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Patient engagement technologies (PETs) guide patients through perioperative care, but little is known about their costs-benefits.Retrospective cohort study of patients undergoing elective colorectal, cardiac, thoracic surgery 2015-2020. PET was implemented 2018. Patients were propensity-matched in pre-PET, PET, non-PET groups. Costs of surgical encounter and 30 days post-discharge, mortality, length-of-stay, readmissions, complications, satisfaction were compared.Overall, 4,373 patients underwent surgery and 607 (13.9%) patients enrolled in the PET. PET patients did not have increased costs in any specialty. Colorectal PET patients' variable costs of surgical encounter were $102 lower than non-PET, $1495 lower than pre-PET (p = 0.03). Thoracic PET patients' total costs of surgical encounter were $9224 lower than non-PET, $2187 lower than pre-PET (p = 0.03). Thoracic PET patients had lower mean LOS (2.4 days, 5.1 non-PET, 3.1 pre-PET, p = 0.03). PET patient satisfaction ranged 86.0%-97.8%.Use of a PET did not increase costs and was associated with benefits for patients undergoing elective surgery.

Objectives: To identify reporting guidelines related to surgical technique and propose recommendations for areas that require improvement. Study Design and Setting: A protocol-guided scoping review was conducted. A literature search of MEDLINE, the EQUATOR Network Library, Google Scholar, and Networked Digital Library of Theses and Dissertations was conducted to identify surgical technique reporting guidelines published up to December 31, 2021. Results: We finally included 55 surgical technique reporting guidelines, vascular surgery (n = 18, 32.7%) was the most common among the clinical specialties covered. The included guidelines generally showed a low degree of international and multidisciplinary cooperation. Few guidelines provided a detailed development process (n = 14, 25.5%), conducted a systematic literature review (n = 13, 23.6%), used the Delphi method (n = 4, 7.3%), or described post-publication strategy (n = 6, 10.9%). The vast majority guidelines focused on the reporting of intraoperative period (n = 50, 90.9%). However, of the guidelines requiring detailed descriptions of surgical technique methodology (n = 43, 78.2%), most failed to provide guidance on what constitutes an adequate description. Conclusion: Our study demonstrates significant deficiencies in the development methodology and practicality of reporting guidelines for surgical technique. A standardized reporting guideline that is developed rigorously and focuses on details of surgical technique may serve as a necessary impetus for change.

Background Many patients undergoing general thoracic surgery can be discharged on the same day as chest tube removal, but some are not, leading to increased resource utilization. This study assesses the frequency and duration of extended length of stay (ELOS) after tube removal and identifies risk factors for ELOS. Methods We retrospectively reviewed all adult patients undergoing general thoracic surgery at a tertiary referral medical center captured in the Society of Thoracic Surgeons General Thoracic Surgery Database and obtained detailed clinical data on chest tube management from August 2013 to April 2017. Pre-operative demographics, procedures, diagnoses, comorbidities, hospital service category, and lab values were examined to identify risk factors associated with ELOS after chest tube removal using multivariable generalized linear regression models. Results One thousand and four hundred seventy patients had ≥1 chest tubes placed at the time of operation and discharged after chest tube removal: anatomic lung resection (34%), wedge resection (29%), decortication (16%), and other (21%). Fifty-one percent of these patients were male, 81% were white, and the mean age was 59 years (SD: 15 years). One-third of the patients had prior cardiothoracic operations. Twenty-three percent of these patients had ELOS, defined as discharge ≥1 calendar day after chest tube removal with a median additional hospital stay of 3 days (interquartile range, 2-7 days). A multivariable regression model demonstrated that risk factors for ELOS included being admitted to an oncology or transplant service, undergoing decortication procedure, active smoking, and increased disability. Conclusions Patients with obesity, more severe disability, or actively smoking, undergoing, decortication, admitted to transplant and oncology services were more likely to experience ELOS. These factors should be considered when identifying appropriate patient groups for fast-track algorithms.

OBJECTIVES Surgical management of spontaneous pneumothorax typically involves wedge resection and mechanical pleurodesis. It is unclear whether combining mechanical and chemical pleurodesis can further reduce the recurrence rate. We have performed a meta-analysis of studies comparing the combined approach with mechanical pleurodesis alone. METHODS A comprehensive search of the existing literature was performed using PubMed, EMBASE and Web of Science for all types of studies that compared combined pleurodesis to a single approach. We used the Cochrane Risk of Bias Tool and Strengthening The Reporting of OBservational Studies in Epidemiology (STROBE) to assess the quality of the studies. Relative risk of pneumothorax recurrence was calculated, and the differences between the studies were examined. The primary outcome was the recurrence of pneumothorax. RESULTS Of 2301 eligible studies, 5 studies were included. Five hundred sixty-one patients who received combined pleurodesis were compared to 286 patients who received mechanical pleurodesis only. Patients treated with combined intervention had a 63% lower risk of developing a recurrent pneumothorax compared to single intervention [relative risk 0.37, 95% confidence interval (CI) 0.18–0.76; P = 0.006]. There were no statistically significant differences in the length of stay (standardized mean difference −0.17, 95% CI −0.39 to 0.05, P = 0.138), the duration of postoperative air leak (standardized mean difference 0.17, 95% CI −1.14 to 1.47, P = 0.804) or the duration of postoperative chest tube drainage (standardized mean difference −0.07, 95% CI −0.27 to 0.12, P = 0.471). CONCLUSIONS This meta-analysis demonstrated that combined intervention with mechanical and chemical pleurodesis for spontaneous pneumothorax may be more effective in preventing recurrence than mechanical pleurodesis alone. These findings will provide some guidance to surgeons in the decision-making process.

Cardiothoracic (CT) surgery fellowship websites help applicants determine where they apply and/or accept an interview. However, relevant information from programs is not communicated in a standardized way.We used Fellow and Residency Electronic Interactive Database Access (FREIDA) Online to identify residency programs with traditional CT fellowships. Program-specific variables included presence or absence of tracks, track duration, and annual cardiac and thoracic cases. Resident-specific variables included number of resident(s) a program accepts and case numbers per fellow. Current CT residents completed an online survey in which they rated how important they deemed the presence of these variables in program websites.According to FREIDA Online, 74 traditional CT surgery fellowship websites were analyzed. Among the websites listed on FREIDA, only 16 (22%) linked directly to the CT fellowship page. Surveys were sent to all trainees enrolled in the 74 programs, and 24 responded. There were marked deficiencies in the availability of information on program websites that was highly valued by trainees. Only 31% of websites reported annual program volume, and 14% reported resident case numbers, while this data was highly valued by60% of respondents. Similarly, 11% of program websites described their education curriculum, while 81% of respondents highly valued this information. One-quarter of respondents were dissatisfied with the overall information provided by program websites.CT fellowship program websites lack crucial content that is deemed highly valued by applicants. This study suggests the possible need for a single comprehensive data repository or a standardized method for communicating information through program websites.

Open correction of pectus deformities has evolved since its origin. We performed a Ravitch type repair using a permanent titanium plate fixed with screws and describe the procedure with outcomes after our modifications.A retrospective review of 61 pectus excavatum and pectus carinatum cases from August 2013 to April 2021 was performed. Data were extracted from medical records and reported. In January 2016, we began administering satisfaction surveys at the 6-month postoperative visit; results are reported.The mean age of our cohort was 24.5 years; 43 (70%) were male. Fifty-four underwent pectus excavatum repair, 6 pectus carinatum repair, and 1 mixed repair. Median Haller index was 3.8. Mean operative duration was 98 minutes; mean blood loss was 116.4 mL. Median chest tube duration was 5.0 days; median hospital stay was 4 days. Reexploration for bleeding was 30% in the first 10 patients. Protocol changes including postponing chemical deep vein thrombosis prophylaxis, using intraoperative hemostatic agents, and using shorter implantation screws decreased this to 0% for the remaining cases. The most frequent complication was urinary retention (21.3%). Postoperative surveys were completed for 37 of 50 patients. Seventy-five percent reported health improved, 65% reported exercise capacity improved, 75% reported breathing improved, and 59% reported chest pain improved. Self-esteem improved from 6.6 ± 2.5 (of 10) before surgery to 8.2 ± 2.1 after surgery. Ninety percent were satisfied and 86% would have the operation again.Ravitch type repair with permanent titanium plate fixation is a safe and effective procedure for correction of pectus excavatum and carinatum. Most patients experience improvement in preoperative symptoms.

Foreign body ingestion is common in children. Ingestion of foreign bodies with magnetic properties are less common, but can be associated with more severe complication, especially involving multiple magnets. We present a 16-month-old boy with developmental delay who developed small bowel perforation following multiple magnet ingestion. He had three days history of vomiting and abdominal distension associated with pain, suggestive of an acute intestinal obstruction. Abdominal imaging confirmed foreign body ingestion, and an exploratory laparotomy revealed two magnets attracted across the intestinal lining with resultant intestinal obstruction and perforation. Surgical removal of the magnets and the necrotic bowel tissue was complicated by post-operative wound dehiscence. After secondary suturing, the child subsequently made a complete recovery. We discuss the diagnostic dilemma in multiple magnet ingestion along with the importance of early recognition and prompt management due to the risk of more severe gastrointestinal complication associated with delayed intervention.

Background The majority of ectopic mediastinal parathyroid adenomas are accessible transcervically and those not amenable to this approach pose a significant clinical and technical challenge. Methods Retrospective review of transthoracic robot-assisted mediastinal parathyroidectomy (TTRMP) for primary hyperparathyroidism between 2012 and 2019 at a single institution. Results 16 patients underwent TTRMP, 63% were female with a mean age of 64 ± 2.0 years. Nine of 16 had prior parathyroidectomy; 80% had persistent disease and a mean 2.8-year delay from index operation until TTRMP. Locations included: intrathymic (8), AP window (4), carina (3), and retroesophageal (1). Two patients underwent parathyroid reimplantation. Mean post-operative calcium and PTH were 9.2 ± 0.2 mg/dL and 20.2 ± 5.6 pg/mL, respectively. Complications included: temporary hypocalcemia (4), permanent hypocalcemia (1), DVT (1), hoarseness (1), and subcostal neuralgia (1). Conclusion In experienced hands, TTRMP is a safe and effective approach to mediastinal parathyroids not accessible transcervically. A multidisciplinary approach should be used in reoperative cases.

Background Our objective is to show the effect that standardization of surgical trays has on the number of instruments sterilized and on cost. Methods We reviewed our most commonly used surgical trays with the 3 general thoracic surgeons in our division and agreed upon the least number of surgical instruments needed for mediastinoscopy, video-assisted thoracoscopic surgery, robotic thoracic surgery, and thoracotomy. Results We removed 59 of 79 instruments (75%) from the mediastinoscopy tray, 45 of 73 (62%) from the video-assisted thoracoscopic surgery tray, 51 of 84 (61%) from the robotic tray, and 50 of 113 (44%) from the thoracotomy tray. From January 2016 to December 2016, the estimated savings by procedure were video-assisted thoracoscopic surgery (n = 398) $21,890, robotic tray (n = 231) $19,400, thoracotomy (n = 163) $15,648, and mediastinoscopy (n = 162) $12,474. Estimated total savings were $69,412. The weight of the trays was reduced 70%, and the nonsteamed sterilization rate (opened trays that needed to be reprocessed) decreased from 2% to 0%. None of the surgeons requested any of the removed instruments. Conclusions Standardization of thoracic surgical trays is possible despite having multiple thoracic surgeons. This process of lean (the removal of nonvalue steps or equipment) reduces the number of instruments cleaned and carried and reduces cost. It may also reduce the incidence of "wet loads" that require the resterilization of instruments.

A variety of esophageal diseases are treated with esophagectomy, from benign to esophageal cancer. Careful attention must be given to management of the difficult conduit, including patients who have had prior gastric surgery and other procedures, patients with conditions such as diabetic gastroparesis, which can affect the stomach as a future usable conduit, and patients who have an absent or unusable stomach. In these situations, consideration should be raised for the use of alternative conduits, including jejunal and colonic interposition conduits. The esophageal surgeon should also be adept at management of intraoperative difficulties with the conduit.

Robotic esophagectomy offers similar benefits to the patient as minimally invasive esophagectomy (IE) through thoracoscopic and/or laparoscopic techniques. We consider any patient that is a candidate for esophagectomy to be a candidate for robotic esophagectomy as well. Robotic techniques can be applied to Ivor Lewis, modified McKeown, or transhiatal esophagectomies. We describe our technique for the abdominal and thoracic phases (performed robotically), and cervical phase, of these operations. Advantages of using robotics for esophagectomy include the ability of the surgeon to control the camera and retraction rather than relying on an assistant, better surgeon ergonomics for what can be long and complex cases, the simplicity of using the platform for visualization of real-time perfusion with indocyanine green (ICG) dye, and greater ease of performing an anastomosis in the chest. Operative times, perioperative results, morbidity, and mortality have been comparable to non-robotic MIE.

With the advent of laparoscopic and robotic surgery, transthoracic repair of hiatal hernia has become less common. In certain situations, such as multiple prior transabdominal repairs or otherwise hostile abdomen, a transthoracic approach can be helpful. Indications for surgery mirror those for candidates for transabdominal hiatal hernia repair; preoperative evaluation consists of history, physical examination, barium swallow, CT scan, pulmonary function testing, and, if possible, manometry and pH study. Transthoracic repair is generally performed through a left 6th or 7th intercostal space thoracotomy. The hernia sac is mobilized and reduced along with the herniating organs, and the diaphragmatic crura is tightened around an endoscope or bougie. A Collis gastroplasty is performed if there is inadequate esophageal length, and a Belsey fundoplication encompassing 270 degrees of the stomach is performed. Postoperative care involves multimodality pain management, prevention of vomiting and retching, barium swallow to establish a baseline anatomy following repair, and cautious advancement of diet.

The objective is to report our outcomes of teaching and performing minimally invasive robotic lobectomy.Robotic lobectomy was divided into 19 specific sequential technical maneuvers. The number of steps residents could perform in a set period of time was recorded. Video review by the attending surgeon and coaching were used to improve what residents could safely perform. Outcomes compared were percentage of maneuvers that general surgical or cardiothoracic residents (fellows) completed, operative times, and Society of Thoracic Surgeons-defined metrics of patient outcomes.There were 520 consecutive robotic lobectomies over 5 years. The various maneuvers completed by general surgical residents (N = 35) and cardiothoracic residents (N = 7) increased over time, for example, steps 1 to 5 increased 20% and 70% compared with 80% and 90% (P .001), step 8 increased 0% and 50% compared with 90% and 100% (P .0001), and step 19 increased 30% and 50% compared with 90% and 100% (P = .001), respectively. Operative outcomes, including intraoperative blood loss, median number of lymph nodes, median length of stay, major morbidity, and 30-day and 90-day mortality, were no different. Operative time initially increased and then decreased over time. Conversion to thoracotomy (15% to 2.5%, P = .042) and major vascular injury (3% to 0%, P = .018) decreased.Robotic lobectomy can be safely taught to residents without compromising patient outcomes by dividing it into a series of surgical maneuvers. Recording outcomes for each step and using video review and coaching techniques may help increase the percent of maneuvers residents can complete in a set time.

Background Our objective is to report our incidence, results, and technique for the control of major vascular injuries during minimally invasive robotic thoracic surgery. Methods This is a consecutive series of patients who underwent a planned robotic thoracic operation by one surgeon. Results Between February 2009 and September 2015, 1,304 consecutive patients underwent a robotic operation (lobectomy, n = 502; segmentectomy, n = 130; mediastinal resection, n = 115; Ivor Lewis, n = 103; thymectomy, n = 97; and others, n = 357) by one surgeon. Conversion to thoracotomy occurred in 61 patients (4.7%) and in 14 patients (1.1%) for bleeding (pulmonary artery, n = 13). The incidence of major vascular injury during anatomic pulmonary resection was 2.4% (15 of 632). Of these, 13 patients required thoracotomy performed in a nonurgent manner while the injury was displayed on a monitor, 2 had the vessel repaired minimally invasively, 2 required blood transfusion (0.15%), and 1 patient had 30-day mortality (0.16%). Techniques used to minimize morbidity include having a sponge available during vessel dissection and stapling, applying immediate pressure, delaying the opening until the bleeding is controlled without external pressure, and ensuring there is no bleeding while the chest is opened. Conclusions Major vascular injuries can be safely managed during minimally invasive robotic surgery. Our evolving technique features initial packing of the bleeding for several minutes, maintaining calmness to provide time to prepare for thoracotomy, and reexamination of the injured vessel. If repair is not possible minimally invasively, the vessel is repacked and a nonhurried, elective thoracotomy is performed while the injury is displayed on a monitor to ensure active bleeding is not occurring.

Background Both robotic pulmonary operations and anatomic segmentectomy are being increasingly performed. The largest published series of anatomic robotic segmentectomy comprises 35 patients, and the specific details of port placement are poorly understood. Methods This is a review of a consecutive series of patients from a single surgeon's prospective database. All patients in the study were scheduled to undergo robotic anatomic segmentectomy. Results Between February 2010 and December 2014, 100 patients went to the operating room for a planned pulmonary segmentectomy. A robotic approach was chosen for all. Seven patients underwent conversion to robotic lobectomy, and the remaining 93 patients had an anatomic robotic segmentectomy. There were no conversions to thoracotomy. Indications for resection were lung cancer in 79 patients, metastatic lesions in 10 patients, fungal infections in 4 patients, and other conditions in 7 patients. The median age was 69 years, and 50 patients were men. The median blood loss was 20 mL (range, 10–120 mL), the median number of lymph nodes removed was 19, the median operative time was 1.28 hours (88 minutes), the median length of stay was 3 days, and major morbidity occurred in 2 patients (pneumonia in both). All had undergone R0 resection. There were no 30- or 90-day mortalities. Of the 79 patients with lung cancer, the median follow-up was 30 months, and 3 patients (3.4%) had recurrence in the operated lobe. Overall survival was 95% at 30 months. Conclusions Completely portal robotic anatomic segmentectomy is safe and effective and offers outstanding intraoperative 30-day and 90-day results. The recurrence rate is approximately 3% at 2.5 years.

The use of robotics for lung resection has increased significantly over the past several years. We favor a completely portal 4-arm approach. Left upper lobectomy, which many believe is the most complex of the 5 lobectomies, is well-suited for robotic assistance. Port placement and conduct of the operation are described. Robotic left upper lobectomy can be done with minimal morbidity and extremely low perioperative mortality, with similar postoperative and oncological results when compared with video-assisted thoracoscopic surgery lobectomy.

Background Surgical skills are traditionally taught and practiced in the operating room. However, changes in health care policy and outcome-based evaluation have decreased trainee operative autonomy. We examined cardiothoracic residents' perceptions of operative experience and the role of simulation. Methods The In-Training Examination (ITE) is taken each year by all residents. Completion of a 30-question preexamination survey is mandatory, ensuring a 100% response rate. Survey data related to operative experience, career preparedness, and surgical simulation were analyzed. Opinion questions were asked on a 5-point Likert scale. Respondents were grouped into three cohorts by training paradigm (2-year versus 3-year traditional programs and 6-year integrated programs). Results In all, 314 respondents (122 2-year, 96 3-year, and 96 6-year integrated) completed the survey. Of the three groups, residents in 3-year programs had the highest levels of satisfaction. Advanced training was most common among residents in 6-year integrated programs (66%, versus 49% for 2-year and 26% for 3-year programs; p = 0.63). Desire to specialize drove further training (97%), with 2% stating further training was needed owing to inadequacy and 1% owing to a poor job market. In all assessed categories, the majority of residents believed that simulation did not completely replicate the educational value of an operative case. Conclusions Cardiothoracic residents largely feel well prepared for the transition to practice under the current educational paradigm. Although many residents seek advanced training, it seems driven by the desire for specialization. Residents view simulation as an adjunct to traditional intraoperative education, but not as a viable replacement. Further study is necessary to better understand how best to integrate simulation with operative experience.

Thoracic surgery has evolved since the initial published reports of pulmonary lobectomy by Drs. Norman Shenstone and Robert Janes from the Toronto General Hospital, in which they describe “a long incision... In the general direction of the ribs, passing just below the scapula,” or via a thoracotomy (Shenstone and Janes, Can Med Assoc J 27: 138–45, 1932). Since then, surgeons have found ways to improve on minimally invasive options thereby optimizing postoperative morbidity, recovery time, and pain. Minimally invasive lobectomy has traditionally been performed using video-assisted thoracoscopic surgery (VATS) techniques. The first robotic lobectomies were reported in 2003 by Morgan et al. and Ashton et al. (Morgan et al. Eur J Cardiothorac Surg 23: 883-7, 2003; Ashton et al. J Thorac Cardiovasc Surg 126: 292–3, 2003). Since then, the use of robotic technology for lobectomy has become increasingly common. In 2015, over 6000 robotic lobectomies were performed in the United States, and over 8600 done worldwide.

Morgagni hernia (MH) is a rare, congenital diaphragmatic hernia (CDH). The use of robotic surgery to repair MH in adults has recently been described in the literature, but only on two previous occasions. The objective of this report is to describe four cases of robotic repair of MH in adults performed by a single surgeon to better delineate an emerging approach to this rare condition. A retrospective review of patients who underwent robotic repair of MH by a single surgeon was performed. Four consecutive patients were identified and included. The median age of patients was 43 (range: 23–70). All patients had symptoms prior to diagnosis, including substernal chest pain (n = 3), dyspnea (n = 4), dysphagia (n = 1), and regurgitation (n = 1). All patients underwent hernia reduction, primary tissue repair, and mesh implant with minimal average estimated blood loss. All hernias were right sided, and the average length of surgery was 129.8 min. The average length of stay was 2 days. No intraoperative complications or 30-day postoperative complications were reported. Symptoms, including chest pain and dyspnea, resolved postoperatively for each patient. With this technique, robotic Morgagni hernia repair can be done with short operative time, few complications, and favorable length of stay. This operation takes advantage of the dexterity and wristed nature of the instruments; suturing of the diaphragmatic defect and mesh (performed on the “ceiling” of field) and incorporating pledgets into these sutures become straightforward endeavors when performed robotically. We have found the robotic platform useful for a transabdominal approach to Morgagni hernia repair.

Robotic surgery can be used for completely portal (no utility incision) or robotic-assisted (uses utility incision) techniques. Appropriate patient and port positioning are critical for a successful performance of robotic lobectomy. Perioperative morbidity and mortality for robotic lobectomy are comparable to that for video-assisted thoracoscopic surgical (VATS) lobectomy. Robotic lobectomy may have advantages in terms of surgeon ergonomics, mediastinal lymph node dissection, and intraoperative blood loss over VATS lobectomy. To maintain safe and effective robotic surgery, surgeons must continue to design evidence-based pathways to the credentialing of robotic surgical teams. Robotic lobectomy can be done safely and is being increasingly used for anatomic pulmonary resections.

Objective Left upper pulmonary lobectomy or segmentectomy after coronary artery bypass grafting (CABG) risks injury to the grafts. We reviewed our experience. Methods This is a retrospective review of a prospective database from 1 surgeon, of patients who underwent left upper lobectomy after having previous CABG. Results Between June 1998 and June 2014, a total of 2207 patients underwent lobectomy by 1 surgeon; 458 (21%) had a left upper lobectomy, and 28 (6.1%) had had a previous CABG. Twenty-seven patients (96.4%) had a left internal mammary artery (LIMA) used for the bypass. Twenty-six patients (96.2%) had significant adhesions between their lung and the bypass grafts. Of patients who had a LIMA graft, 25 (92.6%) had the left upper lobe completely dissected free from their grafts, whereas 2 patients (7.1%) had a sliver of their lung left on the grafts. No patient had a postoperative myocardial infarction, and 30-day and 90-day survival rates were both 100%. All patients had a curative resection, and all had complete thoracic lymphadenectomy. Conclusions Left upper lobectomy after CABG, in patients with previous CABG and LIMA grafting, is safe. Usually the entire lung can be safely mobilized off the bypass grafts; if needed, a small sliver of lung can be left on the grafts. A curative resection is possible with minimal perioperative cardiac morbidity, and excellent 30- and 90-day mortality.

The objectives of this study are to review the complicated and often confusing technical changes required when converting from the Si robotic system to the Xi when performing pulmonary lobectomy and segmentectomy. We reviewed a prospective database of a consecutive series of patients who intended to undergo robotic lobectomy or segmentectomy by one surgeon. There were 101 lobectomies and 25 segmentectomies performed on the Si robot in 2015-2016, and 95 lobectomies and 28 segmentectomies in 2016 on the Xi robot. The two groups were similar for age, height, weight, pulmonary function, anatomic resections, and co-morbidities. Technical differences in robotic arm numbering, port placement, and instrumentation are shown below. Median docking time was shorter with the Xi robot [7.5 (95% CI 6-8) versus 10 (95% CI 9-12) min, p = 0.003] as was operation duration [114 (95% CI 104-123) versus 119 (95% CI 116-126) min, p = 0.041] and skin closure to room exit [12 (95% CI 10-24) versus 13 (95% CI 12-15) min, p = 0.081]. Anesthesiologists expressed greater comfort with the Xi system, because the patient's head was not covered by the robot. Outcomes for Si and Xi operations such as median blood loss (20 cc versus 20 cc), transfusion rate (0 versus 0), major complication rate (3.2 versus 3.3%), and the 30- and 90-day mortality were no different (one 30-day death in the Si group). The technical changes that are required for robotic Si-to-Xi conversion are shown. The Xi system may offer improved operational efficiency.

Our purpose is to identify the metrics used by the Society of Thoracic Surgeons (STS) to rank lobectomy and to show our process to improve. This is a review of our STS data for lobectomy and our results using the process of root cause analysis and lean methodology to improve our outcomes. The STS metrics are 30-day mortality, pneumonia, adult respiratory distress syndrome, bronchopleural fistula, pulmonary embolus, initial ventilator support greater than 48 hours, reintubation and respiratory failure, tracheostomy, myocardial infarction, or unexpected return to the operating room. Sixteen of 231 programs (7%) were ranked 3-star over a 3-year period from July 2011 to June 2014. The most common root cause analysis was failure to escalate care. The lean and process improvements we employed that seemed to improve the results were increasing exercise before surgery, adding a respiratory therapist, eliminating Foley catheters and arterial lines to reduce infection and to increase ambulation, offering stereotactic radiotherapy for marginal patients, favoring left upper segmentectomy over left upper lobectomy, and performing 91% of the last 493 lobectomies via a minimally invasive platform. Our major morbidity complications from August 2003 to December 2014 fell from 9.5% to 5.3% (P = 0.001) and mortality decreased from 3.3% to 0.54% (P 0.0001). The metrics the STS used to rank lobectomy programs are 30-day mortality and predominantly respiratory complications. Root cause analysis, lean methodology, and process improvements allowed us to improve our lobectomy patient outcomes over time and to achieve a 3-star ranking over a 3-year time frame. These results may be obtainable by others.

Robotic segmentectomy can be a useful technique for patients with suboptimal pulmonary reserve, or for small peripheral stage I tumors. Port placement and conduct of operation is described for the various segmentectomies. Results for robotic segmentectomy are comparable to that for video-assisted thoracoscopic surgery (VATS) segmentectomy.

Minimally invasive surgery (MIS) for lung cancer has been associated with decreased perioperative morbidity while maintaining similar long-term survival when compared to open thoracotomy. Robotic thoracic surgery constitutes an evolutionary step in this field, beckoning dramatic advancements both in visualization as well as surgical instrument range of motion and ergonomics. As such, robotic thoracic surgery is growing in adoption worldwide. One of its oft-cited disadvantages, however, is increased operative time, especially for less-experienced surgeons. We describe an assortment of tips and tricks that we conclude can safely reduce robotic operative duration.