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Page 2 of 9 Phillips et al. Mini-invasive Surg 2020;4:12 I http://dx.doi.org/10.20517/2574-1225.2020.02

INTRODUCTION
Robotic resection for lung cancer is becoming increasingly accepted by the thoracic surgery community.
Several recent publications have demonstrated the feasibility, safety, and equivalent oncologic outcomes
for robotic anatomic resections compared to traditional Video-Assisted Thoracic Surgery (VATS) and
[1-6]
improved postoperative outcomes compared to traditional thoracotomy . Advantages of robotic resection
over traditional VATS include improved visualization with three-dimensional viewing, articulated
instruments, and increased flexibility in areas of limited operating space. Previous drawbacks to robotics
have required an experienced bedside assistant for division of the hilar structures with a traditional
VATS stapler, or for the operating surgeon to leave the console to return to the bedside to perform this
critical portion of the operation. In 2014, the da Vinci Xi System (Intuitive Surgical, Sunnyvale CA) was
introduced, with instrument updates in early 2016 which provided a 30-mm curved-tip stapler that was
capable of providing the console surgeon the ability to control and fire staplers for division of vascular,
[7,8]
bronchial, and parenchymal structures . This decreased some of the potential limitations for surgeons to
perform minimally invasive anatomic lung resections by allowing a critical step to be placed back in the
[9]
hands of the operating surgeon at the console .
Currently, there is a paucity of data regarding the perioperative outcomes of robotic anatomic lung
resection comparing robotic staplers to traditional VATS stapling devices. We sought to investigate our
institutional experience with patients undergoing robotic anatomic lung resection stratified by the type of
stapler used over a contemporary period.

METHODS
Patients
A retrospective analysis of an institutional review board approved prospective Thoracic Surgery database
was performed. All consecutive patients who underwent lung resection between 1 January 2015 and 31
December 2018 were included. Patients were excluded if they underwent a non-anatomic resection (wedge),
underwent planned or were converted to a thoracotomy, or had a VATS that did not include the use of the
da Vinci robotic system [Figure 1]. The primary aim of this study was to investigate intraoperative and
postoperative outcomes with the da Vinci EndoWrist® robotic stapler compared to the Covidien Endo
GIA stapler (Medtronic, Fridley MN) in robotic anatomic lung resections. This study was approved by
TM
the Committee for the Protection of Human Subjects (#30040).

Data collection
Demographic data (age, sex, and race), pulmonary co-morbidities, operative data (operative time and stapler
use), pathologic data (stage and lymph nodes collected), postoperative length of stay (LOS), and 30-day
complications were obtained. Operative time, in minutes, was calculated from surgery start and stop times.
Postoperative complications were monitored for 30 days from the index procedure date and graded I-IV as
classified by Clavien-Dindo [10,11] . The primary outcome of interest was presence of a postoperative prolonged
air leak (PAL), which was defined as an air leak lasting more than five days, as defined by the Society of
[12]
Thoracic Surgeons .

Surgical technique
[13]
Anatomic lung resections were performed by two surgeons as previously described . Briefly, all resections
utilized the da Vinci Xi system with a four-arm technique and an additional 15-mm assistant port. The
camera and robotic ports are placed in the 6th-8th intercostal spaces, depending on the tumor site. The
assistant port is placed as low as possible without traversing the diaphragm. When a traditional VATS
stapler is used, 8-mm robotic trocars are placed and the stapler is introduced via the 15-mm assistant port.
[7]
When the robotic stapler is used, one or two 12-mm trocars are placed, as described previously . There are
limited requirements for the assistant to change instruments when the robotic stapler is used, but he/she