1. Robotic Lobectomy: Left Lower Lobectomy by Surgery
Carmelina Cristina Zirafa, MD, Federico Davini, MD, Gaetano Romano, MD, Franca Melfi, MD 
Operative Techniques in Thoracic and Cardiovascular Surgery 
Volume 22, Issue 1, Pages (March 2017)
DOI: /j.optechstcvs
Copyright © 2017 Elsevier Inc. Terms and Conditions

2. Figure 1
(A) Patient position. To perform a robotic lobectomy, general anesthesia with single-lung ventilation is required. The patient is positioned in lateral decubitus, as for a posterior-lateral thoracotomy, with the operating table tilted at the tip of the scapula. In addition, in female patients, it is helpful to place a pillow under the kidney area to align the scapula and the hip, avoiding potential injuries to the hip from the camera port.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 43-57DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

3. Figure 1
Continued (B) Port mapping. The camera port is positioned in the seventh or eighth intercostal space on the posterior axillary line. CO2 insufflation (5-8 mm Hg) is applied at this point to facilitate lung collapse and to push the diaphragm downward. The posterior ports are then positioned (when possible, depending of the chest dimension) along the same intercostal space (seventh to eighth intercostal space) and in the auscultatory area (between the posterior rime of the scapula and the spine). The anterior port is positioned in the fifth to sixth intercostal space on the anterior axillary line, just over the diaphragm. Considering the variability of individual chest dimensions, it is recommended to check the position of each port through the internal camera view to ensure the highest posterior port access at the level of posterior interlobar fissure. With the XI system, it is possible to place the access ports at closer distances, maintaining alignment within the same intercostal space, to decrease postoperative pain. When using robotic staplers, it is advisable to make the surgical access incisions as low as possible to increase robotic arm maneuverability.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 43-57DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

4. Figure 1
Continued (C) SI port mapping with utility incision. A utility incision between the camera port and the anterior port is recommended during one's initial robotic surgical experience. This port mapping is applicable on the right and the left side for all lobectomies.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 43-57DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

5. Figure 1
Continued (D) (SI) Surgical cart positioning. When the SI system is used, the cart is positioned at the head of the patient, and the central point of the column of the cart must be in line with the longitudinal axis of the camera port. A correct distance between the cart and the patient is identified when the marker is at the center of the blue line.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 43-57DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

6. Figure 1
Continued (E) (XI) Surgical cart positioning: laser line allows correct position of the cart. When using the XI system, the cart can be positioned either in the back or in front of the patient. When the robot is driven for docking, a laser line is activated to facilitate the correct positioning. The laser crosshairs must be pointed to the camera port. When the camera is inserted and pointed toward the hilum, the auto-targeting feature can be activated, identifying optimal robotic arm placement. When the cart is placed in the back of the patient, the anesthesiological station is located behind the patient's head. To give the surgical assistant at the table a better view and ability to check the robotic control unit, the control and vision unit should be positioned near the patient's feet. Surgical console can be placed in a corner of the operative room.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 43-57DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

7. Figure 2
(A, B) Dissection of the ligament and section of the vein by stapler. Currently, the instruments used during all major lung resections, including left lower lobectomy, are standardized. A monopolar (eg, Hook, Scissors, Intuitive Surgical, Inc., Sunnyvale, CA) or bipolar instruments (eg Maryland, Intuitive Surgical, Inc. Sunnyvale, CA) and a grasper (eg, Cadiere, ProGrasp, Intuitive Surgical, Inc. Sunnyvale, CA) are used for the hilum dissection to hold the lung and to surround the vessels and the bronchus. The dissection of the hilar structures can be performed by action of monopolar and/or bipolar instruments, whereas a grasper, through the fourth arm, is used to retract the lung to obtain the optimal exposure of the mediastinum thanks to the right tension of the structures. The left lower lobectomy is performed using a caudal approach. After the retraction of the lung cephalad, the pulmonary ligament is the first structure to be identified; it is incised up to the inferior pulmonary vein and any lymphadenopathy present in station 9 is removed. The inferior pulmonary vein is isolated and surrounded by a vessel loop and then divided with the stapler. During the isolation of the vein, it is advisable to stop the CO2 insufflations to reduce the vein's collapse and to obtain an easier dissection.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 43-57DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

8. Figure 2
(A, B) Dissection of the ligament and section of the vein by stapler. Currently, the instruments used during all major lung resections, including left lower lobectomy, are standardized. A monopolar (eg, Hook, Scissors, Intuitive Surgical, Inc., Sunnyvale, CA) or bipolar instruments (eg Maryland, Intuitive Surgical, Inc. Sunnyvale, CA) and a grasper (eg, Cadiere, ProGrasp, Intuitive Surgical, Inc. Sunnyvale, CA) are used for the hilum dissection to hold the lung and to surround the vessels and the bronchus. The dissection of the hilar structures can be performed by action of monopolar and/or bipolar instruments, whereas a grasper, through the fourth arm, is used to retract the lung to obtain the optimal exposure of the mediastinum thanks to the right tension of the structures. The left lower lobectomy is performed using a caudal approach. After the retraction of the lung cephalad, the pulmonary ligament is the first structure to be identified; it is incised up to the inferior pulmonary vein and any lymphadenopathy present in station 9 is removed. The inferior pulmonary vein is isolated and surrounded by a vessel loop and then divided with the stapler. During the isolation of the vein, it is advisable to stop the CO2 insufflations to reduce the vein's collapse and to obtain an easier dissection.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 43-57DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

9. Figure 3
(A, B) Artery dissection and apical segmental artery surrounded with vessel loop. Artery phase. The fissure is incised, when incomplete, dissecting the lymph nodes to expose the arterial branches of the basal and superior segments. Taking into account anatomic variability, each branch of the artery is isolated, surrounded with a vessel loop, and divided with a stapler. Smaller vessels can be ligated with titanium clips or Hem-o-lok clips (Teleflex Incorporated, Wayne, PA), binding (linen 2.0) or specific sealing or cutting instrument, like Vessel Sealer (Intuitive Surgical Inc., Sunnyvale, CA).
Operative Techniques in Thoracic and Cardiovascular Surgery  , 43-57DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

10. Figure 3
(A, B) Artery dissection and apical segmental artery surrounded with vessel loop. Artery phase. The fissure is incised, when incomplete, dissecting the lymph nodes to expose the arterial branches of the basal and superior segments. Taking into account anatomic variability, each branch of the artery is isolated, surrounded with a vessel loop, and divided with a stapler. Smaller vessels can be ligated with titanium clips or Hem-o-lok clips (Teleflex Incorporated, Wayne, PA), binding (linen 2.0) or specific sealing or cutting instrument, like Vessel Sealer (Intuitive Surgical Inc., Sunnyvale, CA).
Operative Techniques in Thoracic and Cardiovascular Surgery  , 43-57DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

11. Figure 4
(A, B) Bronchus phase. The lower lobe is retracted medially and cephalad divided with the stapler after an accurate dissection. Finally, the lobe is removed in a sterile bag through the anterior port enlarged approximately about 3 cm.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 43-57DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

12. Figure 4
(A, B) Bronchus phase. The lower lobe is retracted medially and cephalad divided with the stapler after an accurate dissection. Finally, the lobe is removed in a sterile bag through the anterior port enlarged approximately about 3 cm.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 43-57DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

13. Figure 5
(A, B) Mediastinal lymphadenectomy phase. Usually, dissection of hilar lymph nodes (N10, N11) is performed simultaneously with vascular and bronchial isolation. The mediastinal lymphadenectomy is performed after the removal of specimen, paying specific attention to N5, N6, N7, N8, and N9 stations, according to the Naruke map.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 43-57DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions

14. Figure 5
(A, B) Mediastinal lymphadenectomy phase. Usually, dissection of hilar lymph nodes (N10, N11) is performed simultaneously with vascular and bronchial isolation. The mediastinal lymphadenectomy is performed after the removal of specimen, paying specific attention to N5, N6, N7, N8, and N9 stations, according to the Naruke map.
Operative Techniques in Thoracic and Cardiovascular Surgery  , 43-57DOI: ( /j.optechstcvs )
Copyright © 2017 Elsevier Inc. Terms and Conditions