Uniportal RATS Left Upper Trisegmentectomy (S1-S3) with DaVinci Xi: Initial Experience

Robotic-assisted thoracic surgery (RATS) is rapidly expanding, and new challenges should be continuously proposed regarding this technology. In effect, the community should further seek to understand both its strengths and limits, and consequently, offer better treatment to patients.

Patient and Procedure

This was the case of a uniportal robotic-assisted thoracic surgery (RATS) left upper trisegmentectomy (S1-S3) with the DaVinci Xi system. The patient was a sixty-nine-year-old asymptomatic woman with lung adenocarcinoma of the left upper lobe at stage cT1bN0M0 (TNM eighth edition). A preoperative diagnosis was made on the percutaneous CT-guided fine needle aspiration biopsy. Previous relevant history of the patient included right colon adenocarcinoma (chemotherapy and surgery), diabetes mellitus, systemic arterial hypertension, active smoking, and adrenal adenoma. The tumor diameter was < 2 cm. Positron emission tomography-computed tomography (PET-CT) did not identify hilar or mediastinal lymphadenopathy. A 5 cm anterolateral mini-thoracotomy (ALMT) in the sixth intercostal space at the midaxillary line was performed. A soft tissue retractor (Alexis) was positioned. Three 8 mm robotic trocars were positioned and connected, from back to front, to robotic arms as follows: 30° camera arm, robotic arm 2, robotic arm 1. Assistant access was identified as the most anterior part of the same incision. After segmental artery stapling, intravenous indocyanine green (0.25 mg/kg bolus at a concentration of 2.5 mg/ml, followed by a 10 ml of saline solution flush) was injected intravenously for intersegmental plane identification. The postoperative course was characterized by an air leak complication until postoperative day five (POD 5). The chest drain was removed on POD 7 after twenty-four hours of drain clamping. Finally, the patient was discharged on PO Day 8. The pathological stage was pT1bN0, and the resection status was R0. On subsequent controls, no chronic neuropathic pain or other complications were recorded.

Conclusion

To date, few uniportal lung RATS experiences have been published in the literature (1–3). The choice of experimental uniportal RATS came from the participants’ previous understanding and use of uniportal VATS. In their experience, uniportal RATS with the DaVinci Xi was feasible. However, arm conflicts must be considered and could result in adverse intraoperative events from involuntary movements of instruments. The authors of this article believe that in this kind of procedure, an experienced VATS assistant is mandatory to manage complex intraoperative steps. Even in cases where it is feasible, uniportal RATS with this robotic platform should be open for debate.

References

1. Dunning J, Waterhouse B, Burdett C. Uniportal robotic thoracic surgery—a surgeon's initial impressions. June 2022. doi:10.25373/ctsnet.20113151
2. Yang Y, Song L, Huang J, Cheng X, Luo Q. A uniportal right upper lobectomy by three-arm robotic-assisted thoracoscopic surgery using the da Vinci (Xi) Surgical System in the treatment of early-stage lung cancer. Transl Lung Cancer Res. 2021;10(3):1571-1575. doi:10.21037/tlcr-21-207
3. Gonzalez-Rivas D, Ismail M. Subxiphoid or subcostal uniportal robotic-assisted surgery: early experimental experience. J Thorac Dis. 2019;11(1):231-239. doi:10.21037/jtd.2018.12.94

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