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Gonzalez-Rivas D, Manolache V, Bosinceanu ML, Gallego-Poveda J, Garcia-Perez A, de la Torre M, Turna A, Motas N. Uniportal pure robotic-assisted thoracic surgery-technical aspects, tips and tricks. ANNALS OF TRANSLATIONAL MEDICINE 2023; 11:362. [PMID: 37675313 PMCID: PMC10477623 DOI: 10.21037/atm-22-1866] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 06/06/2022] [Indexed: 09/08/2023]
Abstract
The uniportal access for robotic thoracic surgery presents itself as a natural evolution of minimally invasive thoracic surgery (MITS). It was developed by surgeons who pioneered the uniportal video-assisted thoracic surgery (U-VATS) in all its aspects following the same principles of a single incision by using robotic technology. The robotic surgery was initially started as a hybrid procedure with the use of thoracoscopic staplers by the assistant. However, due to the evolution of robotic modern platforms, the staplers can be nowadays controlled by the main surgeon from the console. The pure uniportal robotic-assisted thoracic surgery (U-RATS) is defined as the robotic thoracic surgery performed through a single intercostal (ic) incision, without rib spreading, using the robotic camera, robotic dissecting instruments and robotic staplers. There are presented the advantages, difficulties, the general aspects and specific considerations for U-RATS. For safety reasons, the authors recommend the transition from multiportal-RATS through biportal-RATS to U-RATS. The use of robotic dissection and staplers through a single incision and the rapid undocking with easy emergent conversion when needed (either to U-VATS or to thoracotomy) are safety advantages over multi-port RATS that cannot be overlooked, offering great comfort to the surgeon and quick and smooth recovery to the patient.
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Affiliation(s)
- Diego Gonzalez-Rivas
- Department of Thoracic Surgery and Minimally Invasive Thoracic Surgery Unit (UCTMI), Coruña University Hospital, Coruña, Spain
- Department of Thoracic Surgery, Policlinico di Monza, Oncology Hospital Monza, Bucharest, Romania
| | - Veronica Manolache
- Department of Thoracic Surgery, Policlinico di Monza, Oncology Hospital Monza, Bucharest, Romania
- University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
| | - Mugurel Liviu Bosinceanu
- Department of Thoracic Surgery, Policlinico di Monza, Oncology Hospital Monza, Bucharest, Romania
| | | | - Alejandro Garcia-Perez
- Department of Thoracic Surgery and Minimally Invasive Thoracic Surgery Unit (UCTMI), Coruña University Hospital, Coruña, Spain
| | - Mercedes de la Torre
- Department of Thoracic Surgery and Minimally Invasive Thoracic Surgery Unit (UCTMI), Coruña University Hospital, Coruña, Spain
| | - Akif Turna
- Department of Thoracic Surgery, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Natalia Motas
- Department of Thoracic Surgery, Policlinico di Monza, Oncology Hospital Monza, Bucharest, Romania
- University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
- Department of Thoracic Surgery, Institute of Oncology “Prof. Dr. Al. Trestioreanu”, Bucharest, Romania
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Gonzalez-Rivas D, Bosinceanu M, Manolache V, Gallego-Poveda J, Paradela M, Li S, Garcia A, Bale M, Motas N. Uniportal fully robotic-assisted sleeve resections: surgical technique and initial experience of 30 cases. Ann Cardiothorac Surg 2023; 12:9-22. [PMID: 36793981 PMCID: PMC9922765 DOI: 10.21037/acs-2022-urats-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 12/26/2022] [Indexed: 01/09/2023]
Abstract
Since the first uniportal video-assisted thoracoscopic surgery (uVATS) performed in 2010, the uniportal approach has evolved up to a point where even the most complex cases can be done. This is thanks to the experience acquired over the years, the specifically designed instruments and improvements in imaging. However, in these last few years, robotic-assisted thoracoscopic surgery (RATS) has also shown progress and distinct advantages compared to the uniportal VATS approach, thanks to advanced maneuverability of the robotic arms as well as the three-dimensional (3D) view. Excellent surgical outcomes have been reported and so too, the ergonomic benefits to the surgeon. The main limitation we find of the robotic systems is that they are designed for a multiport approach, requiring between three to five incisions to be able to perform surgeries. With the aim to offer the least invasive approach, using the robotic technology we decided to adapt the Da Vinci Xi® in September 2021 to develop the uniportal pure RATS approach (uRATS) performed by a single intercostal incision, without rib spreading and using the robotic staplers. We have now reached a point where we perform all type of procedures, including the more complex sleeve resections. Sleeve lobectomy is now widely accepted as a reliable and safe procedure to allow complete resection of centrally located tumors. Although it is a technically challenging surgical technique, it offers better outcomes when compared to pneumonectomy. The intrinsic characteristics of the robot such as the 3D view and improved maneuverability of instruments make the sleeve resections easier compared to thoracoscopic techniques. As in uVATS vs. multiport VATS, the uRATS approach, due to its geometrical characteristics, requires specific instrumentation, different movements and learning curve compared to multiport RATS. In this article we describe the surgical technique and our initial uniportal pure RATS experience with bronchial, vascular sleeves and carinal resections in 30 patients.
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Affiliation(s)
- Diego Gonzalez-Rivas
- Department of Thoracic Surgery and Minimally Invasive Thoracic Surgery Unit (UCTMI), Coruña University Hospital, Coruña, Spain;,Department of Thoracic Surgery, Memorial Hospital, Bucharest, Romania;,Department of Cardio-Thoracic surgery, Lusiadas Hospital, Lisbon, Portugal;,Department of Thoracic Surgery, Apollo Hospital, Hyderabad, India
| | | | - Veronica Manolache
- Department of Thoracic Surgery, Memorial Hospital, Bucharest, Romania;,University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania
| | | | - Marina Paradela
- Department of Thoracic Surgery and Minimally Invasive Thoracic Surgery Unit (UCTMI), Coruña University Hospital, Coruña, Spain
| | - Shuben Li
- Department of Thoracic Surgery, the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Alejandro Garcia
- Department of Thoracic Surgery and Minimally Invasive Thoracic Surgery Unit (UCTMI), Coruña University Hospital, Coruña, Spain
| | - Manjunath Bale
- Department of Thoracic Surgery, Apollo Hospital, Hyderabad, India
| | - Natalia Motas
- Department of Thoracic Surgery, Memorial Hospital, Bucharest, Romania;,University of Medicine and Pharmacy “Carol Davila”, Bucharest, Romania;,Department of Thoracic Surgery, Institute of Oncology “Prof.Dr. Al.Trestioreanu”, Bucharest, Romania
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Gonzalez-Rivas D, Garcia A, Chen C, Yang Y, Jiang L, Sekhniaidze D, Jiang G, Zhu Y. Technical aspects of uniportal video-assisted thoracoscopic double sleeve bronchovascular resections. Eur J Cardiothorac Surg 2021; 58:i14-i22. [PMID: 32083654 DOI: 10.1093/ejcts/ezaa037] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/22/2019] [Indexed: 11/13/2022] Open
Abstract
Double sleeve, bronchial and vascular reconstructions are challenging procedures indicated for centrally located tumours to avoid pneumonectomy. Traditionally, these resections have been performed by thoracotomy, but thanks to advances in imaging systems, better surgical instruments and the gained experience in video-assisted thoracic surgery (VATS), the scenario now is different. During the last decade, we have seen a rapid evolution of the uniportal VATS technique from simple lobectomies to advanced double sleeve bronchovascular procedures and carinal resections. The advantages of VATS over open surgery for major lung resections in terms of postoperative pain and morbidity, length of hospital stay and quality of life have prompted experienced surgeons to adopt uniportal VATS for cases requiring a sleeve resection. However, when a double bronchial and vascular sleeve resection is required, the adoption rate of minimally invasive surgery is still very low even for very experienced VATS surgeons. The difficulty of tumour mobilization, complexity of the suturing technique and the concern about possible uncontrolled massive bleeding during VATS are the main reasons for this low rate of adoption. In this article, we describe the technical aspects and tricks of this procedure when it is done by the uniportal VATS approach.
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Affiliation(s)
- Diego Gonzalez-Rivas
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Thoracic Surgery, Coruña University Hospital, Coruña, Spain
| | - Alejandro Garcia
- Department of Thoracic Surgery, Coruña University Hospital, Coruña, Spain
| | - Chang Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yang Yang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Lei Jiang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Dmitrii Sekhniaidze
- Department of Thoracic Surgery, Regional Oncological Center, Tyumen, Russian Federation
| | - Gening Jiang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuming Zhu
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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Abstract
Prevention of bronchial complications after airway surgery must be our primary goal. Understanding bronchial and anastomotic healing is the first step to success. This can be improved by standardizing operating technique (bronchial closure and end-to-end anastomosis) as well as postoperative care. Bronchopleural fistula after pneumonectomy still remains a feared complication with a high mortality rate. Especially after sleeve resection interpretation of endobronchial healing and postoperative measures of care with the help of an algorithm, may avoid anastomotic insufficiency and therefore reduced the secondary pneumonectomy rate.
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Affiliation(s)
- Corinna Ludwig
- Department of Thoracic Surgery, Florence Nightingale Hospital, Düsseldorf, Germany
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Zhang C, Yu Z, Li J, Zu P, Yu P, Wang G, Miyazaki T, Waseda R, Caso R, Maurizi G, Liu H. Hybrid video-assisted thoracoscopic surgery sleeve lobectomy for non-small cell lung cancer: a case report. J Thorac Dis 2020; 12:6836-6846. [PMID: 33282385 PMCID: PMC7711411 DOI: 10.21037/jtd-20-2679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Chenlei Zhang
- Department of Thoracic Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Zhanwu Yu
- Department of Thoracic Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Jijia Li
- Department of Thoracic Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Peng Zu
- Department of Thoracic Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Pingwen Yu
- Department of Thoracic Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Gebang Wang
- Department of Thoracic Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
| | - Takuro Miyazaki
- Department of Surgical Oncology, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Ryuichi Waseda
- Department of General Thoracic, Breast, and Pediatric Surgery, Fukuoka University, Fukuoka, Japan
| | - Raul Caso
- Department of Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Giulio Maurizi
- Department of Thoracic Surgery, Sant'Andrea Hospital, Sapienza University of Rome, Rome, Italy
| | - Hongxu Liu
- Department of Thoracic Surgery, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang, China
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González-Rivas D, Garcia A, Chen C, Yang Y, Zhu Y, Jiang G. Technical aspects of uniportal video-assisted thoracoscopic sleeve resections: Where are the limits? JTCVS Tech 2020; 2:160-164. [PMID: 34317790 PMCID: PMC8298887 DOI: 10.1016/j.xjtc.2020.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 12/03/2019] [Accepted: 02/02/2020] [Indexed: 11/11/2022] Open
Affiliation(s)
- Diego González-Rivas
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China.,Department of Thoracic surgery and Minimally Invasive Thoracic Surgery Unit (UCTMI), Coruña University Hospital, Coruña, Spain
| | - Alejandro Garcia
- Department of Thoracic surgery and Minimally Invasive Thoracic Surgery Unit (UCTMI), Coruña University Hospital, Coruña, Spain
| | - Chang Chen
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yang Yang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Yuming Zhu
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
| | - Gening Jiang
- Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai, China
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