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Review
. 2023 Aug 30;11(10):362.
doi: 10.21037/atm-22-1866. Epub 2022 Jun 24.

Uniportal pure robotic-assisted thoracic surgery-technical aspects, tips and tricks

Diego Gonzalez-Rivas #  1   2 , Veronica Manolache #  2   3 , Mugurel Liviu Bosinceanu  2 , Javier Gallego-Poveda  4 , Alejandro Garcia-Perez  1 , Mercedes de la Torre  1 , Akif Turna  5 , Natalia Motas #  2   3   6
Affiliations
Review

Uniportal pure robotic-assisted thoracic surgery-technical aspects, tips and tricks

Diego Gonzalez-Rivas et al. Ann Transl Med. .

Abstract

The uniportal access for robotic thoracic surgery presents itself as a natural evolution of minimally invasive thoracic surgery (MITS). It was developed by surgeons who pioneered the uniportal video-assisted thoracic surgery (U-VATS) in all its aspects following the same principles of a single incision by using robotic technology. The robotic surgery was initially started as a hybrid procedure with the use of thoracoscopic staplers by the assistant. However, due to the evolution of robotic modern platforms, the staplers can be nowadays controlled by the main surgeon from the console. The pure uniportal robotic-assisted thoracic surgery (U-RATS) is defined as the robotic thoracic surgery performed through a single intercostal (ic) incision, without rib spreading, using the robotic camera, robotic dissecting instruments and robotic staplers. There are presented the advantages, difficulties, the general aspects and specific considerations for U-RATS. For safety reasons, the authors recommend the transition from multiportal-RATS through biportal-RATS to U-RATS. The use of robotic dissection and staplers through a single incision and the rapid undocking with easy emergent conversion when needed (either to U-VATS or to thoracotomy) are safety advantages over multi-port RATS that cannot be overlooked, offering great comfort to the surgeon and quick and smooth recovery to the patient.

Keywords: Robotic-assisted thoracic surgery (RATS); minimally invasive thoracic surgery (MITS); robotic lobectomy; single port RATS; uniportal RATS (U-RATS).

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Conflict of interest statement

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://atm.amegroups.com/article/view/10.21037/atm-22-1866/coif). The series “Lung Cancer Management—The Next Decade” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Figures

Figure 1
Figure 1
Set up and port placement of Davinci Xi® through a single incision—schematic drawing (A) and intraoperatory aspect (B).
Figure 2
Figure 2
Set up and port placement of Davinci Xi® by using 2 ports—schematic drawing of the robotic arms and room setting (A) and intraoperatory aspect (B).
Video 1
Video 1
Port placement and docking on the left side.
Video 2
Video 2
Set up of robotic arms and coordination with the assistant during the U-RATS procedure. U-RATS, uniportal robotic-assisted thoracic surgery.
Figure 3
Figure 3
Drawing showing arm placement on the right side (A) and on the left side (B).
Figure 4
Figure 4
Laser location for targeting.
Video 3
Video 3
U-RATS right upper lobectomy. U-RATS, uniportal robotic-assisted thoracic surgery.
Figure 5
Figure 5
Dissection of RUL vein during upper lobectomy. RUL, right upper lobe.
Figure 6
Figure 6
Division of truncus anterior with robotic staplers during upper lobectomy.
Figure 7
Figure 7
Hilar lymph node dissection.
Figure 8
Figure 8
Surgical image of paratracheal space after a radical paratracheal lymph node dissection.
Figure 9
Figure 9
Right subcarinal lymph node dissection.
Figure 10
Figure 10
Stapler insertion for inferior vein during right lower lobectomy.
Figure 11
Figure 11
Stapling the posterior part of the oblique fissure during right lower lobectomy.
Figure 12
Figure 12
Subcarinal lymph node dissection during right lower lobectomy.
Video 4
Video 4
U-RATS middle lobectomy. U-RATS, uniportal robotic-assisted thoracic surgery.
Figure 13
Figure 13
Dissection of vein during middle lobectomy.
Figure 14
Figure 14
Dissection of bronchus during middle lobectomy.
Figure 15
Figure 15
Division of middle lobe artery with robotic staplers.
Figure 16
Figure 16
Dissection of apico-anterior trunk during left upper lobectomy.
Figure 17
Figure 17
Dissection of left upper lobe bronchus.
Figure 18
Figure 18
Left subcarinal lymph node dissection.
Video 5
Video 5
U-RATS left lower lobectomy. U-RATS, uniportal robotic-assisted thoracic surgery.
Figure 19
Figure 19
Stapler insertion for division of fissure during left lower lobectomy.
Figure 20
Figure 20
Dissection of basal artery during lower lobectomy.
Figure 21
Figure 21
Division of inferior vein with robotic stapler.
Video 6
Video 6
U-RATS right lower sleeve lobectomy. U-RATS, uniportal robotic-assisted thoracic surgery.
Figure 22
Figure 22
Bronchial anastomosis during left upper double sleeve lobectomy.
Video 7
Video 7
U-RATS left anatomic segmentectomy S8. U-RATS, uniportal robotic-assisted thoracic surgery.
Figure 23
Figure 23
Segmentectomy steps facilitated by robotic tools. (A) Placement of stapler for intersegmental division after anatomic segmentectomy S8. (B) Dissection of A9 during anatomic segmentectomy S9–10.
Figure 24
Figure 24
Drawing showing the help of the assistant with the long-curved suction during anatomic segmentectomy. LUL, left upper lobe; LLL, left lower lobe.
Figure 25
Figure 25
Dissection of main pulmonary artery with the use of a long curved “Tip-up” instrument.
Figure 26
Figure 26
Division of left main pulmonary artery with the robotic stapler.
See this image and copyright information in PMC

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