Uniportal Robotic-Assisted Thoracoscopic Surgery: Left S6 Segmentectomy

This video shows a case of a robotic assisted thoracoscopic surgery (RATS) performed with the DaVinci Xi system through a uniportal approach. An eighty-two-year-old woman with BMI 29 and a history of systemic arterial hypertension, non-insulin dependent type II diabetes mellitus, and ischemic cardiac disease (ASA physical status III) underwent a superior segmentectomy (S6) of the left lower lobe for NSCLC at a clinical stage IA2. Preoperative contrast enhanced chest CT revealed a mixed density ground glass nodule in the superior segment of the left lower lobe measuring 17 x 12 mm that increased in size over a two-month follow-up period. Positron emission tomography-computed tomography (PET-CT) confirmed the lesion with a mild FDG uptake (max SUV=1.9) without identifying hilar or mediastinal lymphadenopathies. Preoperative lung function was normal: the forced expiratory volume in one second (FEV1) and diffusing capacity for carbon monoxide (DLCO) were 126 percent and 97.4 percent, respectively. After intubation, the patient was placed in the lateral decubitus position. A single 4 cm long anterolateral mini-thoracotomy (ALMT) in the sixth intercostal space at the mid-axillary line was performed and an Alexis soft tissue retractor was positioned. The laser was placed in the upper, posterior part of the incision for targeting. Next, three 8 mm robotic trocars were positioned and connected, from back to front, to robotic arms as follows: 30° camera arm, robotic arm two, robotic arm one. The posterior disposition of the camera allowed the other two robotic instruments to work in parallel. In addition, to avoid collision, it was necessary to cancel arm one on the right side (arm two for camera) and arm four on the left side (arm three for camera). Assistant access was identified as the most anterior part of the AMLT. As the right hand, arm one had Maryland bipolar forceps. Arm two acted as the left hand and had a bipolar fenestrated grasper. Next, staplers, clips, and suction were introduced via the uniport by a bedside assistant. Exposure was obtained without collision by mobilizing the lobe through the robotic fenestrated bipolar grasper, facilitated by the use of one long curved suction by the assistant. Operative time was 175 minutes. The postoperative course was characterized by an air leak complication resolved by postoperative day three (POD 3), allowing chest drain removal on POD 4. Finally, the patient was discharged on POD 5, and definitive pathology showed a lepidic predominant adenocarcinoma (pT1bN0, stage IA2) with a resection status of R0. Conclusions Though experiences described in literature have been very limited so far, uniportal RATS may be considered a safe, reliable, and efficient method for the treatment of early stage lung cancer, representing a valid alternative to video assisted thoracoscopic surgery or multiportal RATS in the field of pulmonary minimally invasive surgery. Reference(s) 1. 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 2. Gonzalez-Rivas D, Bosinceanu M, Motas N, Manolache V. Uniportal Robotic-Assisted Thoracic Surgery for Lung Resections. Eur J Cardiothorac Surg. 2022;8:ezac410. doi:10.1093/ejcts/ezac410/6661347