Single-port robot-assisted thoracoscopic right lower bronchial sleeve lobectomy utilizing the Shurui single-port robotic system

Introduction

In the surgical treatment of non-small cell lung cancer (NSCLC), sleeve lobectomy has solidified its position as a preferred alternative to pneumonectomy due to its significant advantage in preserving lung function. With the progression of minimally invasive thoracic surgery and the accumulation of surgeons’ experience, thoracoscopic-assisted sleeve lobectomy has been extensively documented, proving its efficacy and safety in clinical applications.

Specifically, most reported sleeve lobectomy cases focus on the upper lobes, encompassing right upper lobe sleeve lobectomy and left upper lobe sleeve lobectomy, whereas right lower lobe sleeve lobectomy remains relatively uncommon (1,2). This trend is primarily attributed to the consensus among experts that preserving the right middle lobe has a limited impact on lung function, while the surgical reconstruction of the right intermediate bronchus and middle lobe bronchus poses a higher technical challenge. However, reports have indicated that in comparison to bilobectomy of the middle and lower lobes of the right lung, patients who underwent sleeve resection of the right lower lobe with preservation of the middle lobe might obtain a reduced prevalence of complications and shortened hospitalization time with reliable long-term oncological outcomes at experienced centers (3,4). Traditionally, the right lower sleeve lobectomy was predominantly performed via thoracotomy, yet in recent years, there have been numerous reports of right lower sleeve lobectomy being executed through minimally invasive methods, particularly single-port thoracoscopic-assisted surgery (5,6). While thoracoscopic-assisted sleeve resection indeed results in less trauma for patients, it also demands heightened technical proficiency, extensive experience accumulation, and a prolonged learning curve for surgeons. Robot-assisted thoracoscopic surgery (RATS), owing to its 3D vision, bendable wrist joints, and tremor filtration capabilities, has also been implemented in sleeve resection, exhibiting ergonomic advantages and improving maneuverability of instruments compared to traditional thoracoscopic surgery. Gonzalez-Rivas et al. achieved satisfactory outcomes by employing the Davinci Xi system in single-port lung surgery, encompassing a substantial number of sleeve resections (7). However, the Davinci Xi system’s inherent multi-arm design poses challenges for adaptation to single-port surgery; whereas the newer Davinci SP system, with its 2.5 cm port diameter, cannot be inserted through an intercostal incision and can only be utilized for lung surgery via a subcostal incision, thus restricting its application in complex lung surgeries such as sleeve resection. Here we present a case report on a right lower sleeve lobectomy utilizing the innovative Shurui single-port robotic system which exhibits several advantages in the realm of lung surgery compared to traditional procedures. We present this article in accordance with the SUPER reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-957/rc).

Preoperative preparations and requirements

The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This surgical approach was approved by the Ethics Committee of The First Affiliated Hospital of Soochow University (No. 2024117) and informed consent was taken from the patient.

Both the console surgeon and the assistant were thoracic surgeons who had accepted the single-port robotic system training organized by Shurui Company and obtained surgical permission.

Step-by-step description

A 58-year-old male presented with symptoms of cough and the chest computer tomography (CT) scan revealed a 2.5-cm mass shadow in the right lower lobe of the lung. Further investigation via fiberoptic bronchoscopy disclosed a neoplasm blocking the lumen of the right B6 bronchus (Figure S1) and subsequent pathological biopsy confirmed the diagnosis of poorly differentiated squamous cell carcinoma. The positron emission tomography-CT (PET-CT) scan revealed no evidence of mediastinal lymph node involvement or distant metastases. The patient underwent a single-port robotic-assisted right lower lobectomy with sleeve resection.

During the surgical procedure, the patient was positioned in a left lateral decubitus and underwent general anesthesia with double-lumen intubation. We conducted the operation through a 4 cm incision at the fifth intercostal space anterior to the axillary line, utilizing the Shurui single-port robotic system without rib spreading. After inserting the oval-shaped port into the incision (Figure 1A), we selected three of the four robotic arms for surgical execution: the second, third, and fourth. The third arm functioned as the camera, while the second arm served as a Bipolar Grasper. Depending on the surgical requirements, the fourth arm alternated between roles as a Maryland Bipolar Grasper, Scissors, or Needle Driver (Figure 1B).

Figure 1 Port placement and surgical view. (A,B) The oval-shaped port was inserted into the single incision with three robotic arms. (C) Intraoperative view.

The inferior pulmonary vein is dissected first, and then the subcarinal lymph nodes are cleared to fully expose the right bronchus. The video-assisted thoracoscopic surgery (VATS) staplers were used by the assistant to sequentially sever the posterior part of the oblique fissure of the right lung, the inferior right pulmonary artery branch, and the anterior part of the oblique fissure. The bronchus is severed respectively near the distal ends of the right intermediate bronchus and the proximal ends of the middle lobe bronchus, and then the right lower lobe was removed. The resection margin of the right middle lobe bronchus is trimmed into a beveled edge to avoid an excessive gap in caliber with the intermediate bronchus. Two 3-0 v-loc sutures are used to perform a continuous anastomosis of the posterior and anterior walls of the bronchus, starting from the starting from the cartilage-membrane junction (Figure 1C). After the anastomosis is completed, the sutures are tightened and tied for fixation and a lung expansion test with saline injecting into the chest cavity is performed to ensure no air leakage (Video 1). The right mediastinal lymph nodes are dissected according to the routine protocol. No tissue flaps were utilized for safeguarding the anastomosis site. An individual chest drainage tube was positioned via the incision, and the total surgical duration time was 210 min.

Postoperative considerations and tasks

Postoperative monitoring followed standard post-pulmonary resection protocols, including continuous electrocardiography, oxygen saturation, and arterial blood pressure monitoring. Postoperative chest X-ray images were taken on the first day to verify lung expansion and check for air leaks and bleeding. The chest tube was removed on the 2^nd day after operation and the patient discharged on postoperative day (POD) 3. The patient was followed-up in the outpatient clinic approximately 2 weeks after discharge and 3–6 months thereafter. The pathological examination revealed a moderately to poorly differentiated squamous cell carcinoma of the right lower lung with a maximum diameter of 2.5 cm, accompanied by parabronchial lymph node metastasis (T1cN1M0, stage IIA).

Tips and pearls

We offer the following tips and pearls when performing single-port robot-assisted thoracoscopic right lower bronchial sleeve lobectomy utilizing the Shurui single-port robotic system. During anastomosis, it is a relatively safe and practical approach to form the anastomosed bronchus into a telescope-like shape by controlling the stitch spacing. It is necessary to trim the proximal end of the middle lobe bronchus into a bevel to increase its caliber, facilitating anastomosis with the intermediate bronchus. Furthermore, a skilled first assistant and a specially designed extended suction device are both indispensable for the successful completion of a complex single-port robotic surgery.

Discussion

As a specialized surgical procedure, the right lower lobe sleeve resection has relatively few reports in the literature (6). However, some reports have indicated that compared with bilobectomy of right middle and lower lobe, the right lower sleeve resection exhibits advantages in terms of hospital stay, postoperative complication rate, etc. (3,4). Furthermore, for some specific locations such as B6 bronchus involvement in right lower lung tumor patients, right lower lobe sleeve resection is a better choice compared to bilobectomy, which is conducive to preserving postoperative lung function (4).

During anastomosis, there often occurs a discrepancy in caliber between the right middle lobe bronchus and the right intermediate bronchus, which is a major difficulty in the right lower lobe sleeve resection. Some scholars have reported that by controlling the stitch spacing, making the stitch spacing wider on the side of the intermediate bronchus and narrower on the side of the smaller-caliber middle lobe bronchus, the anastomosed bronchus can eventually form a telescope-like shape (8). According to our previous experience in performing VATS right lower sleeve resection, this anastomosis method is mostly safe and effective. However, since the distal bronchus will inevitably nest into the proximal bronchus, it will inevitably lead to an uneven bronchial lumen, resulting in difficulties in sputum excretion and atelectasis complications in some patients after surgery. Other reported methods include using a bronchial flap constructed from the distal bronchial end to correct the caliber disparity, as well as adjusting the proximal bronchial stump by bending and suturing the non-cartilaginous posterior part of the bronchial wall (5,6). Both methods can effectively address the issue of inconsistent bronchus caliber, but they require higher operational technique demands, and the reported cases were all completed through thoracotomy. In the case we reported, we trimmed the proximal end of the middle lobe bronchus into a bevel to increase its caliber, facilitating anastomosis with the intermediate bronchus, and achieved satisfactory results. The flexibility of the robotic arm wrist played a role in this process, while the snake-like arm deployed through the sing-port avoided instrument collisions.

Another potential issue in right lower sleeve resection surgery is that when the right lower lobe is removed, the distance between the distal end of the right intermediate bronchus and the proximal end of the middle lobe bronchus may be too large, leading to difficulties in anastomosis and anastomotic tension. There have been reports of performing a pericardiotomy at the lower edge of the superior pulmonary vein to reduce tension in right lower lobe sleeve resection surgery, as well as fully separating the horizontal fissure to increase the mobility of the middle lobe (8,9). Nevertheless, according to our previous experience with VATS right lower lobe sleeve resection, these methods are not necessarily required. During surgery, placing a gauze pad in front of the middle lobe and pushing it towards the dorsal side can effectively reduce the distance between the two stumps, facilitating anastomosis, and in our opinion maintaining the integrity of the horizontal fissure may help to prevent the occurrence of middle lobe torsion after operation.

Due to the demanding technical requirements for anastomosis in sleeve resection, performing the surgery through a minimally invasive approach becomes a challenging task. Robot-assisted technology has demonstrated its advantages in sleeve resection due to its 3D vision, rotatable wrists, and tremor filtering. Traditional robot-assisted surgery, though minimally invasive, utilizes multiple ports, contrary to the current international trend favoring single-port surgery in thoracic procedures (2). We present a case demonstrating the successful application of the Shurui SP system via a single intercostal incision, with a smooth surgical process and postoperative recovery, thereby validating the feasibility of this single-port robotic approach for complex lung surgeries.

The Davinci SP system, despite its potential application in lung surgery, is inherently constrained by the necessity of a 2.5 cm cannula, significantly limiting its efficacy in conventional intercostal surgical approaches. Furthermore, alternative surgical routes such as subxiphoid or subcostal approaches present challenges including cardiac compression and compromised visibility, thereby precluding its utilization in complex lung surgeries. Conversely, the Shurui robotic system incorporates a specialized three-hole oval-shaped port specifically designed for thoracic surgery, facilitating the deployment of three robotic arms through intercostal incisions without any obstruction, thus enhancing surgical precision and efficiency. Existing SP robotic systems still exhibit certain limitations, particularly the absence of integrated staples. Consequently, procedures like vessel transection necessitate the use of a VATS stapler by an assistant. However, when the single port occupies a significant portion of the incision, it constricts the workspace for the assistant’s VATS instruments. Therefore, the indispensability of an experienced assistant during single-port robotic surgery is paramount. Moreover, echoing the reported single port RATS surgeries executed with the Davinci Xi system, the assistant must employ two elongated, curved suction devices to facilitate surgical exposure and maintain a clear field of vision.

Conclusions

Shurui single-port robotic system is one option by which to perform complex lung surgeries such as lobectomy with sleeve resection and is recommended in select patients.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-957/rc

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-957/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-957/coif). The authors have no conflicts of interest to declare.

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. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). This surgical approach was approved by the Ethics Committee of The First Affiliated Hospital of Soochow University (No. 2024117) and informed consent was taken from the patient.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Huang J, Li S, Hao Z, et al. Complete video-assisted thoracoscopic surgery (VATS) bronchial sleeve lobectomy. J Thorac Dis 2016;8:553-74. [Crossref] [PubMed]
2. Geraci TC, Ferrari-Light D, Wang S, et al. Robotic Sleeve Resection of the Airway: Outcomes and Technical Conduct Using Video Vignettes. Ann Thorac Surg 2020;110:236-40. [Crossref] [PubMed]
3. Kocaturk CI, Saydam O, Sezen CB, et al. Is Right Sleeve Lower Lobectomy Necessary? Is It Safe? Thorac Cardiovasc Surg 2020;68:235-40. [Crossref] [PubMed]
4. Wang J, Guo J, Shi H, et al. A middle lobe sparing sleeve resection versus bilobectomy for right lower central non-small cell lung cancer: a retrospective propensity score matched cohort study. J Cardiothorac Surg 2024;19:234. [Crossref] [PubMed]
5. Ohata K, Zhang J, Ito S, et al. Right lower lobe sleeve resection: bronchial flap to correct caliber disparity. Ann Thorac Surg 2013;95:1107-8. [Crossref] [PubMed]
6. Boudaya MS, Abid W, Mlika M. Sleeve Right Lower Lobectomy: a Rarely Performed Extended Resection. Indian J Surg 2016;78:74-6. [Crossref] [PubMed]
7. Gonzalez-Rivas D, Bosinceanu M, Manolache V, et al. Uniportal fully robotic-assisted sleeve resections: surgical technique and initial experience of 30 cases. Ann Cardiothorac Surg 2023;12:9-22. [Crossref] [PubMed]
8. Hamasaki H, Shirakami C, Yamada T, et al. Specific techniques for right sleeve lower lobectomy: four case reports. Surg Case Rep 2021;7:38. [Crossref] [PubMed]
9. Inoue H, Tsukioka T, Izumi N, et al. Right Lower Sleeve Lobectomy: Detailed Technique and Perioperative Patient Management. Ann Thorac Cardiovasc Surg 2024;30:24-00026. [Crossref] [PubMed]