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Piergiorgio Solli Thoracic Surgery , Bologna, ITALY

FACTORS IN DECISION MAKING BETWEEN RATS and VATS. Piergiorgio Solli Thoracic Surgery , Bologna, ITALY. Rogers, Everett M 1962 Diffusion of Innovations. innovators  – more educated, more prosperous and more risk-oriented

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Piergiorgio Solli Thoracic Surgery , Bologna, ITALY

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  1. FACTORS IN DECISION MAKING BETWEEN RATS and VATS Piergiorgio Solli ThoracicSurgery, Bologna, ITALY

  2. Rogers, Everett M 1962 Diffusion of Innovations innovators – more educated, more prosperous and more risk-oriented early adopters – younger, more educated, tended to be community leaders, less prosperous early majority – more conservative but open to new ideas, active in community late majority – older, less educated, fairly conservative and less socially active laggards – very conservative, oldest and least educated

  3. AsJune 30, 2017 #4,149DaVinci Robot worldwideinstalled Proportion of RATS lobectomies for NSCLC has increased from 0.2% in 2008 to 3.4% in 2010 Kent M Ann ThoracSurg 2014; 97(1):236

  4. 4 categories: technical outcomes, perioperative outcomes, oncological outcomes, cost comparison Although limited by a lack of prospective analysis, this review demonstrates the safety and clinical effectiveness of RATS in early stage lung cancer Multiple comparative studies depict improved patient outcomes compared with thoracotomy, and no difference as compared with VATS, with the exception of costs Prospective studies are required to determine if any outcome differences between RATS & VATS Semin Thoracic Surg 2016; 28:182–

  5. J ThoracCardiovascSurg 2014;147:929- • CONCLUSIONS • no differences in periop. adverse events • increased cost of RATS / per case • increased operative times for RATS • further consideration warranted before using this technology vs standard VATS • future studies and RCTs focused on costs and comparative effectiveness are needed

  6. J Thorac Dis 2016;8(10):E1274-

  7. VATS offerswell-documented benefits over thoracotomy, gold standard for early-stage lungcancer How do weexplain the rise of RATS when an establishedminimally invasive approachalreadyexists? WHY ARE THEY USING ROBOTICS ?

  8. At least two potential clinical benefits of robotic lobectomy have been proposed First, improved visualization and control may enable more complete nodal evaluation compared with VATS. However, a randomized trial of lobe-specific systematic mediastinal nodal sampling vs formal lymph node dissection after VATS or open lobectomy failed to show any advantage to a more radical lymphadenectomy. Second, robotic lobectomy may have a reduced learning curve compared with VATS because of similarities between robotic and open approaches. Wilson JL , Louie BE , Cerfolio RJ , et al . AnnToracSurg. 2014 ; 97 ( 6 ): 1901 - 190

  9. central message: substantial, ideally applicable methodology to create graded, component-based pathways to surgical competency in complex procedures, teaching complex operations to trainees

  10. WHY ARE THEY USING ROBOTICS ? • Obstacles limiting penetration of VATS, particularly in community setting. • As it did with minimally invasive prostatectomy, RATS could theoretically bring benefits of minimally invasive lobectomy to a broader population • Complex procedures (Induction CT, locally advanced stage, sleeve resection) • Non-financial benefits (reputational effects by staying on the “cutting edge” of surgical technology or as a competitive marketing tool) • RATS easier to teach/learn than VATS • US/Asia different from Europe (reimbursement & local competitive dynamics)

  11. CLINICAL DECISION MAKING are seldom single decisions made from fixed choices where one decision can be isolated from others. Rather, decisions are embedded indecision–action cycles where situations evolve and where decisions and actions influence each other Decision making by surgeons during an operation is affected by variables including tactile perception, visual perception, motor skill, and instrument complexity, all of which are changed by robotic surgery

  12. SITUATION AWARENESSimportant component of intra-operative decision making better situation awareness of the surgeon is associated with fewer surgical errors information may be actively sought or perceived without active seeking by remaining observant of what is happening in the OR However, because the surgeon sits at a console away from the patient and the rest of the OR team (not seeing patient or the robot arms directly and with limited access to auditory information) tendency for surgeons to bury themselves in the console (magnified, surgeon-controlled, 3D) Consequently, the surgeon is dependent on the rest of the OR team communicating information that they previously obtained through visual perception intraoperative decision making in robotic surgery needs is more collaborative than open or VATS

  13. RATS NO TACTILE INFORMATION (this considered a limitation of robotic surgery) In open surgery, surgeons work primarily with visual and tactile information. In VATS surgery, tactile information is reduced but, by touching with the instruments, surgeons are still able to determine features such as shape, texture, and consistency The lack of tactile information means that surgeons move more slowly because they have to rely on visual information only However, research suggests that, as experience of robotic surgery increases, surgeons find visual information sufficient for informing their intra-operative decision making

  14. SENSE OF IMMERSION of the surgeon could be a benefit of robotic surgery reduced number of distractions that the surgeon experiences with positive impacts on decision making and subsequent patient outcomes However, it has also been found that equipment and work environment distractions are more frequent in laparoscopic operations than in open operations, due to the more complex technology, suggesting that robotic surgery may also introduce new distractions ? Healey AN et Al. Ergonomics. 2006;49(5-6):589-

  15. THE ERGONOMIC BENEFITS OF ROBOTIC SURGERY Robotic surgery removes the awkward and unnatural movements required during VATS and the surgeon is able to sit down comfortably at the console, potentially reducing physical stress and associated fatigue However results from experimental studies are inconclusive; 2 in favour / 1 where difference was not statistically significant. Stefanidis D SurgicalEndoscopy. 2010;24(2):377-Van DerShatte O SurgicalEndoscopy. 2009;23(6):1365-Berguer R Journal of SurgicalResearch. 2006;134(1):87-

  16. CONCLUSIONS Be aware that many of the proponents of RATS declare relationships with the robotic industries Medical environment different in USA /Asia /Europe VATS still the gold standard and at least equivalent and cheaper BUT… THE ROBOT IS HERE AND IS GOING TO STAY NEW MODELS with new concepts of robotic surgery are coming on the market very soon

  17. THANK YOU FOR YOUR ATTENTION

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