Emergency conversions in robotic thoracic surgery: perspectives and the importance of preparation

Emergency conversions from minimally-invasive thoracic surgery to open thoracotomy, although rare, are life-threatening situations that portend increased morbidity and mortality. With the emergence and evolution of robotic thoracic surgery, a nuanced understanding of the safest methods for conversion is critical (1). A review of The Society of Thoracic Surgeons (STS) General Thoracic Surgery Database from 2015–2018 reported a conversion rate of 11% of video-assisted thoracoscopic surgical (VATS) lobectomies and 6% of robot-assisted thoracoscopic surgery (RATS) lobectomies. In this study, the reason for conversion was classified as “emergent” in 9.6% of the converted VATS cases and 17.9% of the RATS cases (2). Compared to an initial VATS approach, converting from a robotic approach to thoracotomy in an urgent or emergent situation presents the surgeon with a number of unique challenges. How one approaches these challenges is influenced by the level of robotic experience that all members of the operating room (OR) team possess. As such, protocols and stepwise procedures for emergency undocking of the robot have been recently described (3,4); however, there are no societal consensus recommendations as it relates to emergency conversion from RATS to thoracotomy.

The present study aimed to develop a list of essential principles related to safe emergency conversion from RATS to thoracotomy (5). The authors conducted a modified Delphi study with a panel of 21 experts in robotic thoracic surgery, with expert defined as having completed 100 or more robotic anatomic lung resections. Most of the panelists were recruited from either the Thoracic Surgery Outcomes Research Network or the STS Robotic Surgery Task Force. Seventy six percent of the panelists had 1 to 9 years of robotic surgery practice, and all panelists had participated in an emergency conversion from robotic to open for bleeding. After a pilot round to determine feasibility, two rounds of discussion occurred over the course of 3 months. These discussions resulted in a list of 33 statements split into three categories (preoperative preparation, emergency undocking and resuscitation, and debriefing). Consensus, defined as ≥70% agreement among the 21 panelists, was achieved for all but three of the statements. The lack of consensus for these three statements was attributed to “acceptable surgeon- and institution-specific variations”.

Twenty-five of the statements had over 90% consensus, which correlates to a maximum of two dissenting opinions of the 21 experts. Many of those recommendations are more straightforward, with minimal time commitment or effort needed for implementation, for assimilation into OR workflow, and for protocolization. Some examples include sending a type and crossmatch for high-risk patients, having gown and gloves available for the surgeon on console, and having an undocking protocol/checklist posted in the OR. These simple actions can have a tangibly positive impact on the flow of an emergency conversion. With respect to the execution of the conversion, more than 90% agreement was achieved across several statements concerning the preparatory phase leading up to thoracotomy itself, such as calling for additional help (surgical, anesthesia, and nursing), ensuring closed-loop communication, and maintaining uninterrupted visualization of the surgical field. Interestingly, preemptively marking out a skin incision for thoracotomy was agreed upon by only 15 of the 21 experts. Especially in the circumstance of having a bedside assist, whether a surgical assistant or a resident physician, who can start the thoracotomy before the surgeon scrubs back in, having a pre-marked incision is helpful. This is even more so the case if the bedside assist is less experienced with open thoracic surgery.

The degree of consensus started to diminish when discussing the technical elements of the actual conversion, particularly as it relates to the method for undocking and the role of the bedside assistant. This makes sense, as there is certainly variation in both surgeons’ techniques and the capabilities/level of OR team experience with robotic thoracic surgery across institutions. Technique for undocking in emergency circumstances has been described (4,6), and often involves a partial undocking method, wherein tamponade of bleeding is maintained with a single robotic instrument while the remainder of the robotic arms are undocked. Thoracotomy is then performed while tamponade of bleeding is maintained with either the robotic instrument in situ or after this role has been transitioned to the bedside assistant, holding pressure through a utility port or limited thoracotomy that is then extended as needed (4). The present study reports 71.43% consensus in favor of a partial undocking method using the robotic arm for maintaining tamponade until a thoracotomy is performed. However, the group did not reach consensus (66.7% agreement) on the acceptability of transitioning tamponade from the robotic arm to manual compression by the bedside assist via a limited thoracotomy (prior to the surgeon leaving the console). Both are described, reasonable methods, and we would postulate that the application of one or the other depends largely on (I) the quality of hemostasis that can be achieved with a robotic instrument, (II) the capabilities of the bedside assist, and (III) the availability of another thoracic surgeon to assist. Regardless of the technique, we would suggest that there is another thoracic surgeon available for the duration of the surgery and/or that the bedside assist is experienced enough to independently perform a limited thoracotomy and deftly transition and maintain tamponade from a robotic to a handheld instrument. As long as both uninterrupted visualization and tamponade of bleeding are maintained throughout the conversion process, variations in surgical technique based on surgeon experience are certainly acceptable.

The main limitation of the present study is the reliance on expert opinion and consensus rather than results from randomized controlled trials. Differences in surgical technique, institutional practices, and assistant expertise may introduce bias, and the Delphi method specifically can result in herding bias, wherein panelists’ responses are influenced by their peers over the course of rounds of discussion (7). That being said, emergency conversions obviously cannot be studied in a prospective fashion, so retrospective review of outcomes and development of guidelines via expert consensus is likely the best approach.

The study concerns a cohort of patients from 2015–2018. Over the last decade, experience and improvements in conversion from robotic to thoracotomy have led to a lower percentage of emergency conversions. However, the learning curve for robotic surgery is only becoming steeper, for both the surgeon and the non-technical contributions of all the other members of the OR team. For all institutions that offer robotic thoracic surgery, regular simulation of robotic emergencies should be performed consistently. This is especially the case for centers with lower volume of robotic surgery and for surgical teams with relatively less experience. As we continue to evolve both our robotic technology and operative techniques, it will be important to re-visit and update any implemented protocols.

Overall, the consensus statements and the proposed protocol for emergency conversion are valuable resources that centers practicing robotic thoracic surgery should explore, adapt, and apply in their ORs. In fact, it may be that these guidelines are even more applicable to smaller centers performing robotic thoracic surgery compared to large metropolitan academic centers. As with everything in surgery, the key is preparedness: anticipate patients that are higher risk for conversion, but always maintain vigilant situational awareness and OR team engagement even for “routine” cases. In doing so, we can always be ready with the tools and expertise required for the unexpected intraoperative emergency.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Current Challenges in Thoracic Surgery. The article has undergone external peer review.

Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-2025-1-46/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-2025-1-46/coif). J.R. reports a research grant for robotic bronchoscopic work with Intuitive Surgical, unrelated to the content of this article. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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References

1. Towe CW, Kuo EY, Feczko A, et al. The Society of Thoracic Surgeons General Thoracic Surgery Database: 2024 Update on Outcomes and Research. Ann Thorac Surg 2025;119:733-43. [Crossref] [PubMed]
2. Servais EL, Miller DL, Thibault D, et al. Conversion to Thoracotomy During Thoracoscopic vs Robotic Lobectomy: Predictors and Outcomes. Ann Thorac Surg 2022;114:409-17. [Crossref] [PubMed]
3. Shehata DG, Watkins AA, Servais EL. Emergency Conversion During Robotic-Assisted Thoracic Surgery. Thorac Surg Clin 2025;35:279-83. [Crossref] [PubMed]
4. Watkins AA, Ricard C, Hoagland D, et al. Emergency Conversion from robotic thoracoscopy to thoracotomy: a safe, reproducible, and effective technique. Oper Tech Thorac Cardiovasc Surg 2025;30:67-74.
5. Reddington H, Schumacher L, Watkins AA, et al. Recommendations for Emergency Robotic Thoracic Conversions and Intraoperative Resuscitation: A Modified Delphi Consensus Study. Ann Thorac Surg 2026;121:41-52. [Crossref] [PubMed]
6. Shehata DG, Watkins AA, Servais E. Emergency Conversion Preparedness is Paramount in Robotic Thoracic Surgery. ACS Bulletin 2025;110:36-39.
7. Nasa P, Jain R, Juneja D. Delphi methodology in healthcare research: How to decide its appropriateness. World J Methodol 2021;11:116-29. [Crossref] [PubMed]