Robotic open-thoracotomy-view approach using vertical port placement and confronting monitor setting

Abstract

Objectives: Robotic lung resections (RLRs) are conventionally performed using look-up views of the thorax from the caudal side. To conduct RLR with views similar to those in open thoracotomy, we adopted a vertical port placement and confronting upside-down monitor setting, which we called robotic 'open-thoracotomy-view approach'. We herein present our experience of this procedure.

Methods: We retrospectively reviewed 58 patients who underwent RLR (43 with lobectomy; 15 with segmentectomy) with 3-arm open-thoracotomy-view approach using the da Vinci Surgical System between February 2019 and October 2020. The patient cart was rolled in from the left cranial side of the patient regardless of the side to be operated on. Robotic ports were vertically placed along the axillary line, and 2 confronting monitors and 2 assistants were positioned on each side of the patient. The right-side monitor, which was set up for the left-side assistant to view, projected the upside-down image of the console surgeon's view.

Results: All procedures were safely performed. The median duration of surgery and console operation was 215 and 164 min, respectively. Emergency conversion into thoracotomy and severe morbidities did not occur, and the median postoperative hospitalization duration was 3 days. In all procedures, the console surgeon and 2 assistants had direct 'bird-eye' views of the cranially located intrathoracic structures and instrument tips, which are sometimes undetectable with the conventional look-up view.

Conclusions: The open-thoracotomy-view approach setting is a possible option for RLR. It offers natural thoracotomy views and can circumvent some of the known limitations of the conventional procedure.

Keywords: Confronting monitors; Open-thoracotomy-view approach; Robotic lung resection; Vertical port placement.

Figure 1:

Two assistants and the confronting monitor setting. The patient’s head is at the far side of the operating room in this photograph. Assistant A stands on the right side of the patient and has the same view as the console surgeon, whereas assistant B stands on the left side of the patient and views the upside-down monitor. The dorsal or ventral side indicated on the monitors shows the dorsal side of the thorax during the right-lung surgery or ventral side of the thorax during the left-lung surgery.

Figure 2:

Vertical port placements for right-side (A) and left-side (B) surgeries. The lines and numbers drawn on the patient’s body indicate the location of the ribs, and the circles indicate the incision size and the intercostal space where each port is placed. Arrows show the roll-in direction of the patient cart. These figures show the settings for the upper lobes. For middle and lower lobes, the port locations are caudally moved, as described in the text. ICS: intercostal space.

Figure 3:

Views of the surgeon console during lung resections. The left and right sides of all the images are the cranial and caudal sides of the intrathorax, respectively. The images are of different patients. (A) Resection of the superior pulmonary vein during right upper lobectomy. (B) Dissection of the pulmonary artery in an interlobar part during left upper lobectomy. (C) Segmental boundaries between right S6 and basal segments fluorescently enhanced in Firefly after intravenous indocyanine green injection. AZ: azygos vein; LLL: left lower lobe; LUL: left upper lobe; RML: right middle lobe; RUL: right upper lobe; SVC: superior vena cava.

Figure 4:

Lymph node (LN) dissections. (A) Right upper mediastinal zone. The brachiocephalic artery (BCA) was identified in the front. (B) Left upper mediastinal zone. The LNs around the left recurrent laryngeal nerve were dissected. (C) Completion of the subcarinal zone dissection following left lower lobectomy. The left main bronchus (LMB) and the contralateral right main bronchus (RMB) as well as the contralateral right vagus nerve were confirmed. AZ: azygos vein; BCA: brachiocephalic artery; LMB: left main bronchus; LN: lymph node; RMB: right main bronchus; SVC: superior vena cava.