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Page 6 of 9 Phillips et al. Mini-invasive Surg 2020;4:12 I http://dx.doi.org/10.20517/2574-1225.2020.02

Atrial fibrillation 0 2 (1.1) x
Other 10 2 (4.1) 7 (3.7) 0.91
30-day mortality, (%) 0 1 (0.5) x
3
2
1 P-values from student’s t-test or chi-square test where appropriate. Grade 3/4 complication as classified by Clavien-Dindo. Within
5
4
30-days of index procedure. Unexpected return to OR within 30-days of index procedure. Defined as an air leak that lasted beyond
8
10
9
7
6
postoperative day 5. Requiring drainage. Requiring bronchoscopy. Requiring chest tube reinsertion. Requiring treatment. Includes
anemia, bowel obstruction, dehydration, syncope, hyponatremia, gastrointestinal bleed, fluid overload, and thrombus. x: statistics unable
to be performed
pleurodesis and endobronchial valves). There was no difference in grade ≥ 3 complications, readmissions,
or 30-day mortality.
DISCUSSION
As new technology becomes available, it is important that surgeons critically evaluate its use. The 30-mm
curve tip EndoWrist® stapler was introduced in March 2016. However, only a few reports to date in the
literature describe its use in pulmonary resections [7,8,16,17] . To our knowledge, the current study is the first
to directly compare the robotic stapler and a traditional VATS stapler related to perioperative outcomes
in robotic anatomic lung resections. We found no clinically significant differences in preoperative
characteristics between the two stapler groups at our institution. There were also no clinically significant
differences noted in the number of staple loads used, pathologic stage, or lymph nodes harvested. We did
identify a significant increase in operative time in the group that utilized the robotic stapler. As the robotic
stapler was exclusively used by a new attending surgeon, this likely represents a learning curve rather than
an intrinsic delay related to stapler use, as evidenced by the significant reduction in operative time for these
cases over the course of the study period. Moreover, there were no differences in LOS, chest tube duration,
or postoperative complications between the two groups. Overall, our outcomes are in-line with recently
published experiences [6,8,18,19] .

Ultimately, we did not find a difference in the rate of postoperative PAL or chest tube duration between
the two groups. While a recent analysis of the Society of Thoracic Surgeons DataBase reported an overall
[20]
[19]
rate of PAL of 10.4% , rates following anatomic lung resection range from 6% to 30% . Several risk
factors have been reported to increase the risk of PAL, including forced expiratory volume in 1 second
2
< 70% of predicted, body mass index < 25 kg/m , previous smoking, anatomic lung resection, pleural
adhesions, male sex, and right upper lobe procedure [19,20] . Many of our patients have several, if not most
of these risk factors. In addition, our rural patient population has a significant proportion of patients
who began smoking at an early age. Smoking in childhood and during the teenage years can slow lung
[21]
development and increase the risk of chronic obstructive pulmonary disease in adulthood . Early smoke
exposure leads to airway inflammation and parenchymal lung injury with larger saccules, increased
[22]
density of interstitial tissue, and reduced elastin and collagen . These factors may help to explain our
rate of postoperative PAL in the setting of otherwise low rates of complications. However, our study is not
powered or intended to predict an increase in PAL based on these factors. In addition, we are aggressive
about discharging patients from the hospital with a chest tube in place. Given our rural catchment area,
this may result in some delay in actual chest tube removal beyond Postoperative Day 5 when an air leak is
not actually present.

Variability in the techniques of robotic anatomic lung resection exist. A recently published survey of high-
volume robotic thoracic surgeons demonstrated that most respondents utilized a four-arm approach and
94% used an additional non-robotic assistant port . In respondents, there was not a universal standard
[23]
port placement, and stapling port strategies were nuanced by lobe and type of stapler used. As additional
technologies are developed, it will be important to evaluate their efficacy and effectiveness, in terms of both
clinical outcomes and healthcare costs.