Bilateral lung resection via the subxiphoid approach using the da Vinci SP system.
Central Message.
Bilateral lung resection was performed via a subxiphoid approach using the da Vinci SP system. The procedure was performed safely and represents a viable option for minimally invasive surgery.
Various approaches to bilateral pulmonary tumor resection, particularly minimally invasive surgery, have been reported. Video-assisted thoracic surgery via a single subxiphoid incision has been described; however, no reports exist on robot-assisted thoracic surgery using this method. We present the first case of subxiphoid bilateral pulmonary resection (anatomical segmentectomy and wedge resection) using the da Vinci single-port (SP) system.
Case Presentation
A 44-year-old man was referred to our department with bilateral pulmonary metastases from osteosarcoma located in the left tibia. The primary and lung tumors were refractory to chemotherapy; therefore, bilateral lung resection was planned after surgery of the primary site.
The patient had no significant comorbidities. Computed tomography showed a 3.1-cm nodule in the left S4-5, a 0.2-cm nodule in the left S10, and a 1.5-cm nodule in the right S5 (Figure 1). Left S4 + 5 segmentectomy and bilateral wedge resections were planned. Computed tomography−guided pleural dye-marking of the left S10 nodule was performed using indigo carmine before the administration of anesthesia, as it provides clear visibility during robot-assisted thoracic surgery, can be completed quickly, and is routinely used at our institution. The patient was positioned supine with their left side facing up (Figure 2). A 4-cm transverse incision was made below the xiphoid, exposing the sternum without resecting the xiphoid. A single-port access device was inserted for the da Vinci SP (Video 1).
Figure 1.
Computed tomography showed a 3.1-cm nodule in the left S4+5 (arrowhead), a 0.2-cm nodule in the left S10 (arrowhead), and a 1.5-cm nodule in the right S5 (arrowhead).
Figure 2.
A, The patient was positioned supine with the left side up. B, A 4-cm transverse incision was made below the xiphoid.
The AirSeal system (ConMed) was used to establish an insufflation pressure of 8 mm Hg, and the da Vinci SP system was rolled (Figure 3). The first arm consisted of a Round Tooth Retractor, the second of Cadiere forceps, and the third of a Maryland bipolar forceps. The camera was initially placed “below” to dissect the back of the sternum, and the left mediastinal pleura was incised to access the pleural cavity. The camera was then repositioned “above,” allowing the instruments to reach over the heart for better visualization and manipulation in the deeper left thoracic cavity.
Figure 3.
The surgery was performed using the da Vinci SP system via the subxiphoid approach. The assistant inserted the automatic stapler from the edge of the incision using an assistant port.
Left Lower Lobe
The left S10 marking was identified. Wedge resection was performed. Another nodule was found immediately beneath the pleura in the left S9, which was also resected.
Left Upper Lobe
A 2.5-cm nodule was in the left 4 + 5. The fissure was well-formed, allowing dissection. The anterior pleura was incised to expose the upper pulmonary vein. The left upper lobe was suspended using an internal organ retractor (B Braun Aesculap), and the hilum was separated from the heart (Figure 4). V4+5 was then clipped and divided. After A4+5 was ligated, the peripheral part was transected using an energy device. The B4+5 was dissected and stapled under intraoperative bronchoscopic guidance. Indocyanine green was used to confirm the resection margins, and the left S4+5 was removed using an automatic stapler.
Figure 4.
An internal organ retractor (B Braun Aesculap) was used to expose the left S4+5. By fixing it to the chest wall and retracting it cranially, visualization of the pulmonary hilum was improved.
Right Middle Lobe
The right mediastinal pleura was incised and a 1.5-cm tumor in the right S5 was found. Wedge resection was performed. The right pleura was sutured with 3-0 V-Loc after ensuring full expansion of the right lung. This separation of the pleural cavities is a key maneuver to simplify postoperative chest tube management and prevent bilateral pneumothorax. A 28-Fr drain was placed in the left pleural cavity and the wound was closed (Figure 5, A).
Figure 5.
A, A chest drain was inserted below the xiphoid process. B, The image shows the wound site at the time of discharge.
The total surgical time was 228 minutes (left side, 136 minutes; right side, 32 minutes). Blood loss was minimal. The postoperative course was uneventful, with drain removal on day 2 and discharge on day 5 (Figure 5, B).
Dicsussion
In 2013, Suda and colleagues1 reported bilateral pulmonary partial resection using single-port video-assisted thoracic surgery via the subxiphoid approach, which avoids intercostal nerve injury and offers good cosmetic results. However, it is technically challenging because of limited visibility and maneuverability, especially when accessing dorsal structures. Tilting the operating table or pulling the lung can help expand the view.2,3 The da Vinci SP system offers a subxiphoid approach for thymectomy with the advantage of manipulating the posterior sternum by switching the camera view. This case represents the first reported use of the da Vinci SP system for bilateral lung resection.4
All procedures, including anatomical resection of the left lung and hilar dissection, were safely performed. The da Vinci SP flexible camera enhanced visibility and maneuverability without hard-heart compression. An internal organ retractor (B Braun Aesculap) facilitated multidirectional expansion of the left upper lobe without the need for intercostal access, thus ensuring a safe fissure approach. However, the insertion angle of the assistant-operated stapler is limited and, requires close coordination with the console surgeon. Therefore, the Covidien Medtronic stapler with intracavitary articulation and interchangeable anvil tips was used. The small posterior S10 lesion was safely dissected by tilting the table and retracting the lung. On the right side, ventral lesions were easily accessed and dissected. Like thymectomy, communicating the bilateral pleural cavities and using AirSeal had no effect on intraoperative hemodynamics. The subxiphoid approach is particularly effective in treating ventral lesions.1
Subxiphoid bilateral lung resection with the da Vinci SP system has several points that must be considered. First, handling adhesions can be challenging because of the limited reach of the da Vinci SP arm, especially when anatomical structures are unfavorably positioned. In such cases, additional ports or adjustments to the patient's position may be required. Second, managing bleeding can be more difficult when using the subxiphoid approach in the supine position, limiting the ability to perform emergency thoracotomy.5 A semilateral position may improve lung expansion and flexibility in emergencies. Finally, the lack of palpation with the da Vinci SP system necessitates marking for tumor localization. Therefore, although this technique is effective, flexible decision-making during surgery and careful preoperative planning are crucial for ensuring safety.
Conclusions
This case demonstrates that bilateral lung anatomical resection via a subxiphoid approach using the da Vinci SP system is feasible. This approach provides the inherent benefits of avoiding intercostal nerve injury and offering good cosmetic results while avoiding 2-stage surgeries and allowing a quick transition to chemotherapy. Therefore, it may be a promising option for minimally invasive thoracic surgery in the future. Written informed consent was obtained from the patient for this case report (institutional review board number: H 2025-092, June 3, 2025).
Conflict of Interest Statement
The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
Supplementary Data
Subxiphoid single-port robot-assisted bilateral lung resection using the da Vinci SP. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00372-4/fulltext.
References
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Associated Data
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Supplementary Materials
Subxiphoid single-port robot-assisted bilateral lung resection using the da Vinci SP. Video available at: https://www.jtcvs.org/article/S2666-2507(25)00372-4/fulltext.