PURPOSE: The high magnification with the DaVinci Robot (10 - 15x), unfamiliar camera angles, and the normal tendency for anatomic variations, may lead to anatomic problems during robotic lobectomy.
METHODS: We review 10 robotic lobectomy cases that required conversion to a VATS procedure or thoracotomy because of uncertainty about the anatomy. Three cases were at the home institution and seven were at outside institutions.
RESULTS: Ten patients (6 female, Mean age 68) had attempted totally endoscopic robotic lobectomy (RUL - 4, RLL - 3, LUL - 2, LLL - 1). There were 3 identifiable anatomic reasons for conversion. Four patients were converted because of confusing anatomy that upon direct inspection was due to a tendency for the dissection to drift up into the lobe. This resulted in a need to divide more vessels and segmental bronchi beyond their branch points. 3 patients were converted during RLL due to confusion of a low take-off of the RML bronchus with the RLL bronchus. 3 patients required conversion due to an incomplete minor and major fissure making identification of normal structures difficult.
CONCLUSION: Anatomic problems will occur during a totally endoscopic robotic lobectomy, particularly early in the learning of the procedure. Early division of all pleural attachments helps to isolate the target lobe from the rest of the lung. During RUL the minor fissure is frequently incomplete. Partially dividing the fissure with an endoGIA stapler early on can help maintain orientation. Use of the 4th arm improves exposure and may facilitate moving from one area of dissection to another.
CLINICAL IMPLICATIONS: Robotic lobectomy may offer an alternative to VATS lobectomy. It has, however, unique problems that must be anticipated if the procedure is to be widely accepted.
DISCLOSURE: Arthur Martella, No Financial Disclosure Information; No Product/Research Disclosure Information