Uniportal fully robotic-assisted major pulmonary resections

Abstract

Robotic-assisted thoracoscopic surgery (RATS) has proven advantages over that of conventional thoracic surgery, primarily by offering a three-dimensional view and excellent maneuverability, and by providing great ergonomic comfort to the surgeon. The instrumentation specifically offers seven degrees of freedom, allowing for safe, yet complex dissections and radical lymphadenectomies. However, the robotic platform was initially designed with four robotic arms in mind, and therefore four to five incisions were needed for most thoracic approaches. The uniportal video-assisted thoracoscopic surgery (UVATS) approach, the philosophical predecessor to the uniportal robotic-assisted thoracoscopic surgery (URATS) approach, evolved very quickly with the help of the latest technologies during the last decade. Since the first cases of UVATS in 2010, we have improved upon the technique, such that we are now able to do increasingly more complex cases. This is due to the acquired experience, specifically designed instruments, better high-definition cameras and more angulated staplers. In our efforts to improve and adapt robotic surgery to the uniportal approach, we utilized the initial available platforms (Davinci Si and X) to test the feasibility of this approach, in terms of safety and possibilities. The latest platform, the Da Vinci Xi, due to the configuration of its arms, did indeed allow for us to reduce the number of incisions to two initially and finally to one. We hence decided to fully adapt the Da Vinci Xi ® to allow for the URATS approach routinely, and performed the first fully robotic anatomic resections in the world in September 2021, in Coruña, Spain. We define pure or fully robotic URATS as robotic thoracic surgery performed by a single intercostal incision, without rib spreading, using the robotic camera, robotic dissecting instruments and robotic staplers.

The perioperative outcomes of uniportal robotic-assisted thoracic surgeries—a systematic review and meta-analysis of surgical cohort studies and case reports

“…Another key point of criticism is whether the uniportal RATS approach, and even the multiportal RATS approach, can confer a significant benefit over that of the uniportal VATS approach when procedures are completed in expert hands. Comparative head-to-head studies examining multiportal RATS vs. u-RATS are soon to have their results published, which will assist with differentiating between these modalities and their outcomes (8,20,21). Whilst the studies included in this meta-analysis have variations of procedures-and pathology to a lesser extent-the overarching aim of the present paper was to illustrate that irrespective of the specific procedure being completed, operations can be conducted safely, quickly, and with very high rates of technical success.…”

“…Most centers specializing in u-RATS procedures have now also established efficient and standardized procedural steps to facilitate rapid arm docking, transition between instruments, and ultimately a faster dissection/resection time-though notably, an experienced surgical assistant is required as they will usually be responsible for approximately half of the operation (i.e., being by the bedside, docking/ undocking, generating the utility incision, etc.) (21). A clear recommendation across the included studies is that the baseline level of operator experience has to therefore be high with uniportal VATS prior to making the transition across to biportal and uniportal RATS, as the learning curve is likely to be significantly steeper (24), and all parties must be ready in the instance of an emergency to convert.…”

Uniportal fully robotic-assisted bronchovascular sleeve bilobectomy

“…There are many questions to be asked before choosing the optimal surgical approach and offering the best possible treatment to our patients. In our experience, URATS with the DaVinci Xi is feasible even for complex surgical procedures, but extensive experience with both uniportal video-assisted thoracic surgery (VATS) and robotic surgery is an important requirement (1). Advanced procedures, such as the bronchial sleeve resection and even vascular sleeve resections performed by minimally invasive techniques are constantly reported in the literature (2).…”

“…The camera was placed on arm 2 and was maintained on the posterior side of the incision. Arms 3 and 4 were placed in the center and most anterior part of the incision respectively (1). We used 8 mm trocars for camera and robotic instruments and a 12 mm trocar when robotic staplers were inserted.…”

The transition to uniportal robotic surgery in the second decade of uniportal surgery

“…Diego Gonzalez-Rivas, the creator of uniportal VATS, by necessity after COVID had to spend more time in Spain but used this time to investigate the possibilities of robotic surgery (2). He paired up with a cardiac robotic surgeon to watch and understand the benefits of robotic surgery, but the fact remained that these advantages had to be counterbalanced by the fact that five incisions were required compared to a single incision in uniportal VATS (3).…”