Uniportal robotic-assisted thoracoscopic lung resection with the da Vinci Xi surgical system: technical modifications...

Uniportal robotic-assisted thoracoscopic surgery (U-RATS) lung resection using the daVinci Xi surgical system combines the advantages of robotic surgery, namely, superior articulated dexterity of instruments and high-definition three-dimensional (3D) visualization, with the benefits of uniportal video-assisted thoracoscopic surgery (U-VATS), which is characterized by minimal chest wall disruption and accelerated recovery through minimized postoperative pain. This novel approach utilizes a single 4-cm incision at the 5th or 6th intercostal space near the midaxillary line for the camera and two instrument arms. With respect to arm placement, we adopted the cross-arm technique after gaining experience with the original parallel technique, thereby minimizing physical interference between the robotic arms. In U-RATS, because the bedside surgeon faces limitations in maintaining surgical field visibility, the console surgeon must actively clear the field. This is achieved using both robotic arms to hold gauze rolls, thereby enabling efficient dissection via the "hot tearing" technique with SynchroSeal. For lung resection, while robotic staplers are an option, manual staplers combined with reinforcement material are preferred, particularly for patients with interstitial lung disease or emphysema. Because the use of manual staplers in U-RATS lung resection limits the robotic system to a single-arm retraction, the silk loop technique is highly effective for vascular and bronchial traction in such scenarios. During the initial implementation phase, a caudal port should be added for dual-portal RATS if stapler insertion becomes challenging. Technical proficiency can be established through dry lab training and by analyzing overhead video footage. With a proper setup and mastery of these specialized maneuvers, U-RATS offers a safe and reproducible minimally invasive procedure.