Proficiency of Robotic Lobectomy Based on Prior Surgical Technique in The Society of Thoracic Surgeons General Thoracic Database

Abstract

Background: Robotic lobectomy represents a paradigm shift for many surgeons. It is unknown if a surgeon's prior operative approach influences development of proficiency. We compared outcomes based on prior lobectomy experience and used cumulative sum analysis to assess proficiency.

Methods: Using The Society of Thoracic Surgeons General Thoracic Database we grouped surgeons as de novo, open-to-robotic, or video-assisted thoracoscopic surgery (VATS)-to-robotic. Operative time, blood transfusion, mortality, and major morbidity were primary outcomes. Unacceptable and acceptable thresholds were determined by review of the literature. Proficiency was defined as 20 consecutive cases without crossing an upper control line. Surgeons were assessed individually, and proficiency was assessed by transition group.

Results: From 2009 to 2016, 271 surgeons performed 5619 robotic lobectomies for clinical stage I/II non-small cell lung cancer. Of these, 65 surgeons (24%) performed ≥20 lobectomies (4483 cases). Initial proficiency for an operative time target of 250 minutes was 40% for de novo compared with 14% for open-to-robotic and 21% for VATS-to-robotic surgeons, with improvement to 47%, 29%, and 21%, respectively, after 20 cases. Initial and sustained proficiency related to major morbidity was similar for open-to-robotic and VATS-to-robotic but lower for de novo at 40%. After 20 cases most were proficient (de novo, 93%; open-to-robotic, 100%; and VATS-to-robotic, 86%). Proficiency for 30-day mortality and blood transfusion was high in all groups.

Conclusions: Outcomes among all transition groups improved with experience. Operating room duration proficiency was challenging for all groups. Cumulative sum may be useful to monitor proficiency in not only subsequent studies but in clinical practice.