Table 1.
Reports for robotic port placement for anatomical lung resection.
| First Author/Year [Reference] | da Vinci System | View Type | Number of Skin Incisions a | Number of Robot Arms b | Scope Type | Location of Scope (ICS) |
Location of Utility Port for Assistant (ICS) |
CO2 Insufflation | Number of Patients [Reference] |
Features |
|---|---|---|---|---|---|---|---|---|---|---|
| Melfi 2002 [1] | Standard c | Look-up | 3 | 3 | 0-degree | 7th | 4th | No | 12 (5 lower lobectomies) | The first report on robotic surgery for thoracic diseases. A utility incision “service entrance” is placed at the 4th ICS, which is shared for an assistant and a robotic arm. |
| Ashton/2003 [2] | Standard c | Look-up | 5 | 3 | 0-degree | 5th | 3 utility ports, anterior 5th, 7th, and posterior 5th | No | 1 (lower lobectomy) | Three utility incisions were placed at the anterior 5th, 7th, and posterior 5th ICSs. The anterior 5th ICS was shared with a robotic scope. |
| Park/2006 [3] | Standard c | Look-up | 3 | 3 | 30-degree, down/up | 7–8th | Superior pulmonary vein level or one ICS lower | No | 34 | The incisions used for authors’ thoracoscopic lobectomy were applied. A utility incision is placed at the level of the superior pulmonary vein or one ICS lower, which is shared for an assistant and a robotic arm. |
| Gharagozloo/2008 [4] | ND d | Look-up | 4 | 3 | ND | 8th | ND | ND | 61 | A hybrid robotic-VATS technique. In addition to 3 robotic ports, a 1cm assistant port for an endoretractor was placed. Authors used a robot to dissect the pulmonary artery and the hilum. Once dissection was completed, the robot was withdrawn, and lobectomy was completed by VATS. |
| Veronesi/2010 [5] | S e | Look-up | 4 | 4 | ND | 7th | 4th | No | 54 | A posterior port for the 4th retraction arm was placed. The additional retraction by the 4th arm could reduce the requirement to change instruments and avoid possible interferences between robotic and assistant’s instruments. |
| Ninan/2010 [6] Dylewski/2011 [7] |
ND d | Look-up | 4 or 5 | 3 or 4 | 0-degree | 5–7th | Subcostal | Yes | 74 [6], 200 [7] | The “total endoscopic robotic video-assisted approach.” The subcostal trans-diaphragmatic incision was placed for a utility port by a bedside assistant. |
| Cerfolio/2011 [8] | ND d | Look-up | 5 | 4 | ND | 7th | 9–10th | Yes | 106 (robotic lobectomies) | The “completely portal robotic pulmonary lobectomy with 4 arms (CPRL-4).” |
| Pearlstein/2016 [9] | Xi | Look-up | 5 | 4 | 0-degree | 7th | 9th | ND | ND | Specific techniques to use robotic staplers were described. Locating the stapling ports as low caudal as possible (close to the diaphragm) allows the greatest degree of maneuverability of the stapler in the chest. |
| Kim/2017 [10] Khan/2017 [11] |
Xi | Look-up | 5 | 4 | 30-degree c | 7th | 4th | Yes | ND | “Five on a dice” method. Improved control of vascular stapler via inferior ports in the both sides and good retraction of the lung using tip-up grasper with sponge. A challenging robotic left pneumonectomy was performed [11]. |
| Yamazaki/2020 [12], 2021 [13] | Si | Horizontal | 5 | 4 | 30-degree, down | 4th | 7–9th | Yes | 87 (anterior approach) [13] | “Anterior approach” technique. Intrathorax is always viewed from the ventral side of the patient regardless of the side to be operated on. |
| Funai/2020 [14] | Xi | Horizontal | 5 | 4 | ND | 5th | 10th | Yes | ND | A four-arm, horizontal-view approach, the “Hamamatsu method.” A change of port distribution from the conventional Cerfolio’s CPRL-4 technique was shown on the right-side surgery. |
| Sakakura/2021 [15], 2022 [16] | Xi | Horizontal | 4 | 3 | 30-degree, down/up | Right 5–6th, Left 4–6th |
Right 5–7th, Left 7–9th |
Yes | 58 [15], 114 [16] | “Three-arm, open-thoracotomy-view approach” using vertical port placement and confronting up-side down monitor setting. All surgeons obtain “bird-eye” views as though they perform thoracotomy surgery. Ventral/dorsal hilum becomes visible by switching the 30-degree camera down/up. |
| Kang/2019 [17] | Xi | Look-up | 4 | 4 | ND | 9th | 5th | Yes | 36 | “Anterolateral approach.” A utility port in the 5th ICS shares with a robotic arm. Fully use the 4-arm technique, minimize the assistant’s role and establish a solo surgical method, and avoid painful posterior ports. |
| Ueda/2021 [18] | Xi | Look-up | 3 | 3 | 30-degree, down | 8th | 5th | No | 39 | A “three-incision robotic surgery.” A 4cm incision was shared for two robotic arms (scope and instrument). Interference between the two arms were prevented by “para-axial method.” |
| Han/2022 [19] | Xi | Look-up | 2 or 3 | 3 | ND | 7–8th | 7–8th | Yes | 142 | A matched analysis for “two-port” and “three-port” approaches. In the two-port setting, a 3–4cm working port was shared for two robotic arms (scope and instrument) and an additional assistant instrument using multi-instrument laparoscopic port. |
| Yang/2021 [20] | Xi | Undefined f | 1 | 3 | 30-degree | 4th | 4th | No | 1 (right upper lobectomy) | Uniportal RATS. A single 4–4.5cm incision was created to be shared by three robotic arms and the assistant. Robotic arms were intercrossed inside the chest and the control of the arms needed to be reset on the console accordingly. |
| Gonzalez-Rivas/2022 [21] | Xi | Undefined f | 1 | 3 | ND | ND | ND | No | ND | Pure uniportal RATS. To avoid collision, cancel arm 1 on the right side (arm 2 for camera) and arm 4 on the left side (arm 3 for camera). The camera is placed in the posterior part of the incision to allow the other two robotic instruments to work. All types of lung resections, including segmentectomies, sleeves and carinal resections were performed. |
| Eguchi (Shinshu University, unpublished data) | Si | Look-up | 5 | 4 | 0-degree | 6–7th | 7–10th | Yes | 180 (50 lobectomies, 130 segmentectomies, unpublished data) | A modification of Cerfolio’s setting. Moving the three ventral ports from the Cerfolio setting to the one or two ICS cranial side to avoid port collisions, considering the smaller body sizes of Asians compared to Westerners. |
a All skin incisions including a utility port. b Operating arms including robotic scope and instruments. c Initial da Vinci Surgical System. d The original report simply described the “da Vinci Surgical System” as being used [5,7,8,9]. e Not described in text but recognized on a picture or a movie adopted in the original report. f. In uniportal settings, categorizing the camera direction may be difficult as either the look-up view or the horizontal view. ICS, intercostal spaces; ND, no description; RATS, robot assisted thoracoscopic surgery, VATS, video assisted thoracoscopic surgery.