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Page 2 of 13 Gharagozloo et al. Mini-invasive Surg 2020;4:55 I http://dx.doi.org/10.20517/2574-1225.2020.42

lung cancer than of colon, breast, and prostate cancers combined. The overall five-year survival for lung
cancer is approximately 23%. This dismal outlook is due, largely, to the fact that over 50% of patients are in
stage III and IV at the time of diagnosis. On the other hand, the five-year survival for patients with stage I
disease is 80%-95%. Besides, it is estimated that at any one time approximately 650,000 patients with early
lung cancer remain undiagnosed. Lobectomy is indicated as the treatment for early-stage lung cancer.

The first report of the use of the Robotic System for lobectomy in the treatment of primary lung cancer
[2]
came from Melfi et al. in 2002. Due to safety concerns, the surgery was converted to a thoracotomy in
two of five patients. Nevertheless, the report demonstrated the feasibility of the procedure. The first robotic
[3]
[4]
lobectomies were reported in 2003 by Morgan et al. and Ashton et al. .
[5]
In 2006 Park et al. reported Robot-assisted thoracoscopic Surgery (RATS) technique which represented
[6]
a hybrid procedure. In 2009, Gharagozloo et al. reported a series of 100 consecutive patients who
underwent the RATS procedure which was performed as a hybrid operation using robotic dissection on a
[7]
video-assisted thoracic surgical (VATS) platform. In the same year, Veronesi et al. described a modified
RATS technique with the use of 4 robotic arms. Since that report, the robotic surgical systems and
instruments have evolved and the procedures have become more standardized, such that in 2015, over 6000
robotic lobectomies were performed in the United States .
[8]

Several factors have been responsible for the greater acceptance and use of robotics for lobectomy: (1)
introduction of robotic dissecting instruments such as the Endotip Bipolar Dissector (curved tip bipolar),
Vessel Sealer, Endowrist Staplers ( curved tip vascular stapler) have facilitated dissection and vascular
control; and (2) the newer robotic surgical platform (DaVinci Xi) which has given active control of stapling
to the surgeon and relegated the bedside assistant to the more passive role of instrument exchange and
specimen retrieval.

More recently, a four-arm completely port-based robotic lobectomy technique (CPRL) was reported by
Cerfolio et al. . This technique is much simpler and more standardized and can be adapted for all the
[9]
lobes. It also allows for relatively more efficient use of the assistant port by the bedside surgeon.

CPRL has become the technique of choice for lobectomy as it is completely port-based, uses 4 arms, and
[9]
CO insufflation. Both Si and Xi da Vinci platforms can be used. As described by Cerfolio et al. , with the
2
da Vinci Si system, the procedure uses three 8-mm ports (left and right robotic arm ports, fourth robotic
arm port), and a 12-mm port (camera). With the Si system, many surgeons also use a 12-mm assistant port
that can be used for stapling, occasional suction, specimen retrieval, and exchange of items such as rolled-
up sponges and vessel loops. The assistant port is also important for the management of bleeding in the
event of a pulmonary artery or vein injury. With the Xi system, three of the ports are 8-mm ports, and the
4th is a 12 mm, however, the camera port and the right and left arm ports are 8 mm, and the 12 mm port is
used for the introduction and firing of the robotic Endowrist stapler.

[10]
Gharagozloo et al. reported their experience with 638 consecutive robotic lobectomies for early-stage
lung cancer. Median operative time was 176 min (range 160-456), Median Chest tube time was 3 days
(2-8 days), Median air leak time was 0 (0-3 days), Median length of stay was 3 days (1-26 days). Minor
complications were observed in 133 patients (21%). The most common complication was atrial fibrillation
which was seen in 13% of patients. Thirteen (2.1%) patients had major complications, including
bronchopleural fistula (3), pulmonary embolism (5), acute renal insufficiency (3), hemorrhage (2).
Conversion to a thoracotomy occurred in 11 (1.7%) patients. 6/11 conversions were for bleeding. The other
conversions (5/11) was due to anatomic and oncologic reasons. There were 3 deaths (0.5%). All 3 deaths
occurred in the first 20 patients and during the learning curve of the procedure. This was attributed to