Uniportal fully robotic-assisted major pulmonary resections

Abstract

Robotic-assisted thoracoscopic surgery (RATS) has proven advantages over that of conventional thoracic surgery, primarily by offering a three-dimensional view and excellent maneuverability, and by providing great ergonomic comfort to the surgeon. The instrumentation specifically offers seven degrees of freedom, allowing for safe, yet complex dissections and radical lymphadenectomies. However, the robotic platform was initially designed with four robotic arms in mind, and therefore four to five incisions were needed for most thoracic approaches. The uniportal video-assisted thoracoscopic surgery (UVATS) approach, the philosophical predecessor to the uniportal robotic-assisted thoracoscopic surgery (URATS) approach, evolved very quickly with the help of the latest technologies during the last decade. Since the first cases of UVATS in 2010, we have improved upon the technique, such that we are now able to do increasingly more complex cases. This is due to the acquired experience, specifically designed instruments, better high-definition cameras and more angulated staplers. In our efforts to improve and adapt robotic surgery to the uniportal approach, we utilized the initial available platforms (Davinci Si and X) to test the feasibility of this approach, in terms of safety and possibilities. The latest platform, the Da Vinci Xi, due to the configuration of its arms, did indeed allow for us to reduce the number of incisions to two initially and finally to one. We hence decided to fully adapt the Da Vinci Xi^® to allow for the URATS approach routinely, and performed the first fully robotic anatomic resections in the world in September 2021, in Coruña, Spain. We define pure or fully robotic URATS as robotic thoracic surgery performed by a single intercostal incision, without rib spreading, using the robotic camera, robotic dissecting instruments and robotic staplers.

Keywords: URATS; URATS lobectomy; Uniportal RATS; robotic lobectomy; single port RATS.

Figure 1

Illustration showing the port placement and set up of robotic arms on the right side and left side. Right side: arm 1 cancelled, arm 2 for camera, arm 3 for left hand and arm 4 for right hand; left side: arm 4 cancelled, arm 3 for camera, arm 1 for left hand and arm 2 for right hand.

Figure 2

Use of robotic clip applicator with right hand of the surgeon, inserting a polymer clip on a segmental vein (V3b) during a right upper anatomic segmentectomy S3. The bipolar fenestrated on the left hand helps with lateral retraction of the segment S3.

Figure 3

Illustration showing the paratracheal lymphadenectomy. SVC, superior vena cava.

Figure 4

Illustration showing the stapler insertion dividing the superior pulmonary vein. The bipolar fenestrated, in the left hand of the surgeon, is keeping traction with a vessel loop on the vein to facilitate stapler insertion.

Figure 5

Illustration showing dissection of the right upper bronchus with a long tip up dissector.

Figure 6

Illustration showing dissection of the posterior ascending artery with the bipolar Maryland dissector.

Figure 7

Illustration showing the stapler insertion, from the right hand of the surgeon, dividing the fissure as the last step of the right upper lobectomy (fissureless technique). SVC, superior vena cava.

Figure 8

Illustration showing the dissection of lingular artery on the fissure with Maryland bipolar (right hand of surgeon) and the bipolar fenestrated to provide a vessel loop for traction (left hand of the surgeon).

Figure 9

Illustration showing the stapler placement to divide the anterior part of the fissure, from the right hand of the surgeon. The bipolar fenestrated instrument, on the left hand of the surgeon, keeps lateral retraction of the lingula to facilitate the stapler insertion.

Figure 10

Illustration showing the dissection of the superior pulmonary vein with the Maryland bipolar. The bipolar fenestrated, in the left hand of the surgeon, is keeping traction with a vessel loop on the vein to facilitate stapler insertion.

Figure 11

Illustration showing the stapler placement dividing the left upper lobe bronchus, inserted from the right hand of the surgeon. The bipolar fenestrated, in the left hand of the surgeon, is keeping lateral traction of the upper lobe to facilitate stapler insertion.

Figure 12

Illustration showing the anastomosis during a right lower sleeve lobectomy (middle lobe bronchus reimplantation to bronchus intermedius). In the left hand, a bipolar fenestrated is used to grab the edge of the bronchus and on the right hand a needle holder with needle is used to perform the running anastomosis with double 25 cm barbed suture.