Robotic-assisted thoracic surgery (RATS) provides excellent visualization and instrument dexterity; however, pulmonary artery (PA) management remains one of the most critical and potentially hazardous steps, particularly when dealing with small-caliber branches. Although energy devices are widely used for vessel sealing, concerns remain regarding sealing reliability, thermal injury, and limited safety margins in fragile pulmonary arteries. Mechanical clipping, on the other hand, offers secure occlusion but may be technically challenging in confined robotic fields when used alone. We describe a clipping plus vessel sealing (CV) technique for the management of small PA branches during RATS. This approach integrates the mechanical security of a proximal polymer clip with distal transection using a bipolar vessel sealing device. After circumferential skeletonization of the target branch, a Hem-o-lok clip is applied proximally at an appropriate distance from the vessel origin, followed by distal sealing and division with an energy device. Particular attention is paid to clip positioning, spacing between the clip and the sealing site, and gentle withdrawal of the clip applier to avoid inadvertent vessel injury. In our institutional experience, this technique was applied to 41 small PA branches (with an estimated diameter of ≤5 mm) in 28 patients undergoing robotic lung resection, with a median of 1 branch per patient (range, 1-3), without intraoperative bleeding or technique-related complications. The CV technique provides an additional safety margin by serving as a mechanical backup to the energy seal, thereby minimizing the risk of uncontrolled hemorrhage even in the event of incomplete sealing. Furthermore, distal application of the energy device may help reduce thermal spread to the vessel root. The CV technique represents a practical and structured approach for PA management in RATS using standard robotic instruments without additional cost or complexity. This approach may be particularly useful for surgeons introducing robotic lung resection, trainees in robotic surgery, or experienced surgeons seeking to further enhance safety when managing small pulmonary arterial branches.
Identifying the intersegmental plane (ISP) of the target segment is a key step in anatomical segmentectomy. Although multiple methods are available for ISP identification, the most appropriate approach for segmentectomy remains unclear. Traditionally, intersegmental veins or inflation-deflation lines have been used to demarcate the ISP. In the last decade, near-infrared fluorescence imaging combined with intravenous indocyanine green (ICG) injection has become widely used for ISP identification. More recently, an original method using the concave portion of the apical visceral pleura has been introduced as a simple ISP demarcation approach in patients undergoing anterior or apical segmentectomy. Small tumors indicated for segmentectomy have distinct computed tomography (CT) and intraoperative characteristics, such as ground-glass opacity, solid nodules, and features indicating whether the tumor location is detectable or undetectable during surgery. Thus, ISP identification methods should be selected according to these tumor characteristics. In sublobar resection, securing an adequate surgical margin is essential to avoid cancer recurrence. Specifically, determining whether the tumor location is detectable or undetectable during surgery is vital for ensuring an adequate surgical margin. Therefore, in segmentectomy for detectable tumors, approximate ISP identification can be achieved via the ICG method or simple demarcation of apical structures on the lung, because the distance from the tumor can be confirmed to ensure an adequate surgical margin. Conversely, segmentectomy for undetectable tumors requires more precise ISP identification using a combination of the ICG method, intersegmental vein demarcation, and inflation-deflation. In summary, the appropriate combination of intersegmental identification methods should be selected based on specific tumor characteristics.
Dual-portal robotic-assisted thoracic surgery (DRATS) is a reduced-port robotic approach intended to preserve the core advantages of robotic surgery while limiting the number of intercostal entries. Anatomical segmentectomy requires precise bronchovascular identification, reliable intersegmental plane (ISP) control, and appropriate patient selection, particularly in complex segmentectomy where bronchial misidentification or suboptimal parenchymal division can compromise procedural safety. This article provides a step-by-step, multimedia guide to a standardized DRATS workflow for anatomical segmentectomy. The workflow includes patient-specific preoperative three-dimensional planning, laterality-specific port placement and arm assignment, coordinated console-patient-side teamwork, and protocolized confirmation steps. Intravenous indocyanine green (IV-ICG) fluorescence imaging is used for ISP delineation, while bronchial verification is applied selectively when anatomy is complex or bronchial misidentification is a concern. Two representative videos, right S6 and left S1+2 segmentectomy, demonstrate how the same standardized operative sequence can be adapted to different segmental anatomies. We also summarize perioperative outcomes from a consecutive institutional cohort, including operative time, blood loss, chest tube duration, length of hospital stay, complications, and R0 resection, to provide context for feasibility and safety. DRATS may be a useful reduced-port option for parenchyma-sparing robotic segmentectomy in appropriately selected patients, without implying superiority over multiport or uniportal robotic approaches. Standardized setup, careful planning, coordinated patient-side workflow, and selective verification steps may improve reproducibility and reduce avoidable technical errors during adoption.
Uniportal robotic-assisted thoracoscopic surgery (U-RATS) lung resection using the daVinci Xi surgical system combines the advantages of robotic surgery, namely, superior articulated dexterity of instruments and high-definition three-dimensional (3D) visualization, with the benefits of uniportal video-assisted thoracoscopic surgery (U-VATS), which is characterized by minimal chest wall disruption and accelerated recovery through minimized postoperative pain. This novel approach utilizes a single 4-cm incision at the 5th or 6th intercostal space near the midaxillary line for the camera and two instrument arms. With respect to arm placement, we adopted the cross-arm technique after gaining experience with the original parallel technique, thereby minimizing physical interference between the robotic arms. In U-RATS, because the bedside surgeon faces limitations in maintaining surgical field visibility, the console surgeon must actively clear the field. This is achieved using both robotic arms to hold gauze rolls, thereby enabling efficient dissection via the "hot tearing" technique with SynchroSeal. For lung resection, while robotic staplers are an option, manual staplers combined with reinforcement material are preferred, particularly for patients with interstitial lung disease or emphysema. Because the use of manual staplers in U-RATS lung resection limits the robotic system to a single-arm retraction, the silk loop technique is highly effective for vascular and bronchial traction in such scenarios. During the initial implementation phase, a caudal port should be added for dual-portal RATS if stapler insertion becomes challenging. Technical proficiency can be established through dry lab training and by analyzing overhead video footage. With a proper setup and mastery of these specialized maneuvers, U-RATS offers a safe and reproducible minimally invasive procedure.
Rib fractures are a common consequence of chest trauma. In some instances, the presence of rib fractures may cause chest instability, leading to respiratory failure, dependance from ventilatory support and increased risk of pulmonary infections. Surgical stabilization of rib fractures (SSRF) is a well-established treatment to restore the stability of the rib cage and prevent respiratory complications. While this procedure is commonly performed through an open approach that allows a wide exposure of the ribs surface, in recent years a minimally invasive procedure consisting in thoracoscopic-assisted rib plating has been introduced. The lower invasiveness of this technique is associated with excellent post-operative outcomes. We present the case of a patient with post-traumatic flail chest treated with thoracoscopic rib stabilization, with a video describing the surgical procedure step-by-step. The sixth and the seventh left rib were stabilized with dedicated intrathoracic bridges. Surgery time was 120 minutes. The patient was extubated 8 hours after surgery. Pain score decreased from 6/10 to 2/10 according to the Numeric Rating Scale and respiratory parameters improved, with partial pressure of arterial oxygen (PaO2)/inspiratory fraction of oxygen (FiO2) increasing from 250 to 420. Discharge occurred on post-operative day 8. Thoracoscopic rib plating demonstrated to be a viable, seemingly less invasive treatment option for rib fractures with chest instability. The lower invasiveness of a minimally invasive approach and the anatomical basis to favor an intrathoracic deployment of the costal implants makes the procedure particularly suitable for this indication. Comparative prospective trials are required to confirm our findings.
Hartmann's reversal following prior multiple laparotomies represents on of the most technically challenging procedures in colorectal surgery. Dense adhesions, altered anatomy, and impaired tissue planes increase the risks of enterotomies, anastomotic complications, and conversion to open surgery. Although minimally invasive techniques offer improved postoperative recovery, their role in complex reoperative settings remains limited, prefering an open approach. This article presents a structured laparoscopic approach to enhance safety and reproducibility. A standardized laparoscopic Hartmann reversal was performed in a patient with a history of multiple open abdominal surgeries. The standardization proposed in this article is based on the systematic application of the following operative steps. Peritoneal access was obtained through the colostomy site using an Alexis® retractor to ensure controlled entry and stable pneumoperitoneum. Adhesiolysis was conducted using a cold-blade technique to minimize thermal injury. Following mobilization of the rectal stump and proximal colon, a Knight-Griffen stapled colorectal anastomosis was performed. Indocyanine green (ICG) fluorescence angiography was employed to assess bowel perfusion. Anastomotic integrity was evaluated using an air-leak test, a selective reinforcement using barbed sutures when then performed. Postoperative care followed the enhanced recovery after surgery (ERAS) protocol. The procedure was completed laparoscopically without conversion. No diverting stoma was required. The postoperative course was uneventful, and the patient was discharged on postoperative day three. This approach may reduce morbidity and facilitate early recovery, supporting the adoption of minimally invasive techniques even in challenging Hartmann reversals. As experience accumulates and technologies such as ICG become integrated into routine practice, minimally invasive reversal surgery is likely to become increasingly standardized, safe and feasible even in highly complex reoperative settings.
Segmentectomies are potentially more complex than lobectomy because of gradually more complex anatomic relationships between more delicate bronchovascular structures. Operative approaches include thoracoscopic (multiport, uniportal), and robotic. The details of surgical technique continue to evolve, especially for so-called "atypical" or "complex" segmentectomies. In theory, most segments are amenable to individual resection or may be resected as a portion of bisegmentectomies (e.g. lingular resection). Most surgical approaches involve an anterior approach and at least some dissection within the fissures to identify the pulmonary artery and its branches. This approach may work well for segments whose bronchovascular hila are readily accessible anteriorly, such as segments S3, S7, and S8. However, the hila of other segments, specifically S2, S6, S10, and often S1 are located posteriorly and complex dissection is required through an anterior approach just to reach their hila. The posterior approach aims to simplify the surgical procedure, minimize surgical tissue trauma and preserve tissue planes. This may help minimize air leaks, decrease postoperative complications and length of stay, and facilitate future surgical resections in the case of metachronous lesions. This paper describes the anatomic rationale and step-by step technique for a posterior approach for right-sided segmentectomies S1,2,6,10.
Uniportal robotic-assisted thoracic surgery (U-RATS) has gained increasing attention as a further evolution of minimally invasive thoracic surgery. However, the da Vinci Xi system was originally designed for multi-port procedures, and its application in a uniportal setting presents technical challenges, including robotic arm interference and difficulty in stapler manipulation. Although dedicated single-port robotic platforms have been developed, their adoption remains limited. We present a modified uniportal robotic-assisted lobectomy technique using the widely available da Vinci Xi system. This approach combines a single-incision fifth intercostal access with the cross-arm technique to minimize arm interference and enable safe, surgeon-controlled robotic stapling. Optimized arm configuration allows stable visualization and effective manipulation within a single incision. In our experience of 120 consecutive cases, this technique was safely performed with acceptable perioperative outcomes. The median operative time and blood loss were within acceptable ranges, and conversion to thoracotomy or video-assisted thoracic surgery (VATS) was required in a limited number of cases. Postoperative recovery was generally favorable, with early mobilization and a short hospital stay. Without requiring a dedicated single-port robotic platform, this approach offers a practical and reproducible option for uniportal robotic lobectomy. This technique may facilitate broader adoption of U-RATS, particularly in institutions already equipped with multi-port robotic systems.
Since 2021, multiportal robotic-assisted thoracic surgery (RATS) has developed into a more minimally invasive approach, uniportal RATS, as conventional multiportal video-assisted thoracic surgery (VATS) has developed into uniportal VATS. The uniportal pure RATS allows surgeons to perform a minimally invasive approach in which all procedures are robotically controlled. Although uniportal pure RATS seems to be the ultimate surgical approach, this approach is not applicable to every patient owing to the following technical issues. The handling difficulties of the robotic stapler in uniportal pure RATS due to the insufficient distance from the trocar to the hilar structure seem to limit the surgical indications in some patients, such as patients with short stature and those undergoing middle lobectomy, complex segmentectomies in the lower lobe, and dissection of the inferior pulmonary vein. Alternative approaches are useful for overcoming the limitations of uniportal pure RATS. In this report, we present our surgical methods for uniportal hybrid RATS and biportal pure RATS with a subcostal port as alternatives to uniportal pure RATS. In uniportal hybrid RATS, we describe the placement of standard 8-mm trocars in a triangular configuration and the manipulation of forceps in head-to-tail positioning to avoid collisions between the trocars and robotic arms. In biportal pure RATS, we describe the insertion of an additional port placed under the costal arch to reduce pain at the port site and to provide sufficient distance from the hilar structure.
Robot-assisted thoracic surgery (RATS) has evolved toward reduced-port approaches to further minimize surgical invasiveness. However, current uniportal RATS techniques are associated with technical challenges, including limited working space and instrument interference, particularly in patients with smaller physiques. To overcome these limitations, we developed a non-assistant help operation in dual-portal RATS (neoDRATS), which fully utilizes all four arms of the da Vinci Xi system without canceling any arm. This technique enables console-surgeon-driven lung retraction and robotic stapling through a dual-portal configuration consisting of a 4-cm main incision and a single auxiliary port. In this article, we describe the step-by-step surgical technique of neoDRATS, including patient positioning, port placement, robotic arm configuration, use of the third arm, and robotic stapling strategies. Representative operative videos of right upper and left lower lobectomy are provided to illustrate key technical aspects and demonstrate the feasibility of this approach in clinical practice. neoDRATS offers a practical reduced-port RATS approach that balances minimal access with operative safety and maneuverability, while preserving familiar surgical views and workflows from conventional video-assisted thoracic surgery (VATS) and thoracotomy. This technique may facilitate the safe and reproducible adoption of reduced-port robotic thoracic surgery in a wide range of clinical settings, particularly for anatomical pulmonary resections. Furthermore, this approach may help bridge the gap between conventional multiport RATS and uniportal techniques by combining technical stability with reduced invasiveness.
Background:Anomalous left circumflex coronary artery (ALCx) is a rare condition where the left circumflex artery (LCx) originates from the right sinus of Valsalva (RSV) or the proximal right coronary artery (RCA). In some cases, this condition carries a risk of ischemic manifestations related to its course and anatomical features, potentially leading to extrinsic compression by surrounding structures. Hereditary hemorrhagic telangiectasia (HHT) is characterized by the presence of multiple arteriovenous malformations and hemorrhagic manifestations, but it is also associated with a prothrombotic state. We present the first reported case of acute coronary syndrome (ACS) in which extrinsic compression of the ALCx was documented by intravascular imaging. Case Description:We present the case of a 56-year-old patient with HHT associated with chronic anemia, treated with requiring periodic supplementation, and chronic coronary syndrome due to previous ACS involving the left main and left anterior descending artery, on single antiplatelet therapy. The patient was on the heart transplantation waiting list because of severe left ventricular dysfunction, recurrent heart failure, and ventricular arrhythmias. He was admitted for chest pain and dyspnea and was diagnosed with non-ST-elevation myocardial infarction (non-STEMI) complicated by acute heart failure exacerbation with diffuse crackles on lung examination and B-type natriuretic peptide 1,372 pg/mL. The first percutaneous coronary intervention (PCI) resulted in stent implantation in the ALCx, but the patient subsequently developed early in-stent thrombosis. Optical coherence tomography (OCT) revealed extrinsic compression of the ALCx and the implanted stent, related to the retro-aortic course of the vessel, which likely contributed to the thrombotic mechanism. The patient was discharged on dual antiplatelet therapy (DAPT) with escalation from clopidogrel to the more potent P2Y12 inhibitor ticagrelor despite the underlying hemorrhagic risk. During follow-up, no recurrent stent thrombosis occurred, and the patient underwent heart transplantation nine months later. Conclusions:This case illustrates how ALCx may be associated with extrinsic compression of the vessel and possibly a stent, contributing to the pathogenesis of ischemic events. It also raises the question of the optimal treatment of coronary lesions in ALCx, particularly when thrombotic and hemorrhagic risks coexist.
Minimally invasive repair of inguinal hernias offers several advantages over the conventional open approach in the context of reduced postoperative pain and faster return to daily activities with a non-inferior recurrence rate. With the increasing adoption of robotic platforms in surgical units worldwide, robotic transabdominal pre-peritoneal (rTAPP) repair has become an increasingly popular option offered to the patients. Successful surgical outcomes for any minimally invasive inguinal hernia depend on thorough understanding of the internal landmarks of myopectineal orifice (MPO). A conceptual framework such as inverted Y or 5 triangles described by Furtado et al. is essential to be understood prior to embarking on any minimally invasive inguinal hernia repair. While complex inguinal hernia repairs have traditionally been relative contraindication for laparoscopic repair due to technical difficulties, the robotic approach may help overcome these challenges. What sets this technique apart is the integration of a structured teaching framework designed to standardise the dissection process. We present the case of an 82-year-old female who underwent rTAPP for bilateral inguinal hernias, classified per the European Hernia Society (EHS) as right (P L2M0F1) and left (P L1M0F1). Following Veress needle insufflation, a 12-mm visiport was inserted in the right pararectal space, with two 8-mm robotic ports placed in linear alignment. Instrumentation included a bipolar grasper, camera, and monopolar scissors. A self-adhesive mesh and barbed sutures were introduced intra-abdominally at the outset. Total operative time was 80 minutes. The urinary catheter was removed post-procedure, and the patient was discharged the same day following an uneventful recovery. In this surgical technique we visually overlay Furtado's concept onto the robotic intraoperative view to create a reproducible anatomical roadmap. By mapping these defined safety and danger zones during the robotic dissection, we translate theoretical anatomy into a practical, stepwise intraoperative guide. This educational overlay aims to enhance reproducibility, anatomical orientation during the surgical learning curve, and potentially reduce complications or recurrence by promoting consistent identification of key landmarks. Whilst further randomised studies comparing robotic and laparoscopic approaches are needed to fully assess the role of robotic approach in surgical treatment of inguinal hernias, this visual framework serves as a training tool for surgeons adapting rTAPP.
