Multiport robotic anatomic lung resections: a dodecalogue for neophytes

Introduction

The multiportal robotic method remains our preferred technique for anatomical lung resections and is the recommended approach for novice robotic thoracic surgeons. Our interest lies not in debates over the number of ports but in the lessons learned from the fervent, sometimes unproductive, discussions about uniportal, biportal, and triportal video-assisted thoracic surgery (VATS) over the past decade. This chapter aims to impart our insights from practicing multiportal robotic thoracic surgery since 2015 and to offer guidance to peers embarking on what we anticipate will become the standard in thoracic surgical care.

Origins and evolution

Initially, multiportal robotic lung resections involve three or four 8–12 mm incisions for the robotic arms and camera, complemented by an additional assistant port. This configuration is recommended by the manufacturer’s Clinical Specialty Guide and was notably influenced by Dr. Daniel Oh from Fullerton, California, USA (1). Typically, robotic ports are placed within the same intercostal space, spaced 6–10 cm apart, ensuring the dorsal port is at least 4 cm from the spinous process. The assistant port (12–15 mm) is positioned two to three intercostal spaces below, either between the foremost robotic port and the subsequent one or between the second and third robotic ports, closer to the spine.

This configuration has evolved from the initial port placement by the pioneer of robot-assisted lung resections, Dr. Melfi (2), which was essentially a robot-assisted video thoracoscopy with a 3-cm “service entrance”. The technical advancements of the da Vinci robotic system (Intuitive Surgical, Sunnyvale, California, USA) have included slimmer robotic arms, improved staplers, and a fully rotating patient cart boom, enhancing the flexibility in port mapping.

Noteworthy are the three-port techniques from Ninan and Dylewski (3), and the “completely portal robotic lobectomy” by Cerfolio (4), which include variations in the number of ports and their placements. Since the advent of the da Vinci Si system, the team from Pisa transitioned to a “totally endoscopic” approach without an assistant port (5). A comprehensive review by Zirafa (6) details this evolution.

Experienced groups have diverged in their multiportal approaches, with variations in the number of robotic arms used, intercostal spaces and the inclusion of an assistant port (7). Nonetheless, the pursuit of excellent oncological outcomes with minimal surgical trauma continues to drive innovation in thoracic surgery. The uniportal approaches first described by Yang (8) and subsequently developed by Gonzalez-Rivas (9) and others, are commendable advancements. However, rather than engaging in polarizing debates, a constructive scientific discourse and the ‘test of time’ should prevail. Quoting Dr. Sihoe (10) “it must still be acknowledged that (uniportal VATS) UVATS is not the huge advance that conventional (multiportal VATS) MVATS was.” This sentiment is echoed in real practice patterns. A 2016 standardized survey among surgeons from the European Society of Thoracic Surgery mailing list revealed that 62% would never perform a lobectomy with uniportal VATS whereas only 17% of surgeons would employ it in 50% or more of their cases (11). Similarly, prospectively collected data from the GEVATS project of the Spanish Society of Thoracic Surgery recording 3,533 consecutive anatomical resections from December 2016 to March 2018 performed in 33 departments, also showed an 8.3% rate of utilization of uniportal VATS, with most minimally invasive surgeries (64.3%) being performed by biportal VATS (12).

The case for multiportal robotic anatomic resections

As proponents of the multiportal approach, after performing over 450 robotic thoracic cases and evolving from the da Vinci S-HD to the current Xi model, we observed significant benefits in autonomy, dexterity, and the use of capnothorax, which are further detailed. This approach seems to be more accessible and reproducible, facilitating the wider adoption of minimally invasive techniques, benefiting a larger patient population.

Surgeon autonomy

Robotic surgery affords the surgeon greater autonomy compared to laparoscopic or thoracoscopic procedures. Instead of relying on an assistant for camera movement and retraction, the surgeon independently controls these aspects, especially with the use of a fourth arm, which I advocate for in all anatomic lung resections. The assistant’s role is thus reduced to tasks such as specimen retrieval, suction and occasional retraction, which may be advantageous in settings with limited personnel. In uniportal procedures, the console surgeon is objectively less autonomous since an experienced assistant is usually always required and must be continuously engaged to manipulate the manual instruments through a limited space.

Use of capnothorax

The employment of warmed and humidified CO₂ insufflation, or capnothorax, is a widespread recommendation for multiport robotic lung resections. It enables a “completely closed” surgical environment, isolated from the OR’s relatively dry and colder atmosphere, until specimen removal. Other potential advantages of using capnothorax will be outlined below. Although technically feasible, even with makeshift devices (Figure 1), the use of capnothorax is not yet common or practical during most uniportal procedures.

Figure 1 JenyA makeshift system to contain CO₂ insufflation during uniportal robotic thoracic surgery using a surgical glove and elastic bands.

Surgeon dexterity

The da Vinci robotic system’s design incorporates several features that enhance the surgeon’s dexterity. This is particularly evident in the EndoWrist™ instruments, which are engineered to emulate the intricate movements of the human wrist and the thumb-index pincer grasp inside the thoracic cavity. Additionally, these instruments have joints that mimic the motion of the human elbow and shoulder, providing three axes of movement along with the ability to move in and out, pivoting around the instrument’s “remote center”. This remote center, marked by a small 1 cm indicator, must be positioned within the intercostal space. Careful placement ensures that the remote center undergoes minimal movement, thereby exerting little force on the intercostal bundle and reducing the risk of injury.

To optimize the function of these instruments, a minimum distance of 6 cm between ports is recommended to minimize the potential for collisions between the robotic arms. The multiportal setup, therefore, seeks to replicate the natural positioning and movement of the human upper limbs when engaging in complex tasks. This is visualized as having the eyes focused on the task area, with the shoulders positioning the arms laterally and anteriorly from the body, while the elbows allow for convergence and the wrists facilitate precise movements (Figure 2).

Figure 2 Arm and hand positions mimicking multiportal (A) and uniportal (B) procedures.

Contrastingly, the uniportal approach compresses the two instruments and the camera—plus any additional assistant instruments—into the confines of a single incision within the same intercostal space. This setup inherently limits the instruments to operate mostly in parallel to each other, except for the most forward joint and when using instrument crossing. There seems to be less freedom for articulation and a higher likelihood of collisions compared to what is available in multiportal robotic surgery.

Despite these limitations, the performance of complex thoracic procedures using the uniportal robotic approach is not only possible but has been successfully executed by pioneers such as Dr. Gonzalez-Rivas (13) and others, proving to be an inspiring achievement.

Yet, it is our belief that the greater accessibility and reproducibility of multiportal thoracic surgery represent one of its most significant advantages. By harnessing the full ergonomic capabilities of the da Vinci system, the multiportal approach facilitates a surgery that is technically less demanding. This opens the door for a broader spectrum of surgeons to perform complex procedures, not just those with exceptional skill. Consequently, it extends the benefits of minimally invasive thoracic surgery to a larger patient population, increasing equality in surgical practice.

The value of multiportal robotic thoracic surgery for anatomic lung resections

Assessing the value of a surgical approach is challenging due to the concept’s inherent complexity, and it is not the intention of this paper to settle that debate. However, it is beneficial to consider the specific value that multiportal robotic thoracic surgery brings to key stakeholders: hospitals or healthcare organizations, surgeons, and patients. This familiar categorization aids in navigating the extensive body of comparative studies on robotic and conventional lung resection techniques.

For hospitals and healthcare systems, despite higher costs associated with robotic surgery compared to VATS, as documented in literature (14) and national databases like Premier Healthcare (15), it is unclear if benefits such as shorter hospital stays and fewer complications might offset these expenses. Nevertheless, variations in these costs can be substantial, influenced by specific hospital contexts and reimbursement structures. Some institutions report (16) maintaining profitability, while others have taken advantage of reduced pricing to align with revenues (17). Notably, preliminary findings from the RAVAL international trial (18) suggested that robotic lobectomy is cost-effective, claiming an incremental cost/quality-adjusted life year that is economically justifiable.

Beyond cost, robotic surgery’s value to healthcare providers includes the potential to attract patients through innovation and marketing. Some studies indicate that adopting robotic technology can significantly increase the volume of lung surgeries by 85% (19). Surgeons at Cedars-Sinai Medical Center, utilizing data from the National Cancer Database between 2010 and 2017, indicated that employing a robotic platform could potentially increase the number of segmentectomies performed for early-stage lung cancer (20).

The value of robotic surgery for surgeons extends beyond the technical advancements of increased dexterity and enhanced visualization. With these procedures, there is a reduced dependency on a skilled assistant at the operating table, which could also translate to cost savings, especially when compared to uniportal robotic techniques. There are informal suggestions that the improved ergonomics and seated posture in robotic surgery might lessen the physical toll on surgeons, potentially extending their careers. While such benefits have been documented in robotic-assisted laparoscopic procedures (21,22), similar research in the context of robotic thoracic surgery is not yet available, to our knowledge.

For patients, introducing new surgical approaches aims to enhance care, yet assessing their value remains complex. Perspective randomized trials comparing robotic and VATS approaches have not shown dramatic differences in hospital stays or postoperative complications, indicating that VATS already sets a high standard. Oncological outcomes, such as overall and disease-free survival, appear to be similar between the methods, as shown by a recent meta-analysis by Tasoudis and colleagues (23). Focusing on randomized studies that utilize the multiportal technique, which is commonly used by publishing authors, data from both the RVlob (24) and RAVAL (18) trials support the finding that the robotic approach results in significantly more lymph nodes being sampled.

In summary, while future research and time will likely determine the precise value of multiportal robotic lung surgery, for many surgeons who begin using this technique, it is often seen as an irreversible step forward in the evolution of their surgical practice.

General principles of OR streamlining

The surgeon bears ultimate responsibility for all activities within the OR and plays a critical role in evaluating and enhancing operating OR efficiency. While the extent of this responsibility and the capacity to effect change can vary across different hospital settings, the surgeon’s leadership is crucial, directing and empowering the rest of the team. The initiation of a robotic program presents an opportune moment to reassess OR operations and implement improvements. Streamlining—an effort to make an organization or system more efficient and effective through faster or simpler working methods, as defined by the Oxford Dictionary—is paramount. Each step should be scrutinized: does it add value to the patient, the team, or the hospital? Can it be simplified or expedited without compromising safety? When new operational standards align with these principles, standardization becomes highly beneficial. It allows the team to devote their attention to the inherent variability of surgical cases and to effective problem-solving.

OR team synergy and communication

Synergy, the combined effect of multiple agents working together that exceeds their individual effects, is essential to streamlining and often relies on effective communication. Key players in the OR—the console surgeon, table surgeon, scrub and circulating nurses, and anesthesiologist—must operate in concert and synergically. This is especially true in robotic surgery, where the surgeon at a closed console may have diminished OR awareness and relies solely on audio communication with the team. Nevertheless, the benefits of a closed console system which provides an immersive environment that fosters concentration outweigh the former disadvantages. Effective communication within the OR team is essential for preempting or addressing problems during surgery. Challenges encountered can range from simple to complex and are often more manageable when identified early. For example, the table team plays a vital role in monitoring and signaling any potential collisions between the robotic arms and the patient, which could impede movement or result in injury. The anesthesiologist’s vigilance in noting hemodynamic instability is another critical element. Such issues can often be resolved by the surgeon adjusting the capnothorax pressure, thereby avoiding the need for pharmacological interventions. Furthermore, proactive measures by the scrub nurse, such as the timely cleaning of an instrument in preparation for a challenging dissection, contribute significantly to the procedure’s smooth progression. It is the seamless communication among these diverse roles that enhances overall safety and efficiency, ensuring the patient receives the best possible care.

Take-off and landing phases

The “take-off” phase, spanning incision to docking after port placement, and the “landing phase”, from specimen bagging to incision closure, are particularly amenable to standardization. Establishing routine procedures reduces errors and enhances safety and efficiency.

The take-off phase: port placement

Preoperative planning should determine the setup of the OR, including the placement of essential equipment. The complexity of connections and the array of devices—such as the warming blanket, suction systems, and CO₂ insufflation—necessitates meticulous organization, especially in constrained spaces. Detailed written diagrams can be invaluable, especially for those unfamiliar with the setup process.

A comprehensive checklist serves not only to reassure the team but also to enlist each member as a steward of safety and efficiency before the incision. Port placement strategies may vary, but a standardized approach within a team is advantageous. For users of the da Vinci Xi system, the “guided configuration” facilitates optimal placement in standard procedures. Surgeons should also remember the option to change the target area and redock during complex cases (e.g., hard to reach apical and phrenic adhesions).

The landing and taxi phase: concluding with care

The “landing phase” is critical. My experience as a proctor has shown that team vigilance often wanes post-specimen release or bagging. A detailed checklist is crucial to maintain focus. While each team should develop their own, certain practices are universally important:

• Checking for hemostasis. Hemostasis must be confirmed under room pressure after CO₂ insufflation is removed. A 5-mmHg pressure bleeder will be impeded by a 6-mmHg CO₂ pressure and may come undetected until the end of surgery, or worse, until arrival at the recovery room. The most vulnerable bleeding point is often the dorsal port due to the anatomy of the intercostal bundle. Also, careful inspection and cauterization are necessary, particularly around known trouble spots such as the bronchial arteries, which may not have been fully occluded, particularly if using 4.6 mm (black) staples.
• Extracting the specimen bag. The auxiliary incision should be methodically enlarged to facilitate bag extraction. Ensuring clear access and visibility for the table surgeon may require repositioning the robotic arms or even removing instruments. A careful plane-by-plane (not en-bloc) section and closure is a good practice to avoid lung herniation and paresthesia, occurrences often discussed informally among surgeons but less frequently documented in literature.
• Checking for air leaks. In our practice, routine checks for air leaks are not conducted in most cases, and we report a notably low incidence of persistent air leak extending beyond five days (less than 5%). Instead, we adopt a tailored approach where the surgeon evaluates the integrity of the remaining lung parenchyma and the precision of the stapling lines, among other factors. Should there be any uncertainty, we would certainly conduct a check under ventilation and saline immersion to implement necessary interventions. Careful attention is required during lung inflation when instruments are placed in the thorax, particularly for lung retraction and leak detection, to avert any lung tears. Such tears might go unnoticed until the chest is closed. As a final safeguard, we measure air leaks using the ventilator or a digital system connected to the chest tube, ensuring all is clear before proceeding with extubation.
• Swabs and gauzes count. Our procedures involve the liberal intraoperative use of swabs and rolled gauzes within the thoracic cavity, balanced by stringent written accounting prior to incision closure. This is essential, particularly in the context of completely “closed” surgeries, and aligns with the protocols set forth in the WHO surgical safety checklist. Although all textiles are embedded with radiopaque threads for detection, additional counts are mandated by the surgeon throughout the procedure to maintain situational awareness of all materials. The inadvertent retention of a swab within the chest cavity is classified as a “never-event” in safety terms; nonetheless, such incidents continue to be reported, albeit underreported, in surgical practice.

Dealing with conversions to VATS or thoracotomy

We classify conversions into two categories: elective and emergent, or catastrophic. The guiding principle for elective conversions is the understanding that “Conversion is not a failure”, but rather a prudent choice made for the patient’s benefit in light of intraoperative findings. We recommend new teams to establish and adhere to a written set of criteria for elective conversion. Current criteria in our team are prolonged console time beyond 4 hours (exceptions being complex cases, defined in advance), insufficient lung deflation [while robotic completion is usually feasible with continuous positive airway pressure (CPAP) or intermittent ventilation], unmanageable lung adhesions to critical structures, and the surgeon’s judgment of exceptional technical challenges or bleeding risks. This latter point requires the surgeon’s humility, prioritizing patient safety over personal pride. Given the surgical team’s awareness of the established criteria and their commitment to effective communication, all essential equipment for conversion should be prepared and accessible at the moment the decision to convert is made.

Emergent conversions should ideally be pre-empted by timely elective conversions but will statistically occur, albeit infrequently. Our emergent conversion rate stands at 0.6%. Cao et al.’s (25) principles of Preparation, Pressure, Poise, and Prolene/Proximal control are indispensable in such scenarios. This is a mainly technical perspective, and we also align with Dr. Baste’s (26) advocacy for non-technical skills training, stressing that rehearsing responses to surgical crises is crucial for effective team action. We, like other authors (27), encourage periodic simulations or “dry-runs” to practice managing emergencies, much like the aviation industry’s reliance on simulations and checklists, which have also proven to enhance crisis management in surgery (28).

Pre-planned protocols for emergent conversion are a must for any surgical team, with specific procedures varying according to the team’s dynamics and the operating environment. In the face of a vascular emergency, quick and stable control of the injury is crucial. Utilizing a fixed robotic instrument holding a rolled-up gauze maintains consistent pressure on a vascular injury, ensuring that the compression remains steady when the console surgeon steps away from the controls. This method allows the assisting surgeon to efficiently prepare for the additional incision without the need to continuously monitor the bleed.

Great caution is required to avoid shifting the patient’s position during this maneuver, as any movement could alter the location of the compressed structure while the instrument remains static. In our practice, where the robotic cart is positioned posteriorly, the most dorsal instrument is typically employed for compression. After establishing compression, the anterior robotic arms can be disengaged and moved back, providing the necessary room to proceed with an anterolateral thoracotomy, our standard approach for emergent situations. Other surgeons, working with different robotic cart configurations and preferring a posterolateral thoracotomy, might choose the most anterior instrument for stable compression (29).

We also advise against the instinct to expand robotic port incisions for emergent thoracotomy, as this can restrict access to the hilum from these lower intercostal spaces. A thoracotomy in the 4th or 5th intercostal space is preferable, offering superior visibility and maneuverability during these high-pressure scenarios.

The dodecalogue for neophytes

In a more practical vein, we have compiled a 12-point list (Table 1) aimed at thoracic surgeons embarking on their robotic journey. These points should not be viewed as “commandments” but rather as a compilation of experience-based, easily remembered advice. If embraced, they could provide a budding surgeon with enhanced confidence while navigating their initial cases. It is our aspiration that, as the domain of robotic thoracic surgery continues to grow, more esteemed colleagues will contribute to, critique, or create their own lists to further enrich our collective knowledge.

The lymph node will be my friend

Lymph nodes are commonly encountered adjacent to vascular and bronchial structures, often at their branching points. Approaching these lymph nodes with care and patience—a “friendly” approach—involves dedicating time to thorough dissection, meticulous sealing of hilar vessels, preservation of the nodal capsule, and careful traction without direct grasping of the node until it is completely ready to be detached. This deliberate method (Videos 1,2) demands more time compared to a quick “pass” under the vessel, yet we believe it pays dividends. It maintains a clean surgical field, which is vital in a procedure guided predominantly by visual cues, virtually eliminates the need for disruptive suction, and ensures a complete, intact lymph node for pathology, minimizing the risk of disseminating tumor cells. Moreover, once the lymph node is excised, the dissection around the vessel is largely complete, ultimately conserving time.

Exceptions to treating lymph nodes as “friends” include certain calcified nodes that may adhere tenaciously to the walls of pulmonary arteries, preventing safe separation. The same holds true for metastatic nodes with extracapsular growth that invade vessels, which must be addressed with strict oncological protocols in mind.

In cases involving patients who have undergone neoadjuvant immunotherapy, lymph nodes may be more challenging to handle (Video 3). However, barring vessel infiltration, an even more meticulous dissection is advisable for effective management based on our experience.

The fissure will not be my enemy

For the less experienced surgeon, partial or entirely incomplete fissures may initially appear formidable; however, the technique of “fissure diving” using bipolar dissectors is remarkably safe in most instances (Video 2). Such devices provide excellent hemostasis for small vessels, and the enhanced visual clarity afforded to the surgeon ensures the trans-fissural veins are controlled and sealed before being disrupted. Patience is essential, allowing for a meticulous and clean dissection deep into the fissure until the vascular, lymphatic, or fatty plane is reached, from where the dissection can safely continue. Based on our experience, except in cases involving severely emphysematous lungs or incorrect dissection trajectories, the incidence of air leaks is typically much lower than one might anticipate with this approach to incomplete fissures. Diligently checking for leaks after lung inflation and addressing them with standard techniques and materials is crucial to prevent what could otherwise result in an unnecessarily prolonged postoperative recovery.

My sequence will be adaptable

Lobectomies can typically be performed using a variety of sequences for bronchovascular occlusion and division. Moreover, the “vein first” concept, proposed to prevent the theoretical spread of cancer cells, has not been substantiated with evidence and should not be rigidly adhered to. Take, for example, a right upper lobectomy; it can be executed from a completely posterior approach (addressing the bronchus, then A2b, A1+2+3, the minor fissure, and finally the upper lobe vein), but also from “above” (A1+2a+3, A2b, bronchus, vein, fissure), from an anterior perspective, or fully through the fissure (A2b, A1+2+3, bronchus, fissure, and vein). This flexibility is applicable to most lobectomies. “My sequence will be adaptable” signifies that the surgeon should leverage the unique anatomical characteristics of each patient to facilitate a smoother and safer dissection, being willing to alter the approach mid-procedure if a particular aspect proves challenging (Video 4).

I will prepare the entrance and exit (around bronchovascular structures)

We regard this as the second most critical principle in our dodecalogue. A robotic surgeon fully relies on visual cues for dissection, at least until haptic feedback technology becomes a standard feature for robotic instruments. Currently, we use these visual cues to gauge tissue response to applied forces, but this method has its limitations, especially with fragile or aged anatomical structures. When it comes to maneuvering dissecting instruments or staplers around bronchovascular structures, taking the time to meticulously clear and dissect both the entrance and exit points of the passage allows for a near “stress-free” and safer handling of these structures thereafter (Video 5). The robotic camera’s magnification and resolution afford the surgeon a clear view beneath and almost behind the vessel, facilitating this task.

The vessels will not surprise me

It is our conviction that the surgeon should be the one to ‘uncover’ the vessel, rather than be caught off-guard by it. The value of three-dimensional reconstructions of pulmonary vessels is increasingly recognized by thoracic surgeons, particularly when planning anatomical segmentectomies. Yet, even for the ostensibly ’simpler’ lobectomies, meticulous preoperative planning is essential. Such planning encompasses forecasting the number and location of lobar arteries, as well as any anatomical variations in both arteries and veins, thereby circumventing unforeseen complications. This forethought not only allows the surgeon to focus on the procedure’s planned steps but also facilitates the handling of initially concealed or atypical vessels from a more advantageous perspective. We consider a preoperative review of a contrast-enhanced computerized tomography scan with 1.5 mm slice reconstructions to be a minimum safety standard.

The capnothorax will be my companion

Carbon dioxide insufflation is an invaluable aid in robotic thoracic surgery. The CO₂ pressure naturally dissects along connective tissue planes within the mediastinum and around bronchovascular pulmonary structures, acting as an ally for the surgeon working to complete a fissure over the arterial plane or performing a lymphadenectomy behind the superior vena cava. Furthermore, CO₂ insufflation expands the operative space within the thoracic cavity, which is especially beneficial when using bulkier instruments like staplers.

The notion that CO₂ helps to ‘deflate’ the lung is, in our view, a perpetuated misconception. For a healthy, non-ventilated lung, simply relieving the pleural negative pressure is typically sufficient to induce collapse. The lungs we encounter in thoracic surgery often exhibit some degree of air trapping due to chronic obstruction in the medium and small airways. From our experience, excessively high CO₂ pressures can exacerbate this air trapping at the onset of the procedure and should be cautiously regulated. In situations where non-ventilated lungs remain partially inflated because of air trapping, patience is required for absorptive atelectasis to occur, leading to a more pliable lung.

Our standard practice is to maintain CO₂ insufflation pressure between 4–10 mmHg, favoring the lower end of this spectrum to mitigate hemodynamic impacts and based on visual indicators such as mediastinal movement or caval venous collapse.

The assistant will assist me

While multiportal robotic surgery indeed enhances the surgeon’s autonomy, a discerning surgeon will judiciously utilize a surgical assistant’s capabilities. In an ideal scenario, the assistant is proactive, anticipating the surgeon’s movements and requirements, readying the appropriate instrument either at the dissection site or outside the surgeon’s field of vision to avert distractions. Routine tasks such as specimen retrieval, suction, and retraction ought to be either standardized or outlined during the preoperative briefing for optimal efficiency and time management. Clear communication and well-established protocols are vital when handling instruments to prevent any critical incidents. In sum, although multiportal surgery may not demand as much from the surgical assistant, thus permitting participation from those with less experience, this should in no way be construed as an allowance for inactivity.

My stapler will be anterior and low

In robotic thoracic surgeries, curved tip 45 mm staplers are preferred for their suitability. These single-patient, 12-fire instruments often suffice for most lobectomies, enhancing cost-efficiency. Despite being shorter than the 60 mm models, their spatial demands are significant; they must be fully inserted into the thoracic cavity, with the rubber-protected articulation extending beyond the trocar’s edge to function correctly. Sureform™ staplers, with their 120-degree cone of movement, offer substantial maneuverability, though they are not as agile as other Endowrist™ instruments. These factors lead us to advise placing the 12-mm stapler port in an ‘anterior and low’ position, potentially in a lower intercostal space when necessary. This approach is especially prudent for patients with smaller or ‘flatter’ chests, where an incorrectly positioned instrument may fail to retract sufficiently to access areas like an anterior basilar artery. Conversely, a stapler placed too high may struggle to flex adequately to engage a vertical, posterior, A2b branch, or go over obstacles like the descending aorta (Video 6). To avoid ‘adventurous’ maneuvers, if a stapler trocar is misplaced, the surgeon might consider converting an 8-mm trocar to a 12-mm one for the stapler, or even partially withdrawing the trocar to create more space. However, rotating the instrument around a misaligned remote center could potentially damage the chest wall, necessitating vigilant monitoring. The safest practice: Position the stapler anteriorly and low.

I will use the “green” when planes are doubtful

Indocyanine green (ICG) is a fluorescent dye used intravascularly that, when administered, rapidly delineates the perfused areas of the lungs. It becomes visible within seconds using the Firefly™ mode of the da Vinci camera system. For a comprehensive review of ICG’s application in robotic surgery, we refer readers to the study by Lee et al. (30). We advocate for the availability of ICG in the robotic OR, as it effectively and swiftly highlights interlobar or intersegmental planes. It does necessitate the prior transection of the arteries and veins supplying the area of interest, though isolating only the afferent arteries can provide a brief window of clear demarcation of segmental or lobar boundaries before retrograde perfusion obscures these limits (Video 7). Additionally, ICG has been instrumental in our practice for mapping the thoracic duct and identifying the phrenic nerve via the phrenic artery. While the maximum daily dosage is 5 mg/kg of body weight, we have found that a dose of 0.2 mg/kg diluted in 20 mL of saline is sufficient and ensures rapid clearance, allowing for potential re-infusion later in the surgery if necessary. The only absolute contraindication to intravenous ICG is a history of a prior allergic reaction after its use. Surgeons should be cautious when using ICG in patients who have a history of allergy to iodides (31) since sodium iodide is a component of the drug solution. This reason also demands caution in patients with hyperthyroidism. Safety during pregnancy has not been established.

I will move the lung to accommodate the instruments

In surgery, optimal exposure is paramount, which is the essence of this straightforward concept. Occasionally, robotic instruments may struggle to dissect or navigate around a bronchovascular structure or find the structure compressed against another. In such cases, instead of attempting a hazardous maneuver, the surgeon should consider moving, retracting, or applying traction to the lung to reposition it more favorably for the instrument’s angle. The availability of a fourth robotic arm, specifically for retraction that can be easily maneuvered and locked into place, not only enhances safety but also improves the efficiency of the surgical procedure.

I will grasp what needs to be grasped

Da Vinci grasping instruments are designed with a fixed maximum force. From the firm grip of the needle-holder to the strong hold of the ProGrasp™, the moderate grip of the Cadiere, and the gentler clasp of the Tip-Up, surgeons must be mindful of the force applied to tissues. Grasping vascularized lung tissue is generally inadvisable; even with the delicate Tip-Up, tissue damage and subsequent bleeding or air leaks in tissue slated for preservation are probable, potentially requiring repair. Many surgeons, including we, advocate for using instruments to grasp swabs or rolled gauze (‘cigars’) to reposition lung parenchyma using friction—this distributes pressure evenly and minimizes tissue damage. What, then, should be grasped? It depends on the surgeon’s discretion, but typical examples include devascularized lymph nodes, surrounding connective tissue, bronchi, and even pulmonary arteries with caution (expecting some adventitial hematoma). Particularly effective is firmly holding the distal bronchial stump post-stapling (Video 8), a maneuver that greatly aids in separating any adhering vessels from the hilum and allows for suspension of the lobe or segment, facilitating subsequent dissection or fissure completion.

I will bag in the bagging zone

Many steps of multiportal robotic thoracic surgery are amenable to standardization as frequently proposed by Cerfolio (32), and specimen bagging is no exception. The “bagging zone” for us refers to the anterior costophrenic recess on the right side and the anterolateral costophrenic recess on the left. The capnothorax-induced diaphragmatic inversion creates enough space for bagging even large specimens. The retrieval bag should be unfurled in this area, avoiding contact with the pericardium and chest wall, while the specimen is maneuvered over the zone with the aid of an opposing instrument (Video 9). With the bag positioned below, the grasping instrument guides the specimen downward as the assistant secures the bag. This instrument also ensures the entire lobe or segment is enclosed within the bag before sealing. Using an anterior instrument to ‘assist’ during this phase is unnecessary and can be counterproductive, as its shaft may collide with the bag’s rigid side, displacing it and risking the specimen’s egress. Most crucially, this “bagging zone” ensures all manipulations are conducted away from the sensitive bronchovascular stumps, creating a “safe space” for the procedure.

Conclusions

The swift expansion of robotic techniques in thoracic surgery across healthcare systems worldwide reflects a trend that transcends geographic and economic boundaries. The debate over whether robotic thoracic surgery represents a revolution or an evolution from the well-established VATS methodologies continues. With each new surgical innovation, practitioners are refining their techniques, optimizing the use of advanced equipment, and engaging in vigorous debates on the optimal number of ports, instruments, and the necessity of auxiliary incisions.

Most current literature originates from practitioners of multiportal robotic surgery; however, expanding expertise and the advent of novel robotic platforms may soon diversify perspectives in the field. The outcome of forthcoming randomized clinical trials is anticipated to clarify the actual value of robotic surgery in thoracic interventions, yet the momentum of its adoption seems poised to continue unabated.

Drawing from our substantial practice in multiportal robotic lung surgery, we have endeavored to equip new entrants to the field with foundational, practical advice encapsulated in a ‘dodecalogue’. It is our aspiration that these points will be beneficial, not just to novices but also to seasoned surgeons. Given the dynamic nature of thoracic surgery, where definitive truths are elusive, we champion the thriving exchange of scientific dialogue—through case studies, trials, and technical advice—that enriches our entire specialty.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editor (Gregor J. Kocher) for the series “Robotic Thoracic Surgery: Established Procedures & Current Trends” published in Journal of Visualized Surgery. The article has undergone external peer review.

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-23-46/prf

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-23-46/coif). The series “Robotic Thoracic Surgery: Established Procedures & Current Trends” was commissioned by the editorial office without any funding or sponsorship. F.J.M. is a proctor for Abex Excelencia Robótica SL. The author has no other conflicts of interest to declare.

Ethical Statement: The author is 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 Helsinki Declaration (as revised in 2013). Publication of this article and accompanying images and videos was waived from patient consent according to the ethics committee or institutional review board.

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