Four arms robotic-assisted pulmonary resection—left lower lobectomy: how to do it

Video-assisted thoracic surgery (VATS) for anatomic pulmonary resection, including lobectomy, offers significant benefits over open thoracotomy regarding shorter hospital stay, post-operative pain and complications and better quality of life for the patient after surgery and to date is worldwide accepted as the standard approach for lung resections (1). However, VATS is technically demanding. The surgeon has restricted the ability to manoeuvre long and rigid instruments and should deal with “only” two-dimensional (2D) visualisation with the lack of the eye-hand target axis. The da Vinci robotic surgical system with the three-dimensional (3D) high-definition stereoscopic camera and the endo-wrist technology, leading to intuitive tools manoeuvrability, has helped to overcome these limitations. The 3D magnified view and precise dissection allow the surgeon to virtually perform anatomical lung resection with “his own hands” (2). However, clinical benefits and long-term results of the robotic approach, compared to VATS, are still under investigation. There are no randomised trials available and retrospective or case control analysis, reported in the literature, present controversial results (3). In the last few years numerous authors have shown that robotic-assisted pulmonary lobectomy is a safe and efficient procedure for the treatment of early stage lung cancer and more recently, experienced surgeons have proven the feasibility of more complicated operations such as pneumonectomy and bronchial/vascular sleeve resection performed robotically (4,5). Several techniques have been described to carry out a robotic lobectomy. Park and colleagues in 2006 reported the successful initial results of the robotic-assisted VATS dissection approach in 34 patients. More recently Cerfolio and colleagues published the largest series on robotic lung lobectomy resections indicating the safety and effectiveness of the completely portal robotic lobectomy technique (CPRL) (6). Since the beginning of our experience with robotic lung resection, we adopted the 4-arms robotic-assisted approach described by Veronesi and Melfi in 2010 (7)