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Implementing The Single Port Robot In Thoracic Surgery: Lessons From The Learning Curve
Mansi Shah, Alan Parr, Madison Sands, Shari Meyerson.
University of Kentucky, Lexington, KY, USA.
BACKGROUND:Single Port (SP) robotic technology was approved for thoracic surgery in the United States in 2024. Although early studies have demonstrated the feasibility and safety of this technique in thoracic surgery, there is still much to learn about the adoption of the technique. Our goal is to describe the real-world experience of implementing the newly approved SP robotic platform in a thoracic surgery practice including benefits and challenges.
METHODS:The first 41 SP procedures performed at a single academic tertiary care center were reviewed to identify benefits, challenges, and solutions developed during the learning curve. Patient demographic data, procedure types, and early outcome data were used to qualitatively analyze the experience grouping the observations into themes and identifying iterative changes in approach or technique during the learning curve.
RESULTS:41 procedures were performed by 2 surgeons during the first 162 days after completing training on the system. Procedure types included 3 subcostal mediastinal mass resections, 7 subxiphoid resections, 16 wedge resections, 13 anatomic lung resections, and 2 diaphragm plications. Two lobectomies were converted to thoracotomy due to unexpected lymph node invasion of the airway and pulmonary artery. One postoperative diaphragm hernia was encountered requiring reoperation. Lessons learned were categorized as patient selection, positioning, incision management, instrument management, or stapler use (Table 1). Of 35 patients with postoperative clinic visits to date, excluding the conversions and reoperation, more than half of the patients used no narcotics after discharge. Only 2 patients received narcotic refills postoperatively.
CONCLUSIONS:The SP robotic platform is a safe and effective approach for a wide variety of procedures in thoracic surgery. Our lessons learned may help others facilitate successful adoption of this technology. The observation of limited need for postoperative opiates suggests possible advantages to this approach which need to be more fully studied.
Table 1: Lessons Learned| Challenge | Observation/Solution |
| Patient Selection | Maximum BMI completed: 39 Maximum height completed: 5"11 (subcostal), 6"2" (subxiphoid) |
| Positioning | Keep shoulders perpendicular to table and shift only the hips slightly posterior |
| Incision Management | Lighted breast retractor used to visualize plane between peritoneum and diaphragm muscle |
| Setup/Docking | Subxiphoid: use small ring; large ring obstructs instrument angle (regardless of camera above or below) |
| Exposure | Use a cigarette longitudinally along the lung and place the anterior retractor arm parallel to the cigarette to maximize retraction field and avoid cigarette blocking view |
| Instrument Management | If burping in port during the case (to obtain extra reach), bring camera back with instruments, ensure the cluster is in center of incision, then reset CRC |
| Stapler Management | Once stapler is close, use "adjust" mode to align stapler for optimal angle; then use "camera" mode to visualize the distal tip of stapler |
| Specimen Removal | Use Applied Medical 12/15 mm specimen bag through the assistant port of the globe to retrieve large specimens |
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