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The use of the robotic platform is increasingly being utilized for lung resections. Our aim was to compare outcomes of thoracoscopic (VATS) versus robotic-assisted thoracoscopic (RATS) lobectomy early in a program's adoption of robotic surgery, including perioperative outcomes, cost, and long-term quality of life. A prospective database was retrospectively reviewed for all patients undergoing minimally invasive lobectomy by either VATS or RATS techniques from 2010 to 2012. Patients' operative, post-operative complications, cost (operating room and hospital) and quality of life were compared between the two resection techniques. Long-term follow-up including assessment using the European Organization for Research and Treatment of Cancer quality of life questionnaire was documented. During the first 25 RATS lobectomies, there were 73 VATS lobectomies performed, for a total of 98 cases. There was no significant difference in cancer stage, operative time, estimated blood loss, lymph node count, or hospital length of stay. The RATS resections had significantly higher operative and total hospital cost (p < 0.0001 and p < 0.05). At a median of 65-month follow-up, 29 patients (9 robotic; 20 VATS) completed the EORTC questionnaire. The global health status and symptom scale median scores were similar to the general population and did not significantly differ between groups. While transitioning from thoracoscopic to robotic lobectomy incurs increased operative and total hospital cost, equivalent operative outcomes, length of hospitalization, and long-term quality of life can be maintained during this transition. With increasing patient and surgeon interest in robotic resection, it appears both safe and feasible to adopt this approach while maintaining outcomes.

Background: Major pulmonary resections for early-stage non-small-cell lung cancer (NSCLC) are increasingly being performed by thoracoscopy, but there are economic concerns related to the use of many disposable items and increased operative time. We evaluated and compared the costs of thoracoscopic lobectomy versus open lobectomy., Methods: Data from all patients who underwent lobectomy for clinical stage I NSCLC from January 1, 2007, to December 31, 2009 were reviewed. Two hundred eighty-seven major pulmonary resections (269 lobectomies and 18 anatomic segmentectomies) for NSCLC were performed: 98 cases via a totally endoscopic approach (TS) and 189 via a classical posterolateral thoracotomy (PLT). Direct medical costs [hospital stay, intensive care unit (ICU) stay, disposables, theatre time, laboratory, and radiology costs] were evaluated., Results: Patient demographics were similar in both groups. The two groups did not differ in histology, pathologic stage, or type of lobectomy. There were no differences in postoperative complications or readmissions during the 30-day postoperative period; however, patients in the TS group had significantly fewer chest tube days and shorter hospital length of stay (p < 0.001). Theatre costs were significantly higher in the TS group [2,861 ± 458 vs. 2,260 ± 399 (p < 0.001)]. Mean cost for disposables for TS was 1,800 ± 560.46 vs. 901 ± 328 for PLT (p < 0.001). Thoracoscopic upper-right lobectomy and anatomic segmentectomy were more expensive than other thoracoscopic lobectomies. Mean costs for hospital stay, laboratory, and radiological services for TS were less than for PLT (p < 0.001), although mean ICU stay was similar in both groups. Finally, overall costs were significantly greater for the PLT group (14,145.57 ± 7,117.84) than for the TS group (11,934.13 ± 6,690.25) (p < 0.001)., Conclusion: Thoracoscopic lobectomy was less expensive than open lobectomy for patients with early-stage NSCLC. Although thoracoscopic lobectomy has a higher initial cost, overall cost is less expensive due to a shorter hospital stay.

Background: Currently, few data exist regarding the relative costs associated with open and minimally invasive pectus excavatum repair. The aim of this study was to compare the surgical and hospitalization costs for these two surgical techniques and to identify factors responsible for cost differences., Methods: A retrospective review of hospital charts, patient and parent questionnaires, and hospital accounting records was performed for 68 patients who underwent surgical correction of pectus excavatum between June 1996 and December 1999., Results: In this series, 25 patients underwent open repair, whereas 43 patients underwent minimally invasive repair of pectus excavatum (MIRPE). The patient ages ranged from 4 to 19 years. The average ages for open repair (12 years) and MIRPE (11 years) did not differ significantly. As compared with open repair, MIRPE was associated with a 27% lower overall cost of hospitalization ( p < 0.05). The operating room costs were 12% higher for the patients who underwent MIRPE ( p < 0.05). The mean operative time for open repair was 3 h 15 min, whereas MIRPE required 1 h 10 min ( p < 0.001). The hospital stay for open repair averaged 4.4 days, as compared with 2.4 days for MIRPE ( p < 0.001). In contrast to other published series, the postoperative analgesia after MIRPE in this series consisted of narcotics, ketorolac, and methocarbamol. No patient received epidural analgesia, regardless of the repair technique selected. The postoperative complication rate was 4% in the open group and 14% in the MIRPE group. Most of the patients treated with either open or MIRPE reported postoperative oral narcotic usage for 2 weeks or less and returned to routine activities within 3 weeks. The patients and parents alike reported good to excellent overall outcomes in 85% or more of the open repair cases and 90% or more of the MIRPE cases., Conclusions: These data demonstrate for the first time that the use of an alternate pain management strategy including, narcotics, NSAIDs, and methocarbamol, but without epidural catheters, results in reduced hospital length of stay and decreased overall hospitalization costs for MIRPE, as compared with open pectus repair. This cost benefit was achieved without compromising pain management or patient satisfaction with surgical care.

Background: The endoscopic treatment of spinal lesions in the thoracolumbar junction (T11-L2) poses a great challenge to the surgeon. From November 1, 1995 to December 31, 1996, we successfully used a combination of video-assisted thoracoscopy and conventional spinal instruments to treat 38 patients with anterior spinal lesions. Twelve of them had lesions in the thoracolumbar junction., Methods: The so-called extended manipulating channel method was used to perform vertebral biopsy, discectomy, decompressive corpectomy, interbody fusions, and/or internal fixations in these patients. The size of the thoracoscopic portals was greater than usual in order to allow conventional spinal instruments and a thoracoscope to enter the chest cavity freely and be manipulated by techniques similar to those used in standard open surgical procedures. In this series, the procedures were performed by using either a three-portal approach (2. 5-3.5 cm) or a modified two-portal technique involving a 5-6 cm larger incision and a small one for introducing the scope., Results: None of the operations resulted in injury to the great vessels, internal organs, or spinal cord. The total time for the operation ranged from 1.5 to 4.5 h (average, 3); and the total blood loss ranged from 50 to 3000 cc (average, 1050). One patient was converted to an open procedure due to severe pleural adhesion. Complications included two instances of transient intercostal neuralgia, one superfical wound infection, and one residual pneumothorax., Conclusions: The video-assisted technique with the extended manipulating channel method presented in this report simplifies thoracoscopic spinal surgery in the thoracolumbar junction and makes it easier. It avoids division of the diaphragm, removal of the rib, and wide spread of the intercostal space, and it allows greater control of intraoperative vessel bleeding. Using this technique, the number of portals required during the procedure can be reduced. In addition, the technique reduces the endoscopic materials required, thus lowering overall cost. It is an effective and promising approach.

Background: Video-assisted thoracoscopic surgery (VATS) is now an established approach in the management of many thoracic conditions. However, the high cost of this new technology has deterred many Asian hospitals from widely applying this technique., Methods: This article describes our strategies to reduce cost in our practice of VATS over the last few years., Results: VATS involves (1) careful patient selection, (2) use of conventional thoracic instruments as much as possible, (3) modification of conventional instruments, (4) limited use of expensive consumables, and (5) development and application of endoscopic suturing technique., Conclusions: VATS is still in evolution. Cost containment, while desirable in the West, is a high priority in Asia if this new surgical approach is to be applicable even in developing countries. More research is greatly needed in this area.