Robotic sleeve resection for pulmonary disease
© The Author(s). 2018
Received: 1 December 2017
Accepted: 21 March 2018
Published: 2 April 2018
Few studies have described robotic sleeve resection with pulmonary resection. Here, we report the successful implementation of a completely portal robotic sleeve resection with or without pulmonary resection using a modified suture mode.
In total, 339 patients underwent curative robotic pulmonary surgery at Ruijin Hospital between May 2015 and September 2017. Three of these patients underwent robotic sleeve resection (right upper lobe, one; left upper lobe, one; and lingular segmental bronchus, one). Five port incisions were utilized, and a simple continuous running suture combined with two interrupted sutures of the membranous and cartilaginous junction portion was preferred for the anastomosis.
The postoperative course was uneventful for two patients with squamous cell carcinoma. The lingular segmental bronchus patient without pulmonary resection (a salivary gland tumor) underwent short-term atelectasis. The median operation time was 155 (range 132–230) minutes. The median anastomosis time was 25 (range 23–32) minutes. The median length of postoperative hospital stay was 7 (range 6–10) days. There was no mortality or conversion to thoracotomy for any of the patients. All patients were followed for 3–6 months, and there is no tumour recurrence.
Our limited experience suggested that robotic sleeve resection for pulmonary disease with or without pulmonary resection may be safe and effective. The anastomosis time can be shortened with more robotic surgery experiences and the modified suture mode.
Operation time (min)
Chest tube stay (days)
Postoperative hospital stay (days)
3 months recurrence
Schmid et al. 2011 
Interrupted and running
Nakamura et al. 2013 
Pan et al. 2015 
Cerfolio 2015 
Interrupted and running
Zhao et al. 2016 
Lin et al. 2016 
436.7 ± 200.2#
750 ± 1005#
5.3 ± 4.5#
11.3 ± 9.1#
Stenosis 1 pneumonia 1
Pan et al. 2016 
158.4 ± 42.0#
157.1 ± 97.8#
9.0 ± 8.2#
10.7 ± 7.6#
Qiu et al. 2016 
Material and methods
From May 2015 until September 2017, 339 patients underwent curative robotic pulmonary surgery in our department; 236 patients underwent robotic lobectomy, 78 underwent segmentectomy, 22 underwent wedge resection, and 3 underwent sleeve resection. Of the three sleeve resection cases, there were two cases of sleeve lobectomy with bronchoplasty and one case of lingular segmental bronchial sleeve resection without pulmonary resection.
Demographic and preoperative variables
Salivary gland tumour
After these above procedures, one of the ports was enlarged, and the specimen was placed into an Endobag and retrieved through it. The lung was inflated with 30 cm of H2O airway pressure under saline to ensure that there were no air leaks. A 20-F chest tube was placed in the eighth ICS.
Operative and postoperative variables
Postoperative hospital stay (days)
Chest tube stay (days)
3 months recurrence
The first study describing video-assisted thoracoscopic (VATS) sleeve lobectomy was reported in 2002 ; after more than 10 years, there have been only a small number of case series reports [14–18], although the morbidity, mortality, and survival were comparable between VATS sleeve lobectomy and thoracotomy. The slow adoption of the thoracoscopic technique for sleeve resection is mainly due to the technical challenges involved in the bronchial anastomosis in VATS and its steep learning curve .
With the advent of modern technology, surgical robotics has come of age. Robotic-assisted thoracic surgery has many advantages over conventional VATS, such as an additional four degrees of freedom, superior 3-D vision from the binocular camera, tremor filtration, elimination of the fulcrum effect, and improved ergonomic positioning for the surgeon [20–22]. These advantages facilitate procedures that are typically difficult in conventional VATS, such as suturing and knot tying, and surgeons, including residents, have demonstrated significantly better suturing and knot-tying capabilities using the robotic surgical system [23–25].
The first clinical case of robotic sleeve lobectomy was reported by Doctor Schmid in 2011 . The airway reconstruction was performed using the da Vinci robot. It takes 50 min to accomplish the anastomosis, and the da Vinci robot facilitates the technically challenging procedure. Subsequently, seven reports of robot-assisted sleeve lobectomy have been published in the English literature. According to these publications, the performance of the bronchial anastomosis varied according to the surgeons’ preferences (Table 1).
Our own results, in terms of short-term outcomes, operation time, and morbidity rate, are comparable to those reported in the literature [26–33]. The median bronchial anastomosis time was 25 min. Schmid and coworkers  reported an anastomosis time of 50 min. Nakamura and associates  reported an anastomosis with 16 stitches of interrupted sutures that required a long time because the thread was loosened or cut while ligating. In VATS sleeve lobectomy, Chen and colleagues reported a mean anastomosis time of 37.6 ± 12.0 min , and Wang and associates reported a median time of 44 (37–48) minutes for bronchial anastomosis . The main features of our experience are the suture mode and segment bronchial sleeve resection without pulmonary resection.
In our practice, end-to-end bronchial anastomosis using a simple running suture combined with two interrupted sutures of the membranous and cartilaginous junction portions was preferred. In our experience, there are several advantages to using this suture mode. First, we did not put the proximal and distal bronchial stumps together at the beginning of the suture; this not only made the continuous suture of the membranous part easier with double-armed 3-0 Prolene sutures but also minimized the possibility of clamp injury. Second, the two interrupted sutures were tied to pull the proximal and distal bronchial stumps together easily, and this use of two interrupted sutures prevented potential lateral air leaks. Third, the double-armed 3-0 Prolene was tightened without tension and was then tied with the former interrupted suture at each side; this facilitated the running suture of the remaining cartilaginous parts.
We reported the first case of robot-assisted lingular segmental bronchial sleeve resection while totally preserving the lung parenchyma. Segmental bronchial sleeve resection is complex, and the complication rate is possibly increased compared to the standard sleeve resection . Indeed, the patient who underwent lingular segment bronchial sleeve resection experienced a short-term atelectasis. As a result of the therapeutic interventions, the lingular segment achieved full re-expansion during follow-up.
Despite the advantages of robotic sleeve resection have been reported [26–33], the technique also has some potential drawbacks. First, robotic sleeve resection requires four to five incisions, but VATS only requires two to three incisions, sometimes even only a single port. This may increase the postoperative pain and decrease the aesthetic outcome. Second, the cost is higher; in our centre, an extra 30,000 RMB must be paid for the robotic surgery. Third, the setup of the robotic system is time-consuming. Finally, the worst disadvantage of robotic surgery is the inability of the surgeon to use the tactile sense. We have performed more than 500 robotic surgeries with a single surgeon and the same team. The setup time was reduced as the team experience increased, and the surgeon was able to partially compensate for the lack of haptic feedback by visually observing the deformation of tissue while suturing and knot tying. Some researchers and engineers are working on a means of relaying haptic feedback directly to the surgeon’s control actuators [24, 35].
Our limited experience demonstrates that robotic sleeve resection with or without pulmonary resection appears safe and feasible. The anastomosis time can be shortened with an increasing number of robotic surgery experiences and a modified suture mode.
We thank DR Yanan Wang for the medical editing assistance with an earlier version of the manuscript.
This study was supported by the grant from Science and Technology Commission of Shanghai Municipality Medical Guidance Science and Technology Support Project (16411966100).
Availability of data and materials
The datasets used during the current study are available from the corresponding author.
HL contributed to the design of the study. CL drafted the manuscript. BZ and YH contributed to the data collection. HL, CL, RJ and JX contributed to the interpretation of the study. PA, RJ and JX reviewed and accepted the final version of the manuscript. All authors read and approved the final manuscript.
Ethics approval and consent to participate
The study and procedures were conducted in accordance with the 1964 Declaration of Helsinki and its later amendments. The study was also approved by the Ethical Review Board of Ruijin Hospital. Written informed consent was obtained from all patients.
Consent for publication
All patients consented to publish their information details.
The authors declare that they have no competing interests.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
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