Benjamin Bottet

The use of the robotic approach is rapidly increasing in thoracic surgery worldwide. Mastering this new technique is challenging and teaching robotic surgery is difficult. Nevertheless, to date, no academic certified training program including a standardized approach is available for robotic lobectomy and no objective assessment scale has been proposed. Here we describe new objective criteria for robotic lobectomy including a standardised surgical technique and an objective structured assessment scale to improve educational support for thoracic surgeons. The technique, referred to as the French lobectomy, is a standardized technique, and is based on five exposure and dissection zones. Each zone contains a number of dissection steps, which all together form a complete lobectomy. The technique can be applied to all lobectomies (and segmentectomies) for both the left and right side. In parallel, an objective structured assessment scale is designed to evaluate the performance of trainee surgeons who use the technique. This scale is based on five items with a minimum score of 5 points and a maximum score of 25 points. A conduct to follow based on the score obtained is proposed. This systematic and standardized robotic approach to lobectomies and its assessment scale, may allow surgeons and trainees to improve their technical skills and efficiency.

Lung cancer remains the leading cause of cancer-related deaths worldwide. The introduction of targeted treatments and immunotherapy in lung cancer has transformed patient care by offering “precision medicine” focused on the characteristics of the disease. The same concept has emerged in lung cancer surgery. This “precision surgery” aims to determine the best surgical approach based on the characteristics of the cancer, the patient’s cardiorespiratory status, and technological advances in thoracic surgery. While lobectomy continues to be the gold standard for managing early-stage lung cancer, the implementation of screening programs has enabled the earlier detection of smaller tumors. In this context, sublobar resections, particularly segmentectomy, have emerged as valuable options in the treatment of early-stage lung cancer. Recent studies suggest that sublobar resections, including segmentectomy and wedge resection, provide a viable alternative to lobectomy. This review explores the various resection strategies available, tailored to patient and tumor characteristics, and highlights modern preoperative techniques aimed at advancing precision surgery.

Evaluate theoretical and practical training of thoracic surgeons-in-training in robotic-assisted thoracic surgery (RATS) in France. A survey was distributed to thoracic surgeons-in-training in France from November 2022 to February 2023. We recruited 101 thoracic surgeons-in-training (77% response rate). Over half had access to a surgical robotics system at their current institution. Most (74%) considered robotic surgery training essential, 90% had attended a robotic procedure. Only 18% had performed a complete thoracic robotic procedure as the main operator. A complete RATS procedure was performed by 42% of fellows and 6% of residents. Of the remaining surgeons, 23% had performed part of a robotic procedure. Theoretical courses and simulation are well developed; 72% of residents and 91% of fellows had undergone simulation training in the operating room, at training facilities, or during congress amounting to 30 h (3%). Access to RATS was ≥1 day/week in 71% of thoracic departments with robotic access. Fellows spent a median of 2 (IQR 1–3) semesters in departments performing robotic surgery. Compared with low-volume centres, trainees at high-volume centres performed significantly more complete robotic procedures (47% vs 13%; P = 0.001), as did fellows compared with residents. Few young surgeons perform complete thoracic robotic procedures during practical training, and access remains centre dependent. Opportunities increase with seniority and exposure; however, increasing availability of robotic devices, theoretical formation, and simulation courses will increase opportunities.

Non-small cell lung cancer (NSCLC) is now described as an extremely heterogeneous disease in its clinical presentation, histology, molecular characteristics, and patient conditions. Over the past 20 years, the management of lung cancer has evolved with positive results. Immune checkpoint inhibitors have revolutionized the treatment landscape for NSCLC in both metastatic and locally advanced stages. The identification of molecular alterations in NSCLC has also allowed the development of targeted therapies, which provide better outcomes than chemotherapy in selected patients. However, patients usually develop acquired resistance to these treatments. On the other hand, thoracic surgery has progressed thanks to minimally invasive procedures, pre-habilitation and enhanced recovery after surgery. Moreover, within thoracic surgery, precision surgery considers the patient and his/her disease in their entirety to offer the best oncologic strategy. Surgeons support patients from pre-operative rehabilitation to surgery and beyond. They are involved in post-treatment follow-up and lung cancer recurrence. When conventional therapies are no longer effective, salvage surgery can be performed on selected patients.

Background: Nowadays, video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS) are known to be safe and efficient surgical procedures to treat early-stage non-small cell lung cancer (NSCLC). We assessed whether RATS increased disease-free survival (DFS) compared with VATS for lobectomy and segmentectomy. Methods: This retrospective cohort study included patients treated for resectable NSCLC performed by RATS or VATS, in our tertiary care center from 2012 to 2019. Patients’ data were prospectively recorded and reviewed in the French EPITHOR database. Primary outcomes were 5-year DFS for lobectomy and 3-year DFS for segmentectomy, compared by propensity-score adjusted difference of Kaplan–Meier estimates. Results: Among 844 lung resections, 436 VATS and 234 RATS lobectomies and 46 VATS and 128 RATS segmentectomies were performed. For lobectomy, the adjusted 5-year DFS was 60.9% (95% confidence interval (CI) 52.9–68.8%) for VATS and 52.7% (95%CI 41.7–63.7%) for RATS, with a difference estimated at −8.3% (−22.2–+4.9%, p = 0.24). For segmentectomy, the adjusted 3-year DFS was 84.6% (95%CI 69.8–99.0%) for VATS and 72.9% (95%CI 50.6–92.4%) for RATS, with a difference estimated at −11.7% (−38.7–+7.8%, p = 0.21). Conclusions: RATS failed to show its superiority over VATS for resectable NSCLC.

Our goal was to report our midterm results using imaging-assisted modalities with robotic segmentectomies for non-small-cell lung cancer (NSCLC). This was a retrospective study of all robotic segmentectomies, with confirmed NSCLC, performed at our general and thoracic surgery unit in the Rouen University Hospital (France), from January 2012 through December 2019. Benign and metastatic lesions were excluded. Data were extracted from the EPITHOR French nationwide database. A total of 121 robotic segmentectomies were performed for 118 patients with a median age of 65 (interquartile range: 60, 69) years. The majority had clinical stage T1aN0M0 (71.9%) or T1bN0M0 (13.2%). The mean (standard deviation) number of resected segments was 1.93 (1.09) with 80.2% imaging-assisted segmentectomies. Oriented (according to tumour location) or systematic lymphadenectomy or sampling was performed for 72.7%, 23.1% and 4.1% of patients. The postoperative course was uneventful for 94 patients (77.7%), whereas 34 complications occurred for 27 patients (22.3%), including 2 patients (1.7%) with Clavien-Dindo ≥III complications. The mean thoracic drainage duration was 4.12 days, and the median hospital stay was 4 days (interquartile range: 3, 5) after the operation. The 2-year survival rate was 93.9% (95% confidence interval: 86.4–97.8%). Excluding stage IV (n = 3) and stage 0 tumours (n = 6), the 2-year survival rate was 95.7% (95% confidence interval: 88.4–98.8%) compared to an expected survival rate of 94.0% according to stage-specific survival rates found in a large external reference cohort. Imaging-guided robotic-assisted thoracic surgery segmentectomy seems to be useful and oncological with good midterm results, especially for patients with early-stage NSCLC.

Contexte : La simulation en santé est un outil pédagogique incontournable en formation initiale. But : Rapporter notre expérience d’implantation d’un dispositif de type Objective structured assessment of technical skills (OSATS) pour mesurer les habiletés techniques des internes de chirurgie en phase socle de notre faculté, en évaluer les qualités psychométriques préliminaires et recueillir les opinions des internes sur ce dispositif. Méthodes : Un OSATS composé de quatre puis cinq et six stations de 10 minutes chacune a été administré successivement à trois cohortes d’internes. Chaque station avait pour objectif la réalisation d’une habileté technique de base. La performance des candidats était évaluée par un observateur à l’aide d’une grille préétablie. Les moyennes des scores obtenus aux stations et la cohérence interne des scores (coefficient alpha) ont été analysées. Les besoins ressentis des internes, la validité apparente et de contenu de l’examen ont été évalués par questionnaire. Résultats : Soixante-dix neufs internes ont été évalués sur trois ans. Les performances n’étaient pas corrélées au rang aux épreuves classantes nationales [0.13 (IC95% :−0,11 ; +0,36)]. Les indices de cohérence interne se situaient entre 0,61 et 0,87. Les habiletés pour le sondage urinaire masculin et la suture cutanée étaient acquises très tôt. Les internes ont estimé que les gestes proposés à chaque station étaient réalistes. Pour 93% d’entre eux, l’enseignement par la simulation est indispensable à leur formation. Conclusion : L’implantation d’un OSATS est faisable et fournit d’importants renseignements sur les habiletés techniques des internes en chirurgie. Le développement de ce type d’outil renforcerait la place de la simulation dans la formation chirurgicale. Introduction: Simulation-based training has become essential in medical education. Objective: Report our experience of implementing an Objective Structured Assessment of Technical Skills (OSATS) to measure technical skills of year 1 surgical residents of our faculty, assess their preliminary psychometric qualities and collect the opinions of residents on this tool. Methods: An OSATS of four then five and six stations of 10 minutes each was administered successively to 3 cohorts of surgical residents. Each station aimed to achieve basic technical skill. Residents’ performances were assessed by an examiner using a pre-established scoring sheet. The means obtained from the stations and their internal consistency (alpha coefficient) were analyzed. Residents’ felt needs, the apparent validity and content of the OSATS were assessed using a questionnaire. Results: Seventy-nine residents were assessed over 3 years. Residents’ performances were not correlated with ranking at the National Ranking Examination [0.13 (CI95%: −0.11; +0.36)]. Urinary catheter and skin suturing were controlled very early. All residents considered that the technical skills assessed at each station were realistic. For 93% of them, teaching by simulation was considered essential for their training. Conclusion: This initial experience demonstrated that implementation of an OSATS is feasible and has provided important information on the technical skills of surgical residents. The development of this type of tool would strengthen the role of simulation in surgical training.