Robotic-assisted left lower-lobe pulmonary lobectomy: Eleven steps

Abstract

Central MessageThe technique described herein is an effective and reproducible approach to robotic-assisted left lower lobectomy for lung cancer, which can be extrapolated to other robotic pulmonary operations.See Commentaries on pages 480 and 481.Feature Editor's Introduction—In the following Video Atlas Article, you will find some of the clearest and most comprehensive video-based instruction for robotic lobectomy. Herein, the author distills a robotic left upper lobectomy procedure into a logical and discrete series of steps, each peer-reviewed and each demonstrated with high-quality video and short-format text. Included are instructions for lean instrumentation with printable a case card and illustration of a highly nuanced surgical technique that optimizes economy of motion and that thinks several steps ahead to improve overall case efficiency. Whereas there are no shortage of lobectomy videos dissecting pristine fissures, this proceeding includes video instruction for strategies to approach difficult and incomplete fissures in a reliable and reproducible manner. To the maximal extent possible, this video-based article crystallizes the precious learning experience unique to the operating room into an enduring educational format, epitomizing the spirit of the Video Atlas Article. This article is highly recommended for cardiothoracic surgery residents and junior faculty alike and is offered as a challenge to experienced robotic surgeons to not at least slightly modify their technique after viewing.Bryan M. Burt, MD The technique described herein is an effective and reproducible approach to robotic-assisted left lower lobectomy for lung cancer, which can be extrapolated to other robotic pulmonary operations. See Commentaries on pages 480 and 481. Since its introduction in the early 1990s,1Landreneau R.J. Hazelrigg S.R. Ferson P.F. Johnson J.A. Nawarawong W. Boley T.M. et al.Thoracoscopic resection of 85 pulmonary lesions.Ann Thorac Surg. 1992; 54 (discussion 419-20): 415-419Abstract Full Text PDF PubMed Scopus (203) Google Scholar minimally invasive thoracic surgery for anatomic pulmonary resection has progressively supplanted open thoracotomy, becoming the dominant approach for lung cancer operations performed by board-certified thoracic surgeons.2Servais E.L. Towe C.W. Brown L.M. Broderick S.R. Block M.I. Burfeind W.R. et al.The Society of Thoracic Surgeons general thoracic surgery database: 2020 update on outcomes and research.Ann Thorac Surg. 2020; 110: 768-775Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar Video-assisted thoracic surgery, or VATS, has been shown in several studies to have similar oncologic and improved short-term outcomes compared with open thoracotomy for pulmonary resection.3Demmy T.L. Yendamuri S. D'Amico T.A. Burfeind W.R. Oncologic equivalence of minimally invasive lobectomy: the scientific and practical arguments.Ann Thorac Surg. 2018; 106: 609-617Abstract Full Text Full Text PDF PubMed Scopus (15) Google Scholar,4Yang H.X. Woo K.M. Sima C.S. Bains M.S. Adusumilli P.S. Huang J. et al.Long-term survival based on the surgical approach to lobectomy for clinical stage I nonsmall cell lung cancer: comparison of robotic, video-assisted thoracic surgery, and thoracotomy lobectomy.Ann Surg. 2017; 265: 431-437Crossref PubMed Scopus (179) Google Scholar However, the traditional VATS approach is limited by 2-dimensional optics and instrumentation with restricted degrees of freedom. This continues to limit more widespread adoption of VATS, particularly for complex pulmonary surgery. Robotic-assisted thoracic surgery (RATS) offers potential advantages over VATS related to improved 3-dimensional optics with magnification, 3 additional degrees of freedom compared with VATS allowing for wristed instrumentation, instrument stabilization, and a surgeon-controlled camera while operating. Recent studies demonstrate RATS anatomic pulmonary resection to be safe, efficacious, and at a minimum to have