Consensus map for robotic right lower lobectomy—essential components for artificial intelligence and education applications
Introduction
Since the first robotic lung lobectomy was reported in 2001, robotic-assisted thoracic surgery (RATS) for lung cancer has been increasingly adopted in the United States (1) with safe and excellent outcomes (2-4). However, some of the challenges with its wider use include a steep learning curve, requiring advanced technical skills and an increased cognitive load to perform (5). For this reason, standardized processes such as cognitive task analysis (CTA) have been used to generate consensus on the essential components of minimally invasive thoracic operations—limited to video-assisted thoracoscopic surgery (VATS)—to facilitate training and determine the steps that are most suitable for simulation training (6-8).
The purpose of this study was to utilize CTA to develop a consensus on the important steps of a multi-port robotic right lower lobectomy as well as the patient-specific and surgeon-specific factors critical to the operation. Building consensus in the operative phases and steps provides the basis for the annotation of video data that can be utilized to generate and train artificial intelligence-based algorithms that have the potential to augment decision-making, improve safety, and expand teaching. The right lower lobe was chosen for this study as it is considered one of the straightforward resections with less defined anatomic variations, making it suitable as a first target for consensus.
Patients and methods
Participants
The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Mass General Brigham (No. 2020P002613) and individual consent was waived. Seven board-certified expert thoracic robotic surgeons (>200 robotic lobectomies) from four academic institutions were recruited. A sample size of seven was selected based on recommendations from the RAND/UCLA Appropriateness Method User’s Manual (9) and our anticipated complexity and desired level of depth for our research aims. Data saturation was monitored continuously throughout the interviews to ensure it was met by this sample size.
Procedural interview
A semi-structured interview (Appendix 1) was conducted to elicit the patient and surgeon factors considered critical while performing a robotic right lower lobectomy as well as the specific operative steps with similar methods previously described (10). We chose to inductively develop the concept maps with interviews to introduce less bias as it is more grounded in the surgeon’s responses rather than an author’s a priori assumptions.
Procedural map conversion
Each transcribed interview was analyzed to generate procedural maps for each participant. Key steps were extracted from interview transcripts by two independent analysts (C.L.C. and L.L.T.) and outlined in a visual procedural map using CmapTool v6.04 (IHMC, Pensacola, FL, USA).
Survey
To gather more insights about the surgeon’s decision-making and overall goals, each surgeon participated in an online survey that consisted of a series of questions rating the importance of each one of the steps/factors using a 9-point Likert scale, as well as their background and expertise as surgeons.
Consensus procedural map
To form a consensus procedural map, each operative step from an individual were pooled and ranked using the 9-point Likert scale. Consensus was established if at least five out of the seven (71.4%) surgeons rated the step as important, and this cut-off was comparable to prior work on VATS lobectomy (6-8).
Results
Seven board-certified thoracic surgeons from four academic institutions completed the study. They have performed a mean of 557 [standard deviation (SD): 315, range, 200–1,000] robotic lobectomies, including a mean of 154 (SD: 96, range, 40–300) robotic right lower lobectomies, and have a mean of 17 years (SD: 8, range, 5–28) years of experience as faculty surgeons, including a mean of 14 (SD: 7, range, 4–22) years of performing robotic surgeries and a mean of 11 (SD: 5, range, 4–21) years of experience performing robotic lobectomies.
Completion of the interviews led to the identification of 32 unique operative steps, 14 unique patient factors, and 13 unique surgeon factors (Tables 1,2). Initial procedural maps were created for each surgeon and discussed for their approval.
Table 1
| Phase | Step | Mentioned in interview‡ | Rated as important in survey§ |
|---|---|---|---|
| Phase A | Bronchoscopy | 3 (42.9) | 4 (57.1) |
| Patient positioning† | 7 (100.0) | 7 (100.0) | |
| Port positioning (5 ports)† | 7 (100.0) | 7 (100.0) | |
| Docking robot† | 5 (71.4) | 5 (71.4) | |
| Survey chest† | 4 (57.1) | 6 (85.7) | |
| Adhesiolysis† | 3 (42.9) | 6 (85.7) | |
| Phase B | Elevate the RLL† | 3 (42.9) | 6 (85.7) |
| Incise inferior pulmonary ligament† | 7 (100.0) | 7 (100.0) | |
| Harvest level 8 and 9 LNs† | 3 (42.9) | 7 (100.0) | |
| Phase C | Expose superior aspect of inferior pulmonary vein† | 5 (71.4) | 7 (100.0) |
| Dissect subcarinal LN space† | 5 (71.4) | 7 (100.0) | |
| Phase D | Dissect along bronchus intermedius† | 5 (71.4) | 6 (85.7) |
| Expose sump node (level 11) and remove† | 3 (42.9) | 7 (100.0) | |
| Phase E | If incomplete fissure, create tunnel to posterior hilum from PA in fissure† | 4 (57.1) | 5 (71.4) |
| If incomplete fissure, staple fire to divide posterior hilum† | 3 (42.9) | 5 (71.4) | |
| If incomplete fissure, divide anterior fissure† | 5 (71.4) | 5 (71.4) | |
| Assess for anomalous arterial supply† | 2 (28.6) | 6 (85.7) | |
| Phase F | Identify interlobar PA in fissure, circumferentially dissect† | 7 (100.0) | 6 (85.7) |
| Assess for posterior ascending branch† | 1 (14.3) | 6 (85.7) | |
| Identify middle lobe PA, preserve† | 1 (14.3) | 7 (100.0) | |
| Divide superior segmental and basilar PA† | 6 (85.7) | 7 (100.0) | |
| Identify and confirm origin of middle lobe vein, preserve† | 1 (14.3) | 6 (85.7) | |
| Phase G | Retract RLL cephalad and dissect IPV† | 7 (100.0) | 7 (100.0) |
| Phase H | Retract RLL anteriorly and identify RML bronchus, preserve† | 4 (57.1) | 6 (85.7) |
| Apply stapler across lower lobe bronchus† | 5 (71.4) | 7 (100.0) | |
| Test inflate middle lobe | 3 (42.9) | 1 (14.3) | |
| Divide lower lobe bronchus† | 7 (100.0) | 7 (100.0) | |
| Phase I | Remove specimen† | 1 (14.3) | 7 (100.0) |
| Phase J | Dissect additional nodes (e.g., 4R, 10, peribronchial) LNs† | 6 (85.7) | 6 (85.7) |
| Phase K | Paravertebral blocks | 2 (28.6) | 3 (42.9) |
| Test bronchial stump under water | 1 (14.3) | 1 (14.3) | |
| Posterior chest tube† | 5 (71.4) | 6 (85.7) |
Data are presented as n (%). †, consensus achieved; ‡, the number of surgeons that mentioned these aspects in their initial interviews; §, the number of surgeons that rated these aspects as important, strongly important, or extremely important in the survey. IPV, inferior pulmonary vein; LNs, lymph nodes; PA, pulmonary artery; RLL, right lower lobe; RML, right middle lobe.
Table 2
| Type of aspect | Description | Mentioned in interview‡ | Rated as important in survey§ |
|---|---|---|---|
| Patient factors | Patient age | 2 (28.6) | 3 (42.9) |
| Body habitus | 4 (57.1) | 1 (14.3) | |
| Prior VATS/thoracic surgery | 2 (28.6) | 3 (42.9) | |
| ECOG or Zubrod score | 2 (28.6) | 4 (57.1) | |
| Size of tumor | 5 (71.4) | 4 (57.1) | |
| Location of tumor (central vs. peripheral)† | 2 (28.6) | 5 (71.4) | |
| Checking if tumor crosses fissure† | 1 (14.3) | 5 (71.4) | |
| Lymphadenopathy (calcified, enlarged)† | 4 (57.1) | 6 (85.7) | |
| Vascular involvement (PA involvement)† | 4 (57.1) | 7 (100.0) | |
| Completeness of fissure | 2 (28.6) | 0 (0) | |
| Pulmonary function | 4 (57.1) | 4 (57.1) | |
| Local invasion of tumor (chest wall, hilum)† | 2 (28.6) | 6 (85.7) | |
| Neoadjuvant chemoradiation† | 3 (42.9) | 5 (71.4) | |
| Preoperative imaging† | 1 (14.3) | 5 (71.4) | |
| Surgeon factors | Anatomy knowledge† | 4 (57.1) | 7 (100.0) |
| Manipulation/retraction of lung causing air leak† | 3 (42.9) | 6 (85.7) | |
| Delicacy of dissection along PA† | 3 (42.9) | 7 (100.0) | |
| Narrowing of the middle lobe bronchus† | NA | 7 (100.0) | |
| Experience† | 7 (100.0) | 6 (85.7) | |
| Threshold to convert to open† | 4 (57.1) | 5 (71.4) | |
| Efficiency with instrumentation† | 7 (100.0) | 7 (100.0) | |
| Change order (i.e., challenging cases, divide inferior to superior, divide artery first)† | 7 (100.0) | 7 (100.0) | |
| Failure to progress† | 2 (28.6) | 6 (85.7) | |
| Intuitive robot on fine (for every 3 mm movement, instrument moves 1 mm) | 1 (14.3) | 2 (28.6) | |
| Extent of lymphadenectomy | 1 (14.3) | 4 (57.1) | |
| Recognizing concerning areas† | 3 (42.9) | 6 (85.7) | |
| Tissue handling† | 1 (14.3) | 6 (85.7) |
Data are presented as n (%). †, consensus achieved; ‡, the number of surgeons that mentioned these aspects in their initial interviews; §, the number of surgeons that rated these aspects as important, strongly important, or extremely important in the survey. ECOG, Eastern Cooperative Oncology Group; NA, not applicable; PA, pulmonary artery; VATS, video-assisted thoracoscopic surgery.
We identified 28 operative steps (87.5%) (Table 1), 7 patient factors (50.0%) (Table 2), and 11 surgeon factors (84.6%) (Table 2) that met the criteria for achieving consensus status as an important step or factor in robotic right lower lobe lobectomy. The final procedural map with 11 phases and 32 steps (Figure 1).
Discussion
In this study, we performed a CTA that elucidated the important steps of a robotic right lower lobectomy as well as the patient-specific and surgeon-specific factors that are taken into consideration during the operation. We were able to form a procedural map with high consensus on the important steps performed in a robotic right lower lobectomy.
The factors that reached consensus highlight the considerations that trainees should emphasize in their learning. However, there were several operative steps that did not reach consensus. Bronchoscopy is sometimes done to provide real-time visualization of the airways to assist in identifying the precise location of the tumor, but it may not provide much value to peripheral tumors or those without an endobronchial component (4). Test inflating the middle lobe may obscure the view and many felt was not necessary if excellent visualization of the bronchial anatomy is achieved during dissection. With regards to paravertebral blocks, there may be other pain relief methods utilized as part of multidisciplinary approaches. Finally, testing the bronchial stump underwater may not be routine due to the magnified visualization of the bronchial stump with the robot.
There are several limitations to this study. First, we surveyed only seven surgeons from four different institutions. Second, our convenience sample was based on high-volume robotic surgeons from academic institutions, which may not be generalizable to other practice settings. Third, the surgeons did not discuss their ratings with each other, which may have limited our insights into the reason why some factors/steps were not rated as highly, and why some surgeons choose to adopt different approaches. Fourth, while comprehensive, our procedure map is not fully exhaustive to the granular details of the operation. Lastly, these steps do not account for complications that may arise.
To summarize, we developed a procedural map of robotic right lower lobectomy with a high rate of consensus on the essential operative steps based on interviews with expert robotic thoracic surgeons using a CTA framework. We also identified a number of patient and surgeon factors considered by expert thoracic surgeons that impact their operative decision-making for this procedure. Moving forward, this study permits the development of targeted training and curricula on robotic right lower lobectomy, which would be helpful in the education and training of trainees and in developing metrics of competence. Such interventions require a consensus to develop and train algorithms and have multiple downstream implications with regard to safety, efficacy, and training.
Acknowledgments
None.
Footnote
Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-118/prf
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-118/coif). C.F.J.Y. reports he is on the advisory boards for Genentech and AstraZeneca and received honorarium from AstraZeneca for speaking. L.S. receives reports consulting fees from Intuitive Surgical and Medtronic. She received honoraria for speaking engagements from AstraZeneca and is on the advisory board for Intuitive Surgical. The other authors have no conflicts of interest to declare.
Ethical Statement: The authors are 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. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Mass General Brigham (No. 2020P002613) and individual consent was waived.
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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