Complex uniportal robotic-assisted sleeve resections under spontaneous ventilation and with double lumen intubation: a case series and a narrative review of the literature

Abstract

Background and objective: Sleeve lobectomy (SL) has evolved into the preferred surgical option for centrally located non-small cell lung cancer (NSCLC) and other complex thoracic tumors, offering superior functional and oncological outcomes compared to pneumonectomy. The recent advent of robotic-assisted thoracic surgery (RATS), including its uniportal approach (uRATS), has extended the feasibility of SL to minimally invasive approaches. The objective of this study is to present our experience with uRATS sleeve resections, highlighting five complex cases, involving four sleeve lobectomies and one tracheal resection, performed using two different robotic platforms (da Vinci and ShuRui). Additionally, we aim to provide an up-to-date review of SL as a treatment strategy for NSCLC and centrally located tumors.

Methods: We performed a narrative review covering publications from 2010 to 2025. The search was conducted across PubMed, EMBASE, and Scopus databases.

Key content and findings: Although data on RATS SL remains limited, several publications have highlighted the potential benefits of this approach. Comparative studies evaluating different operative approaches for SL have shown that RATS offers advantages over both open and video-assisted thoracic surgery. uRATS SL represents a novel and evolving technique that combines technical precision with favorable perioperative outcomes. However, its adoption is often slow due to the inherent complexity and steep learning curve associated with the procedure.

Conclusions: uRATS SL carinal and tracheal reconstructions have emerged as promising treatment strategies for centrally located tumors. However, there remains an urgent need for further comparative studies assessing both short- and long-term outcomes, as well as evaluating oncologic outcomes and their impact on patients' quality of life.

Keywords: Robotic surgery; minimally invasive thoracic surgery; non-small cell lung cancer (NSCLC); sleeve lobectomy (SL); uniportal robotic-assisted thoracic surgery (uRATS).

Figure 1

Configuration of the ShuRui robotic platform for uniportal robotic surgery (permission provided by medical illustrator Alejandro Garcia).

Figure 2

Uniportal RATS incision and arm with ShuRui system. RATS, robotic-assisted thoracic surgery.

Figure 3

Intraoperative images for uRATS bronchial anastomosis following right upper lobe sleeve. (A,B) Intraoperative bronchial anastomosis; (C) schematic representation of uRATS bronchial anastomosis with the ShuRui system (permission provided by medical illustrator Alejandro Garcia). uRATS, uniportal robotic-assisted thoracic surgery.

Figure 4

Intraoperative image of a uRATS vascular anastomosis with the ShuRui system. uRATS, uniportal robotic-assisted thoracic surgery.

Figure 5

Preoperative, intraoperative, and postoperative images for a patient with a centrally located tumor involving the left lower lobe, fissure, and lingula. (A) Preoperative CT of a left lower lobe tumor extending into the fissure and lingula; (B) postoperative CT following resection and anastomosis; (C,D) intraoperative image for a uRATS bronchial reconstruction and anastomosis on the da Vinci Xi platform. CT, computed tomography; uRATS, uniportal robotic-assisted thoracic surgery.

Figure 6

Preoperative and intraoperative representative images of a centrally located tracheal tumor resected through uRATS. (A,B) Tracheal anastomosis utilizing the da Vinci X platform; (C,D) CT imaging of the tracheal tumor. CT, computed tomography; uRATS, uniportal robotic-assisted thoracic surgery.

Figure 7

Robotic configuration and intraoperative findings for a left main bronchus tumor resected through uRATS with the da Vinci X platform. (A) Arm angulation for uRATS access; (B) uRATS setup demonstrating assistant access for suction introduction; (C) resection of the endobronchial tumor; (D) bronchial anastomosis. uRATS, uniportal robotic-assisted thoracic surgery.