A 61-year old woman with chronic obstructive pulmonary disease but no history of smoking was found to have a right inferior lobe mass by computed tomography (CT) scan during health checkup. Adenocarcinoma was diagnosed by lung puncture. The right main and upper lobe bronchus were not involved. Positron emission tomography (PET)-CT and cerebral magnetic resonance imaging showed no distant metastasis. Preoperative blood analysis and tests of lung, cardiac, liver and renal function were normal. No superficial lymph node enlargement was detected on physical examination. The clinical stage was cT1N0M0. Informed consent for robotic-assisted thoracic lobectomy was obtained from patient before operation (Figure 1).
Anesthesia and body position
The patient received general anesthesia by double-lumen endotracheal intubation and was placed in the lateral decubitus position and in a jackknife position (Figure 2).
The port positions
After the patient was prepped and draped in the usual manner, we placed five ports as follows: a 12-mm camera port was placed in the 8th intercostal space (ICS) at the mid axillary line, and three 10-mm working ports were placed separately in the 5th ICS at anterior axillary line (#1 arm), 8th ICS at the right posterior axillary line (#2 arm), and the right 8th ICS which was 2 cm from the spine (#3 arm). Finally, an auxiliary port was created in the 7th ICS between the camera port and the right working port, about 8-cm far from the right working port (Figure 3).
Connection of robot patient cart
The robot patient cart was positioned directly above the operating table. Two bipolar forceps and one unipolar cautery hook were attached to the arms. An incision protector was placed in the auxiliary port.
The patient was routinely given anti-inflammatory and phlegm resolving treatment postoperatively. The chest tube was withdrawn after 2 days, and the patient was discharged 6 days later after surgery. No complications were occurred during hospitalization. The pathological stage was T1aN0M0 (stage IA).
Currently in our institution, the 3- or 4-arm method is mainly used. When the patient has a small physique, the 3-arm method may reduce interference between arms. However, the 4-arm method become more popular, because the visual field can be set at any angle in the thoracic cavity. Therefore, the position of each port is important. Nakamura et al. suggested a 9-cm distance should be set between ports to reduce interference between surgical arms (1). In our experience, a distance of 8–10 cm effectively reduces the interference between arms. Cerfolio et al. described a complete robotic lobectomy setting all the ports concentrating in the 7th ICS (2,3), and this method was considered applicable for all lobectomies (1).
Conflicts of Interest: The authors have no conflicts of interest to declare.
Informed Consent: Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images.
- Nakamura H, Taniguchi Y. Robot-assisted thoracoscopic surgery: current status and prospects. Gen Thorac Cardiovasc Surg 2013;61:127-32. [Crossref] [PubMed]
- Cerfolio RJ, Bryant AS, Skylizard L, et al. Initial consecutive experience of completely portal robotic pulmonary resection with 4 arms. J Thorac Cardiovasc Surg 2011;142:740-6. [Crossref] [PubMed]
- Cerfolio RJ, Bryant AS, Minnich DJ. Starting a robotic program in general thoracic surgery: why, how, and lessons learned. Ann Thorac Surg 2011;91:1729-36; discussion 1736-7.
Cite this article as: Yang S, Guo W, Jin R, Zhang Y, Chen X, Wu H, Du H, Han D, Chen K, Xiang J, Li H. Robotic-assisted thoracoscopic surgery: right inferior lobectomy. AME Med J 2017;2:14.