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Page 8 of 9 Durand. Mini-invasive Surg 2019;3:35 I http://dx.doi.org/10.20517/2574-1225.2019.31

The size of the wire must not be too thick to prevent the cut of the borders. Because of magnification, the
surgeon might tend to take smaller border margins and quicker steps to progress than in open surgery
during the running suture. It might then be useful to pay attention to the size of the instruments to keep
an accurate scale evaluation of measure.

The surgeons’ hard skills are conserved, indeed enhanced, by the telemanipulator and favor the precise
and tremorless moves of the instruments for either forehand or backhand sutures (bimanual surgery). This
technical improvement ensures manual knot and stitch of distal arteries, which are a key point of these
advanced procedures. First, it is the basis of the surgeon’s hard skills development and retention. Second,
it helps for control and exposure of vascular structures when required. A stapleless artery is safer to
manipulate and the presence of a nude arterial stump to hold can be useful to mobilize/expose the artery.

TM
TM
During our experience, we switched from the Da Vinci Si system to the Xi system. The benefit of this
upgrade is valuable for the surgeon and the operating room setting. With the Si system, we were using a
TM
TM
12-mm camera to ensure the best vision; with the Xi system, the full high definition vision is provided
TM
through an 8-mm camera, and smaller is better for the patient’s postoperative pain. The Si system needed
to be placed on the axis of the scapula line, which limited the head access for the anesthesiologist during
the procedure and prolonged the procedure setting. The Xi system has smaller and wider motion zone
TM
TM
moves than the Si system, as well as an autofocus camera and surgeon console control of the upside-
down twist of camera, which might save time and comfort during the procedure. This might explain the
decreasing trend of procedure lengths between the first half and second half of our series.
In our experience, four-arm robotic bronchial sleeve lung resection and node harvest is safe and feasible.
Patient selection and surgeon’s robotic expertise are mandatory to perform such rare procedures. Dedicated
vascular clamping devices are awaited to enlarge indications to left side and vascular sleeve resections.

DECLARATIONS
Authors’ contributions
The author contributed solely to the article.

Availability of data and materials
Not applicable.

Financial support and sponsorship
None.

Conflicts of interest
Author is an official proctor for Intuitive Surgical.

Ethical approval and consent to participate
Not applicable.

Consent for publication
Not applicable.

Copyright
© The Author(s) 2019.