Uniportal & biportal robotic anatomic lung resection (without CO₂ insufflation): technique, initial experience and...

While first applied in thoracic surgery two decades ago, different studies over the past 10 years confirmed the safety and feasibility of robotic-assisted thoracic surgery (RATS). While initially performed with a multiportal approach (mRATS), the technological advancement now allows a uniportal technique for anatomic lung resections without the use of carbon dioxide (CO₂) insufflation.

We retrospectively analyzed data of the first 13 patients who underwent uniportal RATS (uRATS) or biportal RATS (bRATS) for anatomic lung resection at the Department of Thoracic Surgery St. Claraspital Basel and Hirslanden Clinic Beau-Site & Lindenhof Bern in 2023 using the da Vinci Xi platform. Analyzed data included approach, resected segment or lobe, duration of surgery, blood loss, conversion, number of lymph nodes resected, histology, tumor stage, postoperative complications, chest tube duration, length of hospital stay (LOS) and costs.

In total, 13 patients underwent robotic-assisted anatomic lung resection. For five patients (38.46%) a uniportal approach was used and for eight patients (61.54%) a bRATS approach was used (with robotic stapling). We report no intraoperative complications with zero conversions to video-assisted thoracic surgery (VATS) or thoracotomy. uRATS and bRATS showed no significant difference in perioperative blood loss (uRATS mean: 46.40±45.11 mL, bRATS mean: 16.25±12.75 mL) (P=0.09), duration of operation (uRATS mean: 142.40±49.50 min, bRATS mean: 132.63±38.27 min) (P=0.69) and number of lymph nodes resected (uRATS mean: 11.00±5.57, bRATS mean: 18.14±15.02) (P=0.45). Patients who underwent surgery with a uniportal approach showed similar postoperative chest tube duration (uRATS mean: 3.40±1.52 days) compared to a bRATS approach (bRATS mean: 3.88±3.60 days) (P=0.78). Additionally, LOS was comparable between the groups (uRATS mean discharge after 4.00±1.22 days and bRATS mean discharge after 5.00±2.33 days) (P=0.33). One patient developed a prolonged postoperative air leak, managed conservatively in an outpatient setting. When comparing the cost of uRATS and bRATS to conventional uniportal VATS anatomic lung resections, robotic surgery was costlier resulting in lesser earnings with a mean difference in earnings before interest, taxes, depreciation and amortization of 1,097.6 CHF (Swiss francs).

uRATS and bRATS anatomic lung resections without the use of CO₂ insufflation are safe and feasible approaches with good perioperative outcomes. Due to its improved ergonomics and better maneuverability RATS allows for a profound lymphadenectomy. RATS procedures may take a bit longer than VATS procedures due to the set-up and docking of the robotic system, as well as due to the fact that the team is still in the learning phase with this technique. Overall, with the currently relatively expensive robotic platform, RATS results in higher overall costs compared to VATS.