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Correspondence |

Doing More and Doing Better in Robotic Thoracic Surgery FREE TO VIEW

Pierluigi Novellis, MD; Giulia Veronesi, MD; Marco Alloisio, MD
Author and Funding Information

FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST the following: G.V. has been a consultant for ABI Medica SpA, Italy and for Medtronic, Europe. None declared (P. N., M. A.).

aDivision of Thoracic Surgery, Humanitas Clinical and Research Center, Milan, Italy

bDepartment of Biomedical Science, Humanitas University, Milan, Italy

CORRESPONDENCE TO: Pierluigi Novellis, MD, Division of Thoracic Surgery, Humanitas Clinical and Research Center, Via Alessandro Manzoni 56, 20089 Rozzano, Milan, Italy


Copyright 2017, American College of Chest Physicians. All Rights Reserved.


Chest. 2017;151(4):941-942. doi:10.1016/j.chest.2016.11.059
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We much appreciated the retrospective study of Tchouta et al on the relation between hospital volume and outcomes for robotic pulmonary lobectomies. The authors analyzed 8,253 cases treated from 2008 to 2013 in various US hospitals and archived in the Healthcare Cost and Utilization Project National Inpatient Sample database. They grouped the hospitals into quartiles based on operating volume and found that robotic lobectomies performed in high-volume centers were associated with significantly shorter hospital stays and significantly lower mortality. Furthermore, 50% of the robotic lobectomies were performed in very-low-volume (one to three operations per year) or low-volume (four to six operations per year) hospitals. In our experience a surgeon needs to perform about 20 robotic lobectomies to attain full proficiency. However, the highest quartile of volume (≥ 15 cases per year) included hospitals that performed fewer lobectomies per year than the minimum required for a surgeon to complete the learning curve.

In another US multihospital database study, Swanson et al found that robotic lobectomies were more expensive and time-consuming than lobectomies performed using video-assisted thoracoscopic surgery, with no better complication or mortality rates. Although the analysis was based on equal-sized groups matched by propensity score, only 665 cases (4% of total) received robot-assisted surgery in 40 hospitals (30% of total). Thus, each hospital performed an average of 16.6 robotic procedures over the 2-year study period, suggesting that most robotic operations were performed in low-volume centers.

The periods of these studies (2008-2013 and 2009-2011) coincided with the initial stages of uptake of robotic technology for lung surgery, which would explain the predominance of low-hospital volumes. We believe that high proportions of low-volume centers provide a distorted picture of what can be achieved. Studies from single centers whose surgeons have attained full proficiency with robotic surgical technology provide a more useful indication of what is possible. Thus, Park et al found that robotic lung surgery was less costly than “open”, whereas Nasir et al found that robot-assisted lobectomy was profitable for the hospital and provided excellent outcomes.

Nonetheless, it is evident that robotic surgery for pulmonary resection is an expensive procedure, mainly because of high robot depreciation and the high cost of robotic disposables, which may be holding back the uptake of this promising new technology. We expect that the imminent entry of a competitor company may challenge Intuitive Surgical’s monopoly to drive costs down.

References

Tchouta L.N. .Park H.S. .Boffa D.J. .Blasberg J.D. .Detterbeck F.C. .Kim A.W. . Hospital volume and outcomes of robot-assisted lobectomies. Chest. 2017;151:329-339 [PubMed]journal. [CrossRef] [PubMed]
 
Veronesi G. . Robotic thoracic surgery: technical considerations and learning curve for pulmonary resection. Thorac Surg Clin. 2014;24:135-141 [PubMed]journal. [CrossRef] [PubMed]
 
Swanson S.J. .Miller D.L. .McKenna R.J. Jr..et al Comparing robot-assisted thoracic surgical lobectomy with conventional video-assisted thoracic surgical lobectomy and wedge resection: results from a multihospital database (Premier). J Thorac Cardiovasc Surg. 2014;147:929-937 [PubMed]journal. [CrossRef] [PubMed]
 
Park B.J. .Flores R.M. . Cost comparison of robotic, video-assisted thoracic surgery and thoracotomy approaches to pulmonary lobectomy. Thorac Surg Clin. 2008;18:297-300 [PubMed]journal. [CrossRef] [PubMed]
 
Nasir B.S. .Bryant A.S. .Minnich D.J. .Wei B. .Cerfolio R.J. . Performing robotic lobectomy and segmentectomy: cost, profitability, and outcomes. Ann Thorac Surg. 2014;98:203-208 [PubMed]journal. [CrossRef] [PubMed]
 
Kelly S. Medtronic expects revenue from surgical robot in fiscal 2019.Technology News.http://www.reuters.com/article/us-medtronic-robot-idUSKCN0YS2C3. Accessed June 6, 2016.
 

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Tables

References

Tchouta L.N. .Park H.S. .Boffa D.J. .Blasberg J.D. .Detterbeck F.C. .Kim A.W. . Hospital volume and outcomes of robot-assisted lobectomies. Chest. 2017;151:329-339 [PubMed]journal. [CrossRef] [PubMed]
 
Veronesi G. . Robotic thoracic surgery: technical considerations and learning curve for pulmonary resection. Thorac Surg Clin. 2014;24:135-141 [PubMed]journal. [CrossRef] [PubMed]
 
Swanson S.J. .Miller D.L. .McKenna R.J. Jr..et al Comparing robot-assisted thoracic surgical lobectomy with conventional video-assisted thoracic surgical lobectomy and wedge resection: results from a multihospital database (Premier). J Thorac Cardiovasc Surg. 2014;147:929-937 [PubMed]journal. [CrossRef] [PubMed]
 
Park B.J. .Flores R.M. . Cost comparison of robotic, video-assisted thoracic surgery and thoracotomy approaches to pulmonary lobectomy. Thorac Surg Clin. 2008;18:297-300 [PubMed]journal. [CrossRef] [PubMed]
 
Nasir B.S. .Bryant A.S. .Minnich D.J. .Wei B. .Cerfolio R.J. . Performing robotic lobectomy and segmentectomy: cost, profitability, and outcomes. Ann Thorac Surg. 2014;98:203-208 [PubMed]journal. [CrossRef] [PubMed]
 
Kelly S. Medtronic expects revenue from surgical robot in fiscal 2019.Technology News.http://www.reuters.com/article/us-medtronic-robot-idUSKCN0YS2C3. Accessed June 6, 2016.
 
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