatomic lung resections between 1/1/2006 to 6/30/2016 was verified with the medical center EMR and further verified with blinded double-entry. Inclusion criteria required a documented anatomic resection. Cost and oncologic data was obtained from the analytics department and tumor registry, respectively. Propensity scores were assigned based on age, sex, and five comorbidities. Lung cancer survival was analyzed by the Kaplan-Meier method and compared to the SEER database. Our robotic CT training method consists of a 6-month program over 3 years; the first 3 months focus on simulation and bedside-assist and the last 3 months, on complete case set-up and console training; adjustments made dependent upon the trainees' prior minimally invasive experience. RESULTS: 523 consecutive cases were identified, 91 cases were excluded. The query identified 212 robotic (179 non-small cell lung cancer (NSCLC)), 160 thoracotomy (117 NSCLC) and 60 video-assisted (VATS) (44 NSCLC) cases. Multiple surgeons performed each approach. Operative results and clinical outcomes favored robotic surgery compared to thoracotomy and showed little difference with VATS. Robotics increased lymph node stations, nodes, and upstaging rates, with similar R0 compared to thoracotomy and VATS; there was no significant difference in survival. A CT resident served as the console surgeon in 35% of all cases: 0% in the first two years increasing to 79% in the latest year. Minimally invasive surgeries increased from 32% of all cases in the first year of robotics to 89% in the latest year. The total volume of lung cancer treated at the center increased by 51%, surgical cases by 220%, and clinical trial accrual by 92%, since introducing robotics. CONCLUSION: A robotic surgery training component can be implemented at a state university cardiothoracic training program without sacrificing quality. Robotic surgery in this setting offers the same or better clinical results, is cost-effective, and is oncologically-sound. Additionally, a robotic program may increase an institution's lung cancer volume, enhancing both the CT resident training experience and clinical research. This analysis has also identified opportunities to further improve efficiency and reduce cost.