Uniportal pure robotic-assisted thoracic surgery—technical aspects, tips and tricks

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 roboticassisted 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 uniportal-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.

Early experience with uniportal robotic thoracic surgery lobectomy

“…The possibility of blending the uniportal approach with robotic technology would be an enormous improvement in terms of feasibility, safety, oncological outcomes, and enhanced postoperative recovery. An update of the literature during the revision process of our paper showed a very recent description of the technique ( 10 , 11 ) and a previous case report ( 12 ). Thus, considering our personal experience with U-VATS and standard robotic techniques, we recently started our U-RATS program.…”

Transition from multiportal video-assisted thoracic surgery to uniportal video-assisted thoracic surgery… and evolution to uniportal robotic-assisted thoracic surgery?

“…The former is already coming true as the monopoly of the only RATS system manufacturer is coming to an end, and alternative, cheaper RATS systems are now emerging on the marketplace. The latter may also be coming true as an intrepid handful of surgeons have begun to experiment with a URATS approach for various types of lung resections, using a single intercostal incision, without rib spreading (62)(63)(64)(65). A robotic camera, robotic dissecting instruments and robotic staplers are used, without the need of a bedside assistant to handle any conventional VATS staplers and instruments (63,64).…”

“…The latter may also be coming true as an intrepid handful of surgeons have begun to experiment with a URATS approach for various types of lung resections, using a single intercostal incision, without rib spreading (62)(63)(64)(65). A robotic camera, robotic dissecting instruments and robotic staplers are used, without the need of a bedside assistant to handle any conventional VATS staplers and instruments (63,64). The potential advantage of this URATS approach is the combination of the best of both UVATS and conventional RATS.…”

“…At this point, it is important to remember that this potential remains a hypothesis. At the time of this writing, all that the world knows is that a very small number of surgeons have performed an unspecified number of URATS operations (62)(63)(64). To date, only one group has reported a series of 24 URATS lung resections without mortality (65).…”

Approaches and outcomes of Robotic-Assisted Thoracic Surgery (RATS) for lung cancer: a narrative review

“…A schematic representation is shown in Fig. 7 [72,73]. Many authors stated that an experienced uniportal VATS surgeon is mandatory at the operating table [31,33,35].…”