Subcostal uniportal robotic anatomic lung resection: A pilot trial

Abstract

Objective: Robot-assisted thoracoscopic surgery typically necessitates the use of multiple ports. The new single-port robotic system (da Vinci SP system) platform is designed to perform uniportal surgery. The purpose of this clinical trial is to evaluate the feasibility, efficacy, and safety of the da Vinci SP system when used for anatomical lung resection.

Methods: Patients diagnosed with clinical stage I lung cancer requiring anatomical lung resections were considered eligible for this trial. The primary outcome measure was the rate of conversion, whereas the secondary objective focused on assessing the incidence of perioperative complications.

Results: The study included 35 patients with a median age of 63 years (range, 48-74 years). Of these, 30 underwent lobectomy and 5 received segmentectomy. All surgeries were successfully performed using a subcostal approach, except for 1 patient, who required a thoracotomy conversion due to bleeding (conversion rate: 2.9%). The median docking time was 2 minutes (range, 1-8 minutes). For the 34 patients who completed uniportal surgery, the median total operating time was 194 minutes (range, 63-405 minutes), whereas the console time was 153 minutes (range, 93-267 minutes). The median number of harvested nodes was 13 (range, 5-37), while the median number of nodal stations was 6 (rang, 4-8). There were no in-hospital fatalities, and the median postoperative stay was 3 days (range, 2-12 days).

Conclusions: This study demonstrates the feasibility and safety of using the da Vinci SP system for anatomical lung resection through a subcostal approach.

Clinicaltrialsgov identifier: NCT05535712.

Keywords: lobectomy; lung cancer; robot-assisted thoracic surgery; segmentectomy; single-port.

Graphical abstract

Single-port robotic procedure applied in left lingual pulmonary vein dissection and stapling.

Figure 1

The patient was placed in a lateral decubitus position, with the table tilted at a 10° leg-down angle. An observation port was strategically positioned at the juncture of the fourth intercostal space (ICS) and the anterior axillary line. A 4-cm subcostal port was made to accommodate a Large SP Access Port, which was positioned at the intersection of the subcostal arch and the midclavicular line.

Figure 2

The creation of the subcostal incision is depicted in (A), where the initial step involves an incision through the subcutaneous tissue and oblique muscles until the transverse abdominis layer is reached. Subsequently, a tunnel is formed beneath the costal cartilage and above the diaphragm to access the pleural space. To prevent complications, the cut edge of the diaphragmatic parietal pleura is carefully sutured to the transverse abdominis fascia using 2-0 PROLENE (B).

Figure 3

URAT procedure for dissecting the mediastinal lymph nodes during a left-sided surgery. A, An instrument configuration diagram; B, external view of the instrument arm. C, Internal view. The camera was positioned at the upper quadrate of the entry guide of the SP access port kit. For dissection, the Maryland bipolar forceps (arm #1) and the monopolar curved scissors (arm #3) were used, located on both sides. In addition, the Cadiere forceps was employed to create a surgical field by applying downward traction on the left upper lobe. URAT, Uniportal robot-assisted thoracic surgery.

Figure 4

URAT procedure applied in vessel dissection and stapling during a left upper lobe lingualectomy. A, 3-dimensional reconstruction image of the targeted vessel, with the lingual branch of the left upper pulmonary vein highlighted with a white asterisk. B, Internal view where the lingual branch of the left pulmonary vein was meticulously encircled using a vessel loop and pulled back by a fenestrated bipolar forceps (arm #3). Simultaneously, arm #2 retracted the left lower lobe, creating a clear surgical field. A careful dissection was executed with Maryland bipolar forceps (arm #1), ensuring ample space for a vascular staple's introduction. Finally, an endovascular stapling device, which was handheld, was introduced through the subcostal incision via the assistant port of the da Vinci SP Access Port Kit (C). URAT, Uniportal robot-assisted thoracic surgery.

Figure 5

Graphical abstract demonstrates that utilizing the da Vinci SP system for anatomical lung resection is not only safe and feasible, but also exhibits an acceptable conversion rate and promising perioperative outcomes. LN, Lymph node.

Figure E1

Stages of procedural time. A, Skin incision; B, docking initiation; C, docking completion; D, off console; E, skin closure; F, surgery (OP) finished. This video offers a detailed, step-by-step walkthrough of a da Vinci SP lung surgical procedure, specifically a left anterior basal segmentectomy. The surgery commenced with the application of general anesthesia and intubation using a double-lumen endotracheal tube, with the patient subsequently positioned in a lateral decubitus position. A 10-mm observation port was initially established at the meeting point of the fourth intercostal space and the anterior axillary line and connected to a CO₂ insufflator using a hand-made glove balloon. Subsequently, a 4-cm skin incision was made at the convergence of the subcostal arch and the midclavicular line. The subcutaneous tissue and oblique muscles were dissected until the transverse abdominis fascia was exposed. Access to the pleural space was achieved through tunneling with a finger blunt dissection and electrocauterization beneath the costal cartilage and above the diaphragm, guided by thoracoscopy. To assist the insertion of a uniportal access device, the incised edge of the diaphragmatic parietal pleura was preemptively sutured to the transverse abdominis fascia. After the uniportal access device was inserted and connected to an insufflator, pressure was set at 8 mm Hg, facilitating the docking of a Large SP Access Port to the da Vinci SP patient-side cart arm. The procedure then progressed with the dissection of the inferior pulmonary ligament and posterior mediastinum. At this juncture, mediastinal lymph nodes were carefully harvested. As the surgery proceeded, the interlobar fissure was meticulously dissected. The anterior basal segmental pulmonary artery was gently separated and encircled with a vessel loop. Following this, a handheld endovascular stapling instrument was introduced, enabling the division of the vessel. After the vascular dissection, the anterior basal segmental bronchus was systematically dissected and divided. The intersegmental border was identified using the inflation-deflation method and subsequently divided using a mechanical staple. Upon the successful conclusion of the procedure, a 28-Fr curved chest tube was inserted.