A roadmap to totally switching from video-assisted thoracic surgery to robotics in thoracic surgery: hints and pitfalls from a surgeon’s experience

Introduction

Background

In thoracic surgery, the need for better patient outcomes propelled a change from open surgery and long thoracotomy incisions to minimally invasive video-assisted thoracic surgery (VATS), which nowadays is the gold standard approach. Lately, robotic-assisted thoracic surgery (RATS), following its expansion in other specialties, has become modestly an important rival to VATS.

Few hospitals in the UK and/or in the world, however, have invested, so far, in a separate thoracic robot or in allocating existing robotic systems to thoracic surgery practice (1). Despite this, many thoracic surgery departments are willing to use robotic systems, constituting thoracic surgery as an important market for robotic systems (2).

Studies in literature show that RATS is comparable to VATS, in many clinical metrics such as length of stay, respiratory complications, postoperative pain and overall postoperative recovery (3-7). However, it is not still clear if it has a benefit over VATS. Despite its high cost of purchase and maintenance, it is projected that RATS will be the modality of choice in the, not so distant, future (8).

Rationale and knowledge gap

To date, very few surgeons in thoracic surgery have chosen to totally abolish VATS and/or planned open operating and switch entirely to RATS operating. Consequently, there is little knowledge about how this can be achieved.

Objective

In this article, we describe a single surgeon’s experience on how totally switching to RATS was achieved, providing hints, tricks and pitfalls encountered in the surgeon’s organization during this change.

Roadmap of change

Establishing and delivering the change

A force-field analysis of opposing and supporting forces (Figure 1) was initially created by the surgeon to investigate if the change to convert to solely robotic operating would be supported and to better orientate actions (9). Existing personnel would be expected to oppose this, mainly because as a new technique, RATS would induce fear and uncertainty. A skeptical approach from higher management was encountered, in terms of ability to maintain the workload and finance sustainability by operating only robotically.

Figure 1 Force-field analysis as per Lewin for the change of totally switching to robotic operating in thoracic surgery, at our institute. COVID-19, coronavirus disease 2019.

For the change to be achieved, a modified Kotter’s steps of implementation were endorsed (Figure 2) (10). Despite the strategic vision of the organization towards implementing the robotic services into the practice of various specialties, totally switching to robotics in thoracic surgery was not in the scope of the service implementation and hence for such a change to be successful specific hurdles had to be overcome.

Figure 2 Roadmap of implementation in steps as per Kotter’s for our change to totally switching to robotic operating in thoracic surgery, at our institute.

Measuring the impact of the change

Providing measurable scientific data to support the change was difficult, as there were no published articles comparing differences between the practice of solely robotic surgeons and the practice of surgeons who partially perform robotic cases.

Metrics

Ensuring that the number of cases to be performed per robotic list would be the same as previously, was the first metric investigated. This is because the main belief is that RATS is slower than VATS or open surgery and a decrease in productivity would mean financial loss and prolongation of patient waiting times (11). This is not entirely true and hence, surgical duration should not increase by switching to RATS (12). The number of cases performed per list by the surgeon was shown to be the same as in the non-solely RATS operating era (Figure 3). In the surgeon’s experience, a quick turnaround of patients within a list was of key importance and was achieved by keeping the robot system in the same position in theatre so that to bring it above the patient in the same way and by discussing the plan with the team (including the anesthetist) before the list.

Figure 3 Number of cases per trimester throughout the 3 years 2019–2022 as calculated for the author. The analysis showed that there was no decrease in the number of cases performed throughout the change. VK, surgeon mediating the change to totally RATS operating; RATS, robotic-assisted thoracic surgery; NNUH, Norfolk and Norwich University Hospital.

Next, in order for more lists to be switched to RATS for the surgeon to achieve the change, a comparison between RATS and VATS practice was necessitated, to investigate if additional costs would be accrued by the change. In order to achieve this comparison, the surgeon’s key procedures were identified to regard anatomical lung resections up to 75% of the practice. An index procedure was analyzed in terms of basic costings (Figure 4). This way of comparing the surgeon’s practice was preferred over calculating an average cost of all cases performed RATS and VATS mainly because the surgeon would perform different mixture of procedures VATS and RATS and hence such analysis would lead to discrepancies. This analysis is of course incomplete as it does not include the cost of acquiring/maintaining the robotic system or the screens in the VATS theatre, etc., and hence it cannot be supported that RATS costs less than VATS (13-15). However, a complete financial analysis was not within the scope of this article. Procurement and correct coding, in our experience, was critical in order to ensure minimization of financial losses.

Figure 4 Cost analysis of a typical VATS right lower lobectomy and a Da Vinci RATS right lower lobectomy in terms of consumables and special instruments (not the commonly used trays-drapes-other theatre costings, i.e., personnel costing, bookings, etc., are perceived as similar) used as per the author’s preferences. The costings were sourced from the financial and the procurement departments of the author’s institute in 2022 according to supplier. Prices may differ between institutes and might have changed since the analysis was conducted. VATS, video-assisted thoracic surgery; RATS, robotic-assisted thoracic surgery; Qt, quantity; VAT, value-added tax (United Kingdom).

High utilization of the system will impact future decisions about list allocations amongst specialties. Cancelling patients/lists or low utilization needs to be avoided. An initial analysis performed service-wide showed that the actual organizational robotic service performance was away from the desired one (Figure 5). A more in-depth analysis of the mechanisms and pathways involved was conducted by the surgeon via a fishbone and a Pareto diagram, after analyzing the initial 30 failed robotic cases for all specialties (Figures 6,7). This was performed in order for the surgeon to promote the implementation of corrective actions so that to reduce the unutilized lists and hence increase the success of the change. Based on this analysis it was proposed the creation of a separate theatre robotic coordinator (in our experience this was achieved via internal reallocation of roles) to troubleshoot the issues identified via the above-described analysis. Dedication by the surgeon to minimize list losses after he switched solely to RATS and personal efforts to align the attributed personnel in a strategic management orientation to minimize disruptions were also of key importance.

Figure 5 Measurement of operational management against 5 key performance measures (speed, quality, dependability, flexibility and cost) with regards to the overall organizational robotic program. Polar diagram of the above investigation performed by the surgeon in order to identify areas of improvement of the change.

Figure 6 Fish-bone analysis for lost robotic lists across the whole robotic program. COVID, coronavirus disease.

Figure 7 Pareto analysis for list robotic lists across the whole robotic program.

Patient clinical outcomes

Shorter length of stay, reduced respiratory complications and reduced re-admissions to critical care complex post-surgery were only some of the lung anatomical resection outcomes documented to be better than in VATS procedures, in the surgeon’s experience (Figure 8). This analysis can also help financially materialize the clinical benefit of switching to RATS, by providing the indirect savings achieved from the clinical benefits of RATS (Figure 8). This analysis needs to be performed fairly early in the implementation of RATS operating if surgeons wish to promote a change towards solely RATS operating. These metrics are consistent with the literature and this also needs to be promoted within the organization (6,7). The surgeon promoted these positive outcomes mainly via e-mails to higher management and clinical directors, local presentations, involvement of local press (including patient testimonies) and others.

Figure 8 Clinical outcomes and their cost savings comparing the surgeon’s VATS and RATS practice post switching to totally RATS operating. VATS, video-assisted thoracic surgery; RATS, robotic-assisted thoracic surgery; OR, operating room.

Impact from totally switching to RATS on the surgeon

Learning curve

It would be expected that solely performing RATS will expedite the learning curve and the performance of complex procedures. Literature suggests that for anatomical lung resections, the learning curve varies between 40–100 lung resections (16-18), but again it is not clear if surgeons’ experience investigated include surgeons performing only RATS or both VATS and RATS.

Proctoring can help at the beginning of the learning curve but dedication to totally switching to RATS operating was the key propelling force.

The learning curve of performing sublobar anatomical lung resections (mainly complex) was another consideration (19).

Choosing “straight forward” cases for RATS

At the beginning of RATS operating, avoiding “difficult” cases in terms of fissures, lymph nodes, size of masses, infiltration of surrounding structures, etc., would be perfectly reasonable and advisable. However, we experienced pressures to avoid performing cases which would become open ones in a robotic theatre. In our experience, we encountered cases with the above-mentioned characteristics because of lack of non-robotic theatre time, even early in the course of totally performing RATS. A surgeon wanting to totally switch to RATS, should not feel limited as to what cases can be performed robotically (20-22).

Encountering unfit patients

High-risk patients subjected to lung resections in thoracic surgery were previously shown to have acceptable outcomes when compared with non-high-risk ones (23). Initial studies in the literature show improved outcomes in robotically treated high-risk patients (24). Hence, treating high-risk patients robotically should be acceptable.

Safety issues from totally switching to RATS

RATS is a new technology and as such, many safety issues should be expected to be raised. In order to overcome this, an extensive and robust training pathway has been established by the robotic system provider, albeit different organizations might have their own guidelines and safety procedures. A more senior member of staff, irrespectively of any robotic training, can be approached in order to be on stand-by, should help is needed. The surgeon chose to keep thoracotomy instruments in the robotic theatre opened and ready to be used in an emergency (although with increasing experience this is not common practice anymore) and the performance of a safety huddle at the beginning of each list, identifying key persons to be contacted in every adverse scenario, was implemented. Roles to members of the theatre team were also allocated at the beginning of every list for example who will drive the robot away in an emergency, etc.

The main safety issue, as expected, was the scenario of important bleeding, especially in complicated cases. This was tackled with vigorous allocation of roles and plans during the huddle at the beginning of the list. We did not routinely, however, use an assistant port just to “apply pressure to control bleeding”, as we felt that the console surgeon is the quickest person to put pressure on the bleeding spot and can then re-arrange the instruments once the bleeding is controlled. Then the robot can be safely undocked if needed. In the scenario of uncontrolled bleeding, the camera could stay in the chest via the assistant port, if one is performed.

Personal impact on the surgeon

Apart from the financial and patient centered beneficial outcomes, RATS operating is causing less autonomous nervous system triggered on the surgeons themselves (25). Additionally, in the surgeon’s experience and as shown before, totally switching to RATS operating led to less postoperative issues, which consequently leads to decreased needs for medical input and to less chances of failed procedures, deaths, complaints and litigation, and need for out-of-hours attendance to the hospital. Our experience showed that switching totally to RATS had a beneficial effect on the surgeon’s overall personal life which is summarized in the notion: “live now-live later” which means that the surgeon lives better now while performing RATS procedures achieving minimal impact on his/her health, and can live better in the future, avoiding issues with his/her health, by avoiding personal stress from the practice. Not standing up whilst operating makes an important difference, especially in long cases. Also having total control of the instruments and the camera abolishes the assistant factor from the equation during a demanding and complicated case, which in turn leads to decreased anxiety, stress and inconvenience. Of course, all these are personal reflections and cannot easily be measured in order to be objectively proven.

Total or partial RATS practice?

As more data is published regarding RATS compared to VATS in terms of cost-effectiveness and clinical sufficiency (26), many surgeons are facing the dilemma if they should totally switch to RATS or implement RATS as an adjunct to their already established practice (VATS and/or open). In the UK, a very small proportion of lung resections are being done robotically, with thoracotomy being an acceptable approach, despite the knowledge that this approach is suboptimal than VATS (27,28).

Logically total RATS operating should provide steeper learning curve, quicker training and familiarization with the technique, which consequently should lead to maximization of the benefit of RATS procedures. Consequently, diluting RATS lists amongst more surgeons without new systems will only achieve suboptimal outcomes and will create more “average” surgeons rather than “masters” of this new exciting technology, event that will almost certainly lead to suboptimal outcomes for the patients.

Limitations in theatre access was a major limiting factor in the present change to totally RATS operating. And this follows the fact that there is limited number of systems and time allocated to thoracic surgery, in comparison with other specialties. Many surgeons would not be willing to pursue more exposure to RATS procedures, under the fear of retaliation, difficult discussions and “clashing” with colleagues. This event enlarges as RATS is more progressively becoming an important development in the operating practice of thoracic surgery.

Finally, changes in a surgeon’s practice are mandatory to facilitate special technical issues arising from totally switching to RATS, for example the inability to feel lesions and others. The surgeon early in the course of the change created a robust collaboration with the interventional radiology service which offers coils in such lesions before surgery, making a “non-touch ultimate key-hole experience” feasible (29).

The strength of the present manuscript is that it provides a comprehensive roadmap as to how a total switch to totally RATS operating in thoracic surgery was achieved. Pitfalls, hints and tricks are drawn from a personal experience. The main limitation is that it regards one surgeon’s experience and as there is not extensive literature on the same subject, an extensive comparison to the literature could not be performed.

Conclusions

Herein, the experience of how one surgeon switched to totally RATS operating from VATS and partial RATS operating, is presented. A summary of the roadmap followed in order for this to be achieved is reported. There is still an important argument as to whether total RATS operating is better than partial or VATS. Although there is still not enough data to support that RATS should be the gold standard approach offered in thoracic surgery, accumulating data show encouraging results, propelling more surgeons to get involved with this technology. If RATS becomes the key player in the future of minimal invasive operating remains to be proven.

Acknowledgments

Funding: None.

Footnote

Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-24-5/prf

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-24-5/coif). V.K. is a proctor for Intuitive. The author has no other conflicts of interest to declare.

Ethical Statement: The author is 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. Patient consent was collected prior to the inclusion in the study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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