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Durand. Mini-invasive Surg 2019;3:35 I http://dx.doi.org/10.20517/2574-1225.2019.31 Page 7 of 9

[8]
benefit in terms of disease-free survival and do not push for technical achievement . In our series of ten
patients, 4 had carcinoid tumor, 5 had squamous cell carcinoma (SCC), and only 1 adenocarcinoma; none
had node involvement. It makes sense, as SCC and carcinoid tumors are more proximal, endobronchial
diseases than other tumors and might be more subject to such procedures.

The selection of patients is mandatory and we summarize some criteria below regarding patient status and
tumor standard:
[9]
- Either poor lung function or patient’s comorbidities to avoid pneumonectomy outcome .
- R0 achievement.
- Low degree of aggressiveness of disease (carcinoid tumors and N0 disease).

In our experience, the tumor size is not a major limit as we have removed tumors with size up to 85 mm.
The distance between the tumor and the vascular structure is more limiting than the size itself. We are
still waiting for appropriate tools to clamp either the pulmonary artery or the pulmonary vein to allow safe
vascular sleeve resection. That might explain why we have only performed right-side bronchial sleeve, as
most left-side bronchial sleeve cases require a proximal vascular control.

In our experience, it is a bloodless surgery [mean blood loss: 57 mL (± 57)]. Hemostasis during the
procedure is cautiously realized as the dryness of the operating field is mandatory to assess good vision
(red color decreases brightness and contrast).

The patients were placed in lateral lying position without bending the table to avoid any limitation of the
venous flow of the lower body, which combined with the capnothorax might trouble the cardiac input.
The partial W-shaped port position ensures a non-conflicting position of the arms and instruments
either outside or inside. It can be applied for any anatomical lung resection and is the same for the left
side (mirror effect). The principle is to have the camera above the hands, similar to how the head is above
the shoulders, and to have an assistant on the side coming perpendicularly. This setting avoids conflict
and allows a complete control of the chest target zones. The 30° vision is also important for providing
an overview of the target and to avoid blind spots while twisting the camera. At the beginning of the
procedure, the chest wall is viewed through 30°-up vision and the procedure is achieved through 30°-down
vision. The third-hand position is also meant to avoid conflict with the left hand, inside or outside, as it
enters 90° to the chest, higher and closer to the spine.

For ML bronchial anastomosis, the exposure change (from fissure view for resection of the bronchus to
posterior view behind the pulmonary vein) is of great interest for presenting the 2 bronchial borders and
vanishing pulmonary artery away from the suturing zone. The versatility of exposure during robotic
surgery must be exploited.

The use of barbed wire secures the tension adaptation of the running suture, but it is not mandatory.
Previously published small series of patients have described the use of braided waxed sutures such as Vicryl
running sutures or separate sutures and the use of monofilament such as polydioxanone [6,10-14] . These papers
show similar outcomes to our series but do not describe our fully-closed-chest four-arm robotic technique.
The use of absorbable monofilament might be tricky as its elasticity might be difficult to handle without
haptic feedback. The choice of the needle is also important, as it must be small (17 mm) and semicircular
to be scaled and fit to the instruments and bronchial structures. To limit the risk of wire rupture while
knotting due to excess of “manual” tension, we suggest the use of the strongest V-Loc , i.e., 180. Even
TM
then, the surgeon must be aware of this risk and be as delicate as possible while applying distraction force
on the wire. The barbed suture does not require more than four knots to be stable, which is fewer than
monofilament wires. The lack of haptic feedback is balanced by enhanced vision in most situations.