Modified open-thoracotomy-view approach in robotic-assisted thoracoscopic lung resection

Robotic-assisted thoracoscopic surgery (RATS) is widely performed in thoracic surgery. The open-thoracotomy-view approach (OTVA) is one approach in RATS lung resection. OTVA is a good surgical approach that provides the same field of view as that with open thoracotomy and allows active participation of the assistant. However, the OTVA has certain limitations compared with other approaches, such as difficulty placing a robotic arm in the lower intercostal space, the assistant port is positioned further from the hilum, and CO₂ insufflation is required. We have made some modifications to the OTVA by placing one of the robotic arms in the lower intercostal space, which enhances the operability for the surgeon without the need for CO₂ insufflation. Additionally, by positioning the assistant port between the robotic arms, the assistant is closer to the hilum, and there is no requirement for a closed port owing to the absence of CO₂ insufflation, resulting in improved performance by the assistant. Therefore, for the assistant to perform well, it is necessary to make modifications to the OTVA to widen the typically narrow space between the robotic arms. We performed lung resection using our modified 4-port 3-arm OTVA method in 20 patients from June 2022 to July 2023. Although we have not used our modified OTVA in a large number of cases, we have not observed critical issues to date. In this report, we introduce our modified OTVA as an option in RATS for lung resection.