Patients Selection
Some simple thoracic surgery has been clearly indicated for day surgery, such as sympathetic nerve chain block, small and benign mediastinal tumor resection, pulmonary bulla ligation, and wedge resection of the lung. These operations can be completed using thoracoscopic surgery rather than a robot. Researchers have explicit the VATS value for day surgery in those diseases(Zhang et al., 2022 , Dong et al., 2021).
From 12, 2020 to 8, 2022, a total of 86 patients underwent Robotic assisted thoracic day-surgery in this time period. In the same time, we randomly choose 86 patients that underwent conventional robotic assisted thoracic surgery in the same period.
Surgery approach
Thoracic surgery with an estimated operation time of <3 h has the potential to perform Robotic assisted thoracic day-surgery (RATDS). These operations are mainly those with low risk, short operation time, little impact on physical function and fewer postoperative complications. Lobectomy or simple segmental resection (RS1, RS2, RS6, LS1+2, LS1+2+3, LS4+5 and LS6 ) can be performed using robot system in the day surgery ward. Other surgery suitable for perform RATDS includes bullaeectomy, thoracic duct ligation, pericardial cyst resection and esophageal leiomyoma resection. Since systemic lymph node dissection will affect the length of hospital stay, RATDS only performed among patients requiring lymph node sampling.
Pre-Administration and preparation
Preparation for admission lasts two weeks, including pre-admission examination, physical excise, and pre-admission nutrition management. Exercise cardiopulmonary function test, PET-CT, chest CT, and lung nodules 3D reconstruction are routine examinations before admission. We recommend exercises that fit daily activities for preoperative cardiopulmonary exercises. Propaganda and education are realized through the Internet Hospital network platform. We recommended 30 minutes of moderate intensity exercise every day (exercise heart rate greater than 120bpm), such as stairs climbing and jogging. Since the patients with pulmonary nodules were found by routine physical examination, the general condition of the patients was relative well, which do not require additional nutritional supplements.
Intraoperative Management
The execution of surgical operations in day wards places higher demands on the surgeon and requires proficiency in robotic operations. Long-term lung air leakage can cause delay in extubation. It is necessary to prevent air leakage during the operation as much as possible. The main methods include avoiding lung traction during operation, the use of cutting closure devices, and avoiding lung tissue burning. Minimize postoperative drainage including, reduce sudden separation, use of ultrasonic scalpel, and avoid invalid surgical operations. The anatomy of the pulmonary artery and vein does not require much exposure while ensuring the clipping and the safety of the operation. Indocyanine green was used to determine the intersegment plane during the operation. The robot operation uses 3 surgical arms and uses a small 2cm incision as an auxiliary incision for instrument introduction and specimen removal.
Anesthesia and pain management
The anesthesiologist participated in the pre-surgery evaluation the day before the operation. Anesthesia is routinely performed by double-lumen intubation. There are three methods for postoperative pain, intravenous non-steroidal analgesics, intercostal nerve block, patient controlled analgesi (PCA) and subcutaneous fentanyl patch. We carried out multimodal analgesia mode: self-controlled analgesia pump combined with oral medication. And minimize the use of opioids. The postoperative pain evaluation of patients used visual analogue scale (VAS).
Post-operative drain management
All patients in day-surgery mode used 16F urinary tube while the patients of conventional mode used 28F drainage tube for drainage. In day surgery patients, the drainage volume is less than 100ml for 24 hours after surgery, so the drainage volume is not our main indication of extubation. The patients in this group were rechecked on the chest radiograph 8 hours after the operation. And patients in conventional group were rechecked on the chest radiograph 24 hours after the operation. If the lung recruitment is good and the patient coughs without large-scale water column fluctuations in the chest drainage bottle, the tube can be extubated. The entire day-surgery group of surgical patients does not need to insert a urinary tube but the patients of conventional group need to insert a urinary tube.
Postoperative rehabilitation training
Postoperative rehabilitation training is mainly carried out by the rehabilitation department. It is mainly composed of the following aspects: 1. Life guidance, including guidance on patients' diet and sleep; 2. Breathing exercise training: including breathing training exercises, aerobic training, respiratory muscle training and fatigue testing; 3. Postoperative cardiopulmonary function assessment.
Discharge standard
The discharge criteria are mainly completed through symptom assessment and imaging examination. On the second day after surgery, the patient can get out of bed and exercise autonomously, and the 6-minute walk test is greater than 300 meters. There were no hemothoraxes, pneumothorax, and atelectasis on chest radiograph.
Histopathological Examination
All specimens were formalin fixed, paraffin-embedded, and stained with hematoxylin and eosin. And the pathological classification were evaluated by at least 3 experienced pathologist and graded according to the World Health Organization classification for NSCLC.
Follow-up management
Taken by discharged patients. Follow-up management relies on the network and telephone mode; the network mode mainly uses the Internet hospital platform to evaluate the postoperative imaging data of patients in lower-level hospitals through the network hospital mode. If the patient has serious complications such as high fever and severe chest tightness, he can be transferred to the medical consortium unit of our hospital, and the attending physician of our department will have a network remote consultation to guide the treatment.
Statistical Analysis
Stastistical analyses were performed using the SPSS25.0. Non-parametric tests were used for comparisons, and data were expressed as median(standard deviation). The significance threshold was p< 0.05.