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Phillips et al. Mini-invasive Surg 2020;4:12 I http://dx.doi.org/10.20517/2574-1225.2020.02 Page 7 of 9

The successful performance of robotic lung resection requires a strong team in the operating room
composed of surgeons, nurses, surgical techs, anesthesia providers, and a bedside assistant. The literature
describes the learning curve of a robotic lobectomy as 18-32 cases for a surgeon and 20 for a bedside
assistant [24-26] . Specific to anatomic lung resection, division of the pulmonary vascular structures is a
potentially hazardous portion of the operation that requires significant skill to perform safely. Prior to the
development of the robotic stapler, this required a competent bedside assistant or the console surgeon to
return to the bedside. At our institution, we have dedicated physician assistants or trained residents who
can safely complete these tasks. However, this may not be the case for every thoracic surgeon. Others have
fully described the range of motion capabilities of the EndoWrist® stapler, as well as the safety components
[8]
that ensure adequate closing and prevent the firing of an incorrectly loaded or spent reload . Drawbacks
of using the robotic stapler are the need for a 12-mm port, the long length of the stapler load that can
impede maneuverability in the chest, and the rotational limitation that can occur when the wrist is fully
flexed. This stapler does provide the console surgeon with the ability to control the stapler during division
of critical structures and may improve one’s ability to perform complex minimally invasive techniques
with reduced conversions [9,17] . These benefits may be more apparent at sites where a fully thoracic-trained
bedside assistant is not available.

The findings of our study should be viewed in the context of several limitations. This is a retrospective,
single institution cohort study and subject to potential selection bias, and our results may not be
generalizable to other patient populations. In addition, our data show that the robotic stapler group
operating time was significantly longer. However, as mentioned above, this is likely related to one surgeon’s
learning curve and not an inherently longer time for use of the stapler. Nevertheless, our outcomes are in-
line or better than those reported by multiple authors in the literature, and, to our knowledge, this is the
TM
first study to directly compare the EndoWrist® robotic stapler to a traditional Endo GIA stapler. Clinical
outcomes appear to be equivalent in our patient population and further study is needed to assess if there is
a difference in cost-effectiveness between these devices.

In conclusion, robotic anatomic lung resection has been shown to be safe and feasible with equivalent
long-term oncologic outcomes when compared to VATS and thoracotomy. In this study, we compared
perioperative outcomes of patients undergoing robotic anatomic lung resection to assess whether there
are any differences based on the type of stapler utilized. We found equivalent rates of complications, PAL,
and chest tube duration between the two groups. Based on our data, we recommend that surgeons use the
stapling device with which they are most confident.

DECLARATIONS
Authors’ contributions
Made substantial contributions to conception and design of the study and performed data analysis and
interpretation: Phillips JD, Fay KA, Finley DJ
Made substantial contributions to data interpretation and drafting and critical revisions of the manuscript:
Phillips JD, Fay KA, Hasson RM, Millington TM, Finley DJ

Availability of data and materials
The data source is a prospectively collected institutional database containing personal health information
(PHI). Per Dartmouth-Hitchcock Medical Center (DHMC) policy, any request for data would require an
approved Data Use Agreement (DUA) between DHMC and the requesting individual and/or institution.

Financial support and sponsorship
None.