Abstract
Background
The da Vinci Single-Port (SP) system is a robotic platform designed to facilitate uniportal surgery. This study aimed to evaluate the feasibility and safety of the da Vinci SP system for major pulmonary resections.
Methods
We retrospectively reviewed patients with non-small cell lung cancer who underwent lobectomy or segmentectomy using the da Vinci SP system between August 2023 and June 2025. All procedures were performed through a uniportal subcostal incision. The primary endpoint was procedural feasibility, defined as completion of the planned operation without conversion to an alternative surgical approach or the addition of any supplemental ports. Secondary endpoints included safety and perioperative outcomes.
Results
Nine patients were included: 8 (88.9%) had clinical stage I disease, and 1 (11.1%) with clinical stage IIB received neoadjuvant chemoimmunotherapy. The median age was 55.0 (range, 40.0–70.0) years, and 6 patients (66.7%) were women. Lobectomy was performed in 7 patients (77.8%), and segmentectomy in 2 (22.2%). The median operative and console times were 198.0 (range, 141.0–248.0) min and 151.0 (range, 105.0–190.0) min, respectively. All procedures were completed without conversion, and complete resection was achieved in all cases. The median pathologic tumor size was 20.0 (range, 0.0–40.0) mm. A median of 8.0 lymph node (LN) stations and 22.0 LNs were harvested. No Clavien-Dindo grade ≥ III complications occurred. One patient (11.1%) developed chylothorax, which was managed conservatively. The median durations of chest tube drainage and hospital stay were 3 and 4 days, respectively.
Conclusions
Robot-assisted SP major pulmonary resections via a uniportal subcostal approach appear feasible and safe, demonstrating acceptable short-term postoperative outcomes.
Keywords: Single-port (SP), robotic surgery, subcostal approach, lobectomy, segmentectomy
Highlight box.
Key findings
• Robot-assisted single-port (SP) major pulmonary resections via a uniportal subcostal approach were successfully performed in nine patients (seven lobectomies and two segmentectomies); all procedures were completed without conversion, complete resection was achieved in all cases, and no major complications (Clavien-Dindo ≥ III) occurred.
What is known and what is new?
• Previous attempts at uniportal robot-assisted thoracic surgery using the da Vinci Xi platform had technical limitations such as bulky trocars, limited articulation, frequent instrument collisions, and rib trauma risk.
• The da Vinci SP system was specifically designed for uniportal surgery, providing improved visualization, ergonomics, and reduced collisions; although experience with SP major pulmonary resection remains limited, this study demonstrates acceptable short-term outcomes via the subcostal approach.
What is the implication, and what should change now?
• Robot-assisted SP major pulmonary resections via a uniportal subcostal approach appear feasible and safe, with acceptable short-term postoperative outcomes.
Introduction
Background
Over the past three decades, minimally invasive techniques have markedly advanced in thoracic surgery (1-4). Among these, the adoption of robot-assisted thoracic surgery (RATS) has steadily increased (5). The transition from conventional multiport to uniport approaches has been driven by advantages such as reduced postoperative pain and improved cosmetic outcomes (6-9). In alignment with these developments, the da Vinci Single-Port (SP) system—engineered specifically for uniportal robotic procedures—was introduced (10-13). This system, featuring a fully wristed camera and robotic instruments housed within a single cannula, is optimized for surgeries in confined anatomical spaces.
In August 2020, the Korean Ministry of Food and Drug Safety approved the da Vinci SP system for thoracic procedures, facilitating earlier clinical implementation in South Korea compared to that in other regions. At Asan Medical Center, the first thymectomy using the SP system was performed in October 2020, and our initial experience with an anterior mediastinal mass has been previously reported (10). As proficiency increased, indications for SP surgery expanded, culminating in the initiation of major pulmonary resections in August 2023.
Rationale and knowledge gap
Despite increasing clinical adoption, the application of the SP system for anatomical lung resections remains underexplored.
Objective
This study aimed to evaluate the feasibility and safety of major pulmonary resections using the da Vinci SP system in patients with non-small cell lung cancer (NSCLC). We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-2008/rc).
Methods
Ethical statement
This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Approval was obtained from the Institutional Review Board of Asan Medical Center (No. 2025-1004). Given the retrospective design and use of anonymized data, the requirement for informed patient consent was waived.
Patients
This single-center, retrospective, descriptive study was conducted at Asan Medical Center, Seoul, Korea. Eligible patients included those with a preoperative diagnosis of NSCLC or radiologic findings strongly suggestive of NSCLC. These patients underwent major pulmonary resection using the da Vinci SP system through a subcostal approach between August 2023 and June 2025.
The SP system was offered to patients who expressed interest in the novel platform and provided consent after a detailed explanation of the subcostal approach. As the procedure was newly implemented, selection criteria for major pulmonary resection included adequate pulmonary reserve (predicted postoperative forced expiratory volume in 1 s ≥60% and diffusing capacity of the lung for carbon monoxide ≥60%), absence of severe cardiopulmonary disease, no history of prior ipsilateral thoracic surgery, and no anticipated need for complex vascular or airway reconstruction. Patients with markedly elevated body mass index (BMI) (≥30 kg/m2) or thoracic anatomy that could limit safe subcostal access or instrument maneuverability were considered unsuitable for this approach. All procedures were performed by a single surgeon (J.K.Y.).
Clinicopathological and perioperative data were retrieved from electronic medical records in the institutional database. Preoperative evaluations included chest computed tomography (CT), 18F-fluorodeoxyglucose positron emission tomography-CT, brain magnetic resonance imaging, pulmonary function testing, and endobronchial ultrasound when clinically indicated.
Surgical techniques
Patients were placed in the lateral decubitus position under general anesthesia with single-lung ventilation. A 4-cm incision was made along the subcostal margin at the midclavicular line (Figure 1A). For left-sided procedures, the incision was positioned 1–2 cm more laterally to reduce the risk of cardiac injury from robotic instruments. After skin incision, the external oblique and transverse abdominis muscles were divided parallel to the subcostal margin, followed by blunt dissection along the inferior rib margin. Although an assistant held the robotic endoscope, the diaphragm insertion was dissected using electrocautery to gain access to the pleural cavity. The diaphragm was tagged at three points to the subcutaneous layer using #2 Ethibond (Ethicon, Johnson & Johnson, Georgia, USA) sutures. An airtight multichannel port (SP Access Port Kit; Intuitive Surgical Inc., Sunnyvale, CA, USA) was inserted (Figure 1B), and carbon dioxide insufflation (6–10 mmHg) was applied to expand the pleural space. The da Vinci SP patient-side cart was docked to the access port. For a top-down view, the robotic endoscope was positioned in the 12 o’clock channel. Cadiere forceps were inserted into the 9 o’clock channel (surgeon’s left hand), and Maryland bipolar forceps were installed in the remaining channels (Figure 1C). Pulmonary resections were performed using a fissure-first technique, consistent with the standard approach used in multi-port RATS and video-assisted thoracoscopic surgery (VATS) at Asan Medical Center. Bronchial and vascular structures were divided using an endoscopic stapler (SigniaTM, Medtronic, Minneapolis, MN, USA) introduced via the assistant port (Figure 2A). Stapler manipulation was conducted by an experienced assistant. To reduce instrument collision, the robotic arm adjacent to the assistant port was temporarily removed during stapling (Figure 2B). Segmental vessels were ligated using the robotic Hem-o-lok system (Figure 3A). Specimens were enclosed in a retrieval bag and extracted through the incision. Systematic mediastinal lymph node (LN) dissection was performed in all patients. For right-sided resections, stations 2R, 4R, 7, 8, 9, 10R, 11R, and 12 were routinely dissected; for left-sided resections, stations 5, 6, 7, 8, 9, 10L, 11L, and 12 were included, with station 4L selectively dissected when metastasis was suspected. All LNs were removed en bloc and classified based on the IASLC LN map [2009] (14). The diaphragm was reapproximated to the transverse abdominis and oblique muscles using the pre-placed sutures. After placement of a chest tube (Figure 3B), layered wound closure was performed. The chest tube was removed once daily drainage was <4 mL/kg and radiographs showed no abnormalities, typically permitting discharge the next day. Postoperative pain was managed with patient-controlled analgesia. Patients with unexpected nodal upstaging or other high-risk features were referred to a multidisciplinary team for additional evaluation and adjuvant therapy. Patients with pathological stage I NSCLC were followed up every 6 months; those with nodal upstaging were monitored every 3–6 months.
Figure 1.
Incision and port placement for the da Vinci Single-Port system. (A) Subcostal incision used for the uniportal approach, (B) appearance of the single-port access port, (C) robotic instruments inserted through the four channels of the single-port access port. AXL, anterior axillary line; MCL, midclavicular line.
Figure 2.
Endoscopic stapler use during major pulmonary resection with the da Vinci Single-Port system. (A) Insertion of the stapler through the assistant port, (B) temporary removal of one robotic arm to prevent collision with the stapler.
Figure 3.
Intraoperative and postoperative views. (A) Segmental vessel division using the robotic Hem-o-lok system, (B) postoperative wound appearance, (C) lymph node dissection using the three-arm configuration of the da Vinci Single-Port system, (D) bronchial division guided by a Penrose drain. RUL, right upper lobe.
Definition of variables
Continuous variables are presented as medians with ranges, and categorical variables as frequencies and percentages. Operation time was defined as the interval from skin incision to closure. Subcostal port placement time refers to the period from skin incision to port installation. Docking time was defined as the interval between completion of port placement and robotic arm installation. Console time was defined from robotic arm installation to de-docking of the robotic system. Conversion was defined as the addition of an extra port or a switch to VATS or thoracotomy. Postoperative complications were categorized based on the Clavien-Dindo classification (15). Port-site complications were defined as any wound-related event at the subcostal incision, including seroma, hematoma, surgical-site infection, port-site hernia, or delayed wound healing. Pain was assessed every 8 h using the numeric rating scale (NRS) (16); the highest score recorded during hospitalization was used for analysis. Lung cancer staging was determined based on the 9th edition of the tumor-node-metastasis (TNM) classification (17).
The primary endpoint of this study was feasibility, defined as completion of the planned procedure without conversion to an alternative surgical approach or the addition of any supplemental ports. Secondary endpoints included safety and perioperative surgical outcomes. These were evaluated using operative time, console time, docking time, completeness of resection, the number of harvested LN stations and LNs, length of hospital stay, and the Clavien-Dindo grade of postoperative complications.
Statistical analyses
All statistical analyses were conducted using R software (version 4.5.0; The R Foundation for Statistical Computing, Vienna, Austria).
Results
Between August 2023 and June 2025, nine patients underwent anatomical pulmonary resection using the da Vinci SP system. Baseline characteristics of patients are summarized in Table 1. The median age was 55.0 (range, 40.0–70.0) years, and 6 patients (66.7%) were women. The median BMI was 22.7 (range, 20.7–28.2) kg/m2. Eastern Cooperative Oncology Group performance status was 0 in 7 patients (77.8%) and 1 in 2 (22.2%). Pulmonary function was generally preserved. The median forced expiratory volume in 1 s was 91.0% (range, 74.0–104.0%), and the median diffusing capacity for carbon monoxide was 88.0% (range, 62.0–104.0%). Median tumor size on preoperative chest CT was 22.0 (range, 14.0–40.0) mm. Tumors were most frequently located in the right lower lobe (4 patients, 44.4%), followed by the right upper lobe (3 patients, 33.3%), right middle lobe (1 patient, 11.1%), and left upper lobe (1 patient, 11.1%).
Table 1. Baseline characteristics of the patients (n=9).
| Variable | Value |
|---|---|
| Age (years) | 55.0 [40.0–70.0] |
| Sex | |
| Male | 3 (33.3) |
| Female | 6 (66.7) |
| Body mass index (kg/m2) | 22.7 [20.7–28.2] |
| Number of comorbidities | |
| 0 | 1 (11.1) |
| 1 | 5 (55.6) |
| 2 | 3 (33.3) |
| Smoking status | |
| Current | 0 (0.0) |
| Previous | 2 (22.2) |
| Never | 7 (77.8) |
| ECOG score | |
| 0 | 7 (77.8) |
| 1 | 2 (22.2) |
| FEV1 (%) | 91.0 [74.0–104.0] |
| DLCO (%) | 88.0 [62.0–104.0] |
| Size on imaging study (mm) | 22.0 [14.0–40.0] |
| Location | |
| RUL | 3 (33.3) |
| RML | 1 (11.1) |
| RLL | 4 (44.4) |
| LUL | 1 (11.1) |
| LLL | 0 (0.0) |
| Preoperative confirmation of malignancy | |
| Malignancy | 6 (66.7) |
| Suspected | 3 (33.3) |
Data are presented as numbers (%) or median [range]. DLCO, diffusing capacity of the lung for carbon monoxide; ECOG, Eastern Cooperative Oncology Group; FEV1, forced expiratory volume in one second; LLL, left lower lobe; LUL, left upper lobe; RLL, right lower lobe; RML, right middle lobe; RUL, right upper lobe.
Perioperative outcomes are detailed in Table 2. Lobectomy was performed in seven patients (77.8%): right upper lobe (n=3), right middle lobe (n=1), and right lower lobe (n=3). Two patients (22.2%) underwent segmentectomy (left S1+2+3 and right S6). The median operative and console times were 198.0 (range, 141.0–248.0) and 151.0 (range, 105.0–190.0) min, respectively. Port placement and docking times had median values of 14.0 (range, 10.0–25.0) and 5.0 (range, 4.0–10.0) min, respectively. All procedures were completed via a uniportal approach without conversion to multiport surgery, VATS, or thoracotomy. Complete resection was achieved in all cases. The median pathologic tumor size was 20.0 (range, 0.0–40.0) mm. A median of 8 LN stations (range, 6.0–10.0) and 22 LNs (range, 8.0–31.0) were harvested. Final histopathology showed adenocarcinoma in 8 patients (88.9%) and a benign lesion in 1 (11.1%). No patient experienced major postoperative complications (Clavien-Dindo grade ≥ III), and no port-site complications were observed. One patient (11.1%) developed chylothorax, which was managed conservatively, and he was discharged on postoperative day 7. The median duration of chest tube drainage was 3 (range, 2–7) days, and the median hospital length of stay was 4 days (range, 3–8) days. The median peak NRS score was 3 (range, 3–7). No reoperations or perioperative deaths occurred.
Table 2. Intraoperative and postoperative data of the patients (n=9).
| Variable | Value |
|---|---|
| Surgical extent | |
| Lobectomy | 7 (77.8) |
| RUL | 3 (33.3) |
| RML | 1 (11.1) |
| RLL | 3 (33.3) |
| Segmentectomy | 2 (22.2) |
| S1+2+3 (LUL) | 1 (11.1) |
| S6 (RLL) | 1 (11.1) |
| Operation time (min) | 198.0 [141.0–248.0] |
| Port placement time (min) | 14.0 [10.0–25.0] |
| Docking time (min) | 5.0 [4.0–10.0] |
| Console time (min) | 151.0 [105.0–190.0] |
| Conversion to | |
| Multiport | 0 (0.0) |
| VATS | 0 (0.0) |
| Open | 0 (0.0) |
| Complete resection | 9 (100.0) |
| Pathologic size (mm) | 20.0 [0.0–40.0] |
| Number of harvested LN stations | 8.0 [6.0–10.0] |
| Number of harvested LNs | 22.0 [8.0–31.0] |
| Histology | |
| Adenocarcinoma | 8 (88.9) |
| Squamous cell carcinoma | 0 (0.0) |
| Others | 1 (11.1) |
| Pathologic TNM classification (9th AJCC) | |
| Non-malignant | 1 (11.1) |
| T1bN0M0 | 3 (33.3) |
| T1cN0M0 | 2 (22.2) |
| T2aN0M0 | 1 (11.1) |
| T2aN2aM0 | 1 (11.1) |
| ypT0N0M0 | 1 (11.1) |
| Postoperative complications (Clavien-Dindo classification) | |
| None | 8 (88.9) |
| I | 0 (0.0) |
| II | 1 (11.1) |
| IIIa | 0 (0.0) |
| IIIb | 0 (0.0) |
| Port-site complications | 0 (0.0) |
| Duration of chest drainage (days) | 3 [2–7] |
| Duration of hospital stay (days) | 4 [3–8] |
| Adjuvant treatment | 1 (11.1) |
| Peak NRS pain score | 3 [3–7] |
| Reoperation | 0 (0.0) |
| Mortality | 0 (0.0) |
Data are presented as numbers (%) or median [range]. AJCC, American Joint Committee on Cancer; LN, lymph node; LUL, left upper lobe; NRS, numeric rating scale; RLL, right lower lobe; RML, right middle lobe; RUL, right upper lobe; TNM, tumor-node-metastasis; VATS, video-assisted thoracoscopic surgery.
Discussion
This study presents our initial experience with major pulmonary resection using the da Vinci SP system via a uniportal subcostal approach. Although our prior investigation demonstrated favorable outcomes in relatively simple resections for anterior mediastinal masses, this study extends the application of the SP system to more complex thoracic procedures (Videos 1,2). Notably, we achieved a complete resection in a patient with a single lower paratracheal LN metastasis following neoadjuvant chemoimmunotherapy (Video 3). All procedures were completed without conversion or surgery-related mortality, confirming the feasibility and safety of the SP platform for major pulmonary resections.
Video 1.
Right upper lobectomy performed using the da Vinci Single-Port system.
Video 2.
Upper division segmentectomy of the left upper lobe performed using the da Vinci Single-Port system.
Video 3.
Right upper lobectomy performed using the da Vinci Single-Port system in a patient who received neoadjuvant chemoimmunotherapy.
Although most patients in this initial series presented with clinically node-negative NSCLC, the operative outcomes were acceptable. Median operative and console times were consistent with previous reports (12,13,18). The median number of harvested LN stations and total LNs—8 and 21, respectively—was comparable to multiport RATS and other published experiences (12,18-21). The incidence of postoperative complications was also comparable to that reported in previous studies (11-13). No major postoperative events of Clavien-Dindo grade ≥ III occurred; one patient developed chylothorax, which was successfully managed conservatively, allowing discharge by postoperative day 7. The low complication rate may reflect accumulated institutional experience with uniportal RATS using the da Vinci Xi system through both subcostal and intercostal approaches, facilitating safe transition to the SP platform.
As minimally invasive thoracic surgery evolves, efforts have increasingly focused on integrating the advantages of uniportal access with robotic technology. Previous reports have demonstrated the technical feasibility of uniportal RATS using the da Vinci Xi system (4,22). However, the Xi platform, not originally designed for uniportal access, presents technical challenges such as bulky trocars, limited articulation, frequent instrument collisions, and increased risk of rib trauma (11,23). In contrast, the da Vinci SP system was specifically developed to support uniportal procedures, overcoming many of these limitations and thus supporting broader adoption of uniportal RATS.
The SP system enables triangular deployment of its arms, minimizing internal collision (Figure 3C). However, since the instruments and endoscope enter in parallel as a bundled unit, a minimum diameter of approximately 2.5 cm is required. This constraint is considerable in thoracic surgery, particularly when accessing narrow intercostal spaces. As noted in our prior study, this challenge is more pronounced in small-framed Asian female patients. To address this, we employed the subcostal approach, which offers multiple theoretical advantages. It avoids intercostal nerve injury, potentially reducing postoperative pain and chronic neuralgia (24,25), and provides greater spatial expandability, facilitating specimen retrieval (26). Notably, port placement should be adjusted based on laterality to reduce the risk of cardiac injury during left-sided resections. In such cases, the incision should be placed 1–2 cm more laterally than in right-sided procedures (18).
A key limitation of the SP system is the absence of a robotic stapler, requiring the use of a manual endoscopic stapler by the bedside assistant. This requirement demands not only technical skill but also close coordination between the console surgeon and assistant. Stapling is constrained by the parallel entry of all instruments through a single port, which limits angulation. Therefore, appropriate repositioning of the robotic arms is essential. In some cases, viewing the target from the edge rather than the center of the camera view improves the stapling trajectory. Temporarily removing the robotic arm nearest to the assistant may also create necessary workspace. In all cases, stapling was performed by a junior surgeon experienced in uniportal VATS and RATS. To facilitate safe stapler manipulation, we employed Asan Medical Center technique of passing a Penrose drain beneath the target structure and attaching it to the stapler tip (Figure 3D). This method improves navigation around perivascular and peribronchial tissues, enhancing safety and control during division. Beyond device-related limitations, patient-specific anatomical factors may also influence the feasibility of the subcostal SP approach. Obesity can impose anatomical constraints that diminish technical efficiency. Increased subcutaneous and preperitoneal adiposity creates a deeper access tunnel, limiting instrument insertion and reducing the available range of motion before entry into the thoracic cavity. Moreover, obesity-related elevation of the diaphragm can further narrow the working angle for instrument articulation, making exposure and dissection more challenging. Beyond BMI, body habitus may also play a role; in very tall individuals with increased anteroposterior chest depth, the upper mediastinal structures may lie near the limits of the effective working distance of the platform, potentially restricting access to stations such as 2R and 4R. These considerations highlight the importance of careful patient selection, particularly during the early adoption phase of this approach.
Despite these limitations, the da Vinci SP platform continues to demonstrate expanding potential beyond simple anatomical pulmonary resections. Early reports focused primarily on thymectomy and lobectomy; however, recent experiences have extended its application to procedures such as minimally invasive esophagectomy, suggesting a gradual broadening of its clinical indications (11). As instrumentation evolves and surgical expertise accumulates, the SP system may eventually be applicable to more complex thoracic operations, including tracheal and carinal resections.
This study had certain limitations. As an initial institutional experience, surgical candidates were selected conservatively, resulting in a small cohort. In addition, given the small sample size and single-surgeon experience, caution is warranted when generalizing the findings. The primary aim was to assess feasibility and safety rather than oncologic efficacy. Although LN yield appears acceptable, conclusions regarding oncologic adequacy cannot yet be drawn. Long-term follow-up with larger cohorts is necessary to evaluate survival outcomes. Owing to the single-arm design, direct comparison with other robotic platforms was not performed. Future studies should compare perioperative and oncologic outcomes across platforms. Although the study spanned an extended period, patient volume remained limited owing to institutional factors. Nonetheless, our extensive experience with uniportal approaches using the da Vinci Xi and X platforms supported safe integration of the SP system.
Conclusions
Major pulmonary resection using the da Vinci SP system via a uniportal subcostal approach appears both feasible and safe, with acceptable short-term outcomes. Larger studies are warranted to validate these findings and compare results across surgical platforms.
Supplementary
The article’s supplementary files as
Acknowledgments
The authors thank Editage (www.editage.co.kr) for professional English language editing.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Approval was obtained from the Institutional Review Board of Asan Medical Center (No. 2025-1004). Given the retrospective design and use of anonymized data, the requirement for informed patient consent was waived.
Footnotes
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-2008/rc
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-2008/coif). The authors have no conflicts of interest to declare.
Data Sharing Statement
Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-2008/dss
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