Surgical technique, details and tricks of full robot-assisted uniportal left upper lung lobectomy

Introduction

Background

In the last two decades, thoracic surgery has undergone rapid development with the introduction of minimally invasive techniques [video-assisted thoracoscopic surgery (VATS)] and their evolution thanks to the implementation of available instruments and surgeons’ improved knowledge of videothoracoscopic anatomy. The most commonly used VATS techniques are the multiport technique, in which three or more surgical approaches are used (1), and the uniportal technique [uniportal VATS (uVATS)] developed in 2010 (2) in which all instruments are inserted through a single surgical incision. Since the first robot-assisted lung resection was performed by Melfi in Italy in 2002 (3), robotic-assisted thoracoscopic surgery (RATS) has become established worldwide with a multiport approach.

Rationale

The advantages of robot-assisted surgery lie in the stability of the camera, which also enables a three-dimensional (3D) view, the elimination of tremors during movement; seven degrees of movement provided by the joints of the robotic arms, which allow great manoeuvrability, as well as in the possibility of ensuring extensive lymph node dissection even in difficult-to-access positions. One disadvantage of robotic technology is the high cost of the robotic platform, which still limits its widespread use and the lack of tactile feedback which is compensated for by an improved hand-to-eye coordination. The most common robotic approach, with the DaVinci Si, X and Xi system, is the multi-port, as described firstly by Melfi and modified by Cerfolio (3,4). The multiport approach could have the theoretical disadvantage of an increased intercostal injury due to the increased number of incisions from three to five and an associated increased risk of thoracic pain and discomfort. Recently, a systematic review and meta-analysis comparing uVATS and multiport VATS (mVATS) corroborated the less invasiveness of the uniportal approach because it showed lower pain values at 24 and 48 hours and less opioid consumption in the post-operative period (5). Over time, the RATS techniques have proven to be effective for both surgical and oncological major lung resections including anatomical segmental resections, complex sleeve resections and after neoadjuvant treatment. The most recent evolution of the RATS technique is the uniportal RATS (uRATS) technique, developed by Gonzalez-Rivas in 2021 (6) with an intercostal access similar to the uVATS technique applying the DaVinci platform with modified trocars in this single access made at the 7^th intercostal space. Unfortunately, the uRATS approach has not gained popularity due to the low availability of platforms and also due to the lack of surgeon who master multiport RATS (mRATS) and uVATS. Our technique is different because the working intercostal space is higher (6^th or 5^th) in which three conventional trocars work in parallel.

Objective

In this article we present the surgical technique for uRATS resections used in Thoracic Surgery Unit, Careggi University Hospital, explaining the procedure details and technical aspects of a left upper lobectomy and presenting advantages and disadvantages encountered as well as tips and tricks derived from our experience. In particular, the different access to the chest at the 6^th intercostal space, the parallel use of wristed instruments and the systematic application of robotic staplers to the hilar structures. We present this article in accordance with the SUPER reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-71/rc).

Preoperative preparations and requirements

At Thoracic Surgery Unit, Careggi University Hospital, all patients underwent conventional pre-operative examinations (6), including cardiological assessment and pulmonary function tests (PFTs), contrast enhanced thoracic and abdominal computed tomography (CT) scan, brain CT scan and positron emission tomography-CT (PET-CT) scan.

Robotic surgery has proven its safety from a surgical and oncological point of view in academic and high-volume centers also for extended resections with complex bronchovascular reconstructions. However, we excluded patients with hilar tumor, locally advanced non-small cell lung cancer (NSCLC) with hilar or mediastinal involvement requiring sleeve resection and patients with perivascular calcification due to the high probability of frozen hilum. In this case, we selected a male patient with a peripheral solid mass, with high fluorodeoxyglucose avidity at the pre-operative PET-CT-scan and then highly suspicious for malignancy. The procedure of uRATS left upper lobectomy was scheduled electively in an academic center with a multidisciplinary operative theathre. The leading surgeon has a great experience in uVATS (over 100 procedures per year) and he performed several multiport lung resection (over 50 in the last two years), thymectomies (over 150) and diaphragmatic plication. The bed assistant has great experience in uVATS lung resection and in mastery the robot platform. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article, the accompanying images, and the video. A copy of the written consent is available for review by the editorial office of this journal.

Step-by-step description

Patient position and incision

The patient was placed in a full lateral appropriate decubitus and under general anaesthesia and appropriate one-lung ventilation (OLV). A utility incision approximately 4–6 cm long was made in the mid-axillary line just anteriorly to the latissimus dorsi at the 5^th (for right upper lobes) or 6^th intercostal space (all other procedures) with the placement of a wound retractor (Alexis S—Applied Medical).

Robot platform placement

The Xi DaVinci robotic platform was introduced from the patient’s back using three robot arms out of the four available, as previously described by Gonzalez-Rivas et al. (6). We placed the camera in the posterior part of the incision and, in order to avoid collisions, the other two arms were inserted one in the middle and the last one in the anterior edge of the incision, working in parallel (Figure 1). In this phase is crucial to manually allocate or re-allocate the controls in the console setting ensuring the right setting of all robotic arms (Figure 2). Moreover, the robotic trocars could be placed in the incision or some centimetres above (fly-mode). With this approach the automatic position (aiming) of the robot is not necessary and then the docking process can be completed in 5–10 minutes.

Figure 1 Placement of the robotic trocars into the single access (A: intraoperative image; B: schematic view).

Figure 2 Setting of the controllers for right and left side.

Instruments

Usually, lung resections could be completed with three or four instruments and in particular we used the Maryland bipolar forceps on the right arm to identify and dissect all the structures; on the left hand we preferred the Cadiere forceps or the Fenestrated bipolar forceps for retracting and exposing the structures. During the dissection of large vessels, such as the inferior pulmonary artery or upper lobe vein, we used the tip-up forceps as it is smooth and long enough allowing a safe dissection of these vessels (Figure 3).

Figure 3 Use of the tip-up forceps for dissection of the upper lobe bronchus.

When the vessels or bronchi are identified and dissected, we used the robotic stapler SureForm 45 mm to close these structures with appropriate cartridge colour and stitch length (white for vessels, green for bronchi) (Figure 4). Furthermore, the SureForm stapler is also used for parenchymal dissection and division between the interlobar fissures or intersegmental planes during segmentectomy with blue or black cartridge (Figure 5). No other instruments are necessary to complete a standard lobectomy or segmentectomy.

Figure 4 Use of the SureForm 45 mm stapler with white reload for the left upper pulmonary vein.

Figure 5 Use of the SureForm 45 mm stapler with black reload for the division between upper and lower lobe.

Thoracoscopic instruments

In the uniportal robot-assisted resection the assistant plays an important role retracting, exposing and cleaning the operative field with some standard thoracoscopic instruments: we suggest the use of D’Amico forceps (or snake) and sucker that are the must-have instruments allowing a perfect operative filed exposure (Figure 6).

Figure 6 Adequate exposure of the lingular vessels thanks to the coordination with the assistant who retracts the left upper lobe caudally.

Step-by-step left upper lobectomy (Video 1)

After docking, the lung is posteriorly retracted by the robotic instruments and by the assistant and the first step is to open the mediastinal pleura laterally to the phrenic nerve exposing the left main pulmonary artery. Then a distal dissection is started and the first two artery branches are dissected and divided using the SureForm stapler with white load. Removing the lymph node on the pulmonary artery at this level facilitates the dissection of the upper vein that should be rounded by a surgical loop for more anterior traction of the vein. Before firing, we suggest identification of the lower lobe vein dissecting the pulmonary ligament to be sure of the separate origin of the veins. Then the robotic stapler with white load can be effectively placed on the vein and fired. The next step is the identification of the left upper bronchus and this step started with the removal of interlobar lymph nodes at the division between upper and lower bronchi. Next we prefer to dissect the bronchus with the tip-up forceps and rounding it with a surgical loop in order to push away the bronchus from the pulmonary artery. The curved tip of the SureForm stapler and the possibility of perfect downward traction by the left hand, allowed a safe dissection and firing of the left upper bronchus without any damage on the fragile pulmonary artery. Then following the pulmonary artery, every branch must be dissected and fired: usually A2 is a small branch on the posterior portion of the artery and should be divided with clips or stapler and finally one or two lingular branches are identified and fired with stapler. The last step is the fissure splitting that is performed with staplers (black reload) reducing the risk of alveolar leak in the post-operative period.

After removal of the specimen, the robot was re-docked and a systematic lymph node dissection is performed (mediastinal lymph node station 5, 7, 9, and 8; hilar station 10L and 11L) and at the end a 24 F chest tube was placed at the apex of the left chest and the single incision is closed in a traditional layer-to-layer manner. The whole surgical procedure was completed in 210 minutes of which 176 minutes of console activity. The estimated blood loss was 32 mL.

Postoperative considerations and tasks

After surgery the patient is extubated in the operative theatre and conducted in the general ward or intensive care unit as appropriate. Independently from the setting, the institutional enhance recovery after surgery (ERAS) program is applied to every patient ensuring an early and faster recover (7). In this case the chest tube was removed in post-operative day 3, the patient was then discharged home without need of any opioid drug in post-operative course.

In the last 6 months, we performed n=16 uRATS lung resection (10 lobectomies, five segmentectomies and one wedge) for NSCLC: all procedures were completed with the uniportal approach except for a compromised patient scheduled for pure uRATS anatomical right S6 was immediately converted to thoracotomic wedge because he was not able to maintain the OLV and also for the presence of a highly incomplete interlobar fissure. No 30-day and 90-day mortality, no readmission were observed in this population; in n=5 (31.3%) patients we had the development of at least of one complication and the majority of these complications were classified as minor with Clavien-Dindo grade of 2; the patient operated on thoracotomy developed pulmonary embolism and consequent respiratory failure, but he completely recovered in 10 days. The Table 1 resumes all the surgical, post-operative, patological results of the uRATS resection performed in the last 6 months.

Tips and pearls

First of all the right patient selection is crucial for starting a new and complex technique such as the uRATS anatomic lung resection and we suggest starting with lower lobectomies and then right upper lobectomy in young patients without any sign of hilar adenopathy or calcifications. Although robotic instruments are wristed, robotic arms can constitute an obstacle itself and then a continue repositioning of all instruments is frequently required and sometimes the use of a single instrument (stapler) could be necessary for a safe and effective dissection. In case of struggling or conflicts, it is basilar to clearly identify the collision, then replace the instruments in the right place and order and often to move all the instruments together because they effectively work in parallel. Due to this issue, we suggest performing the incision just anteriorly to the latissimus dorsi edge at the sixth intercostal space in contrast with previously published by Gonzalez-Rivas who suggest the use of 7^th intercostal space (6). In our practice the sixth intercostal space works properly, and we did not find the problems highlighted by Gonzalez-Rivas regarding the closeness of the robotic instruments to the pulmonary hilum (6). In our opinion, the incision at the 6^th is effective also in case of conversion because in this way the access to the pulmonary hilum is not complicated by the extreme distance from the 7^th intercostal space to the hilum.

This approach has the great advantage, in comparison with uVATS, of the presence of two grab instruments useful for an easy dissection of vessels and lymph nodes and another great point of strength is that the Xi platform is armed with an remote controlled robotic stapling system. The passage under vessels is smooth, easy and completely safe also thanks to the 3D view proper of the platform. Moreover, the function of the robotic stapler is helped by the SmartFire technology which compress the structures depending on the different thickness of the bronchus or lung parenchyma. In our experience, this system is particular effective because, after the introduction of robotic staplers, we did not observe any prolonged air leak nor bronchial fistula.

Discussion

Surgical highlights

This approach has the great advantage of reducing the number of surgical accesses, which traditionally involves the creation of 3 to 5 incisions for the robotic arms plus a possible access for the assistant working from the operating table, at the discretion of the surgical team. The choice of the intercostal space for surgical access also allows the robotic stapler to be inserted from a lower point than the uVATS technique to facilitate resection of the broncho-vascular structures.

Strengths and limitations

The uRATS technique has already proven to be safe for major lung resections, whether they are lobectomies, anatomical segmentectomies for simple segments (culmen, lingulae, apical segment of the lower lobe, basal pyramid of the lower lobe) or complex (involving the creation of multiple intersegmental planes) as well as sleeve resections and carinal resections. However, these procedures have been published only by the group of Gonzalez-Rivas, reducing the reproducibility and standardization of the technique.

The major limit lies in the learning curve, whIch first requires full mastery of minimally invasive video-assisted techniques (VATS and uVATS) and then classical robotic techniques (multiportal RATS) by the first surgeon. For example, the first surgeon of this case report performed over 100 uniportal major lung resection per year (from 2021 to the present), he completed over 50 robot assisted thymectomies and 40 multiport lung resection in the last 24 months. Moreover, the bed assistant surgeon has a crucial and decisive role in retracting and exposing the structures and then he/she should have an adequate experience in VATS and also a great experience in the management of the robotic platform almost in resolving the frequent arm conflicts. However, the cost of robotic surgery and the availability of the platfomrs must always be taken into account, as they still limit the capillary spread almost in low volume centers.

Comparison with other surgical techniques and researches

Compared to classical robotic technique, we find here a lower surgical invasiveness linked to the creation of a single surgical access. All the advantages of robotic technology are preserved (3D vision with high-resolution cameras, stability of the instruments with elimination of any tremor) as well as the possibility of an active assistant to clean the surgical field and use thoracoscopic instruments. The fully robotic technique also involves the use of robotic staplers that are used directly by the first operator from the console and have all the advantages of the SmartFire system (8).

Compared with the uVATS, instead, the vision is 3D and the presence of two grab instruments allows easier detection, isolation and sectioning of structures be either vascular, bronchial or lymph nodes.

Considering the recent development of the uRATS technique and limited spread around the surgical community, few papers compared the post-operative results of the uRATS and mRATS (9-11). In particular the first multicenter study (9) showed similar post-operative and oncological results between the two techniques demonstrating the feasibility and safety of the uRATS approach. Others reported lower complications rate for uRATS resection after propensity matched analysis (10) and also a reduced analgesic requirement intraoperatively and in the first post-operative period (11). Although these data seem encouraging, the uRATS technique is still less widespread among the surgical community and then robust, multicenter and prospective data are no available and evidences are still weak.

This is an off-label use of the Intuitive Robotic System and we are aware that all surgeons using this approach do it under their own responsibility. Our opinions and experiences about this technique do not represent the views of intuitive surgical, which is still evaluating this technique for safety and efficacy.

Anyway, we hope that our data, although small and preliminary, could play a role in approving, developing and spreading this approach.

Conclusions

Since its introduction, uRATS has proven to be safe and adequate for oncologic lung resection ensuring all the advantages of robotic surgery (3D vision, seven degrees of motion, tremor filtering, SmartFire system for the staplers) as well as the least invasive surgical approach together with the assistant working from the table with thoracoscopic instruments. Surgeons need to be familiar with uVATS techniques as well as multi-portal RATS before switching to uRATS. Careful patient selection is crucial, especially in the early stages of the learning curve with this new technique. Particular attention must be paid to the presence of calcific lesions, nodal involvement in locally advanced tumours and central lesions requiring complex sleeve resections.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-71/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-71/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-71/coif). S.B. serves as an unpaid editorial board member of AME Surgical Journal from December 2024 to December 2026. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for publication of this article, the accompanying images, and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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