1� 2005 European Association for Cardio-thoracic Surgery

doi:10.1510/mmcts.2004.000448

Video robotic lobectomy

Franca M.A. Melfi*, Marcello C. Ambrogi, Marco Lucchi, Alfredo Mussi

Division of Thoracic Surgery - Cardiac and Thoracic Department of Surgery, University of Pisa,Via Paradisa 2, 56124 Pisa, Italy

Video-assisted thoracoscopic surgery (VATS) is beneficial to the patient but challenging forthe surgeon. Recently, robots have been introduced into surgical procedures in an attemptto facilitate surgical performance. The da Vinci� Robotic System (Intuitive Surgical, Inc, CA,USA) is one of these robots. It consists of a console and a surgical cart supporting threearticulated robotic arms. The surgeon sits at the console where he manipulates the joystickhandles while observing the operating field through binoculars that provide a three-dimen-sional image. Improved ergonomic conditions and instrument mobility at the level of distalarticulation seem beneficial in thoracic procedures. After a period of technical developmentand training we used the robotic systems to treat patients with various thoracic diseases.We focused our efforts on the development of this technique in thoracic surgery particularlyto perform video robotic lobectomy (VRL).

Keywords: Robotic surgery; Thoracoscopy; Lobectomy; VATS

Introduction

Video-assisted thoracic surgery (VATS) in the last dec-ade has allowed surgeons to perform an increasingnumber of operations with minimal tissue trauma,standardization of many procedures and a progres-sive broadening of the indications. This technique hasbecome widespread and is currently used in a widerange of surgical procedures, but many major diffi-culties remain. Sensory information is restricted to atwo-dimensional image, and effectors instrumentshave limited manoeuvrability due to the rigid shaft axisfixed to the thorax or abdominal wall by the entry tro-car. Advanced engineering technology makes it pos-sible to overcome these difficulties. Robotic surgeryis the most recent and advanced stage of this processthanks to ‘micro-mechatronic’ instruments introducedthrough traditional trocars.

* Corresponding author: Tel.: q39-050-995211; fax: q39-050-9957239.E-mail: f.melfi@med.unipi.it

Historical notes

The early robotic systems employed in surgery wererelatively simple – programmed to handle the scopeonly or to maintain an endoscopic instrument in afixed position during surgery w1x. These elementarysystems have given way to extremely complex andsophisticated robots. Human robotic surgery wasintroduced by Cadiere’s team in March 1997 w2x. Athoracic procedure was performed using a voice-con-trolled robot (Zeus� , MMCTSLink 30) w 3 ,4 x and, in thesame period, a different robotic device was used byother surgical teams w5–7x.

At the present time, different types of robotic devicesare used in clinical practice w8–10x (Table 1). The daVinci� Robotic System (MMCTSLink 17) represents acomplete device currently applied in the field of car-diac and general surgery. Although there is a realdifference between thoracic surgery and other disci-plines, an application in thoracic surgery seemed real-istic. Therefore in the last years an increasing numberof thoracic surgeons have used the robot device toperform thoracic procedures some of which included

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Table 1. Surgical robots systems

System Discipline

Aesop EndoscopyEndoAssist EndoscopyZeus Cardiac/thoracic surgeryDa Vinci Cardiac/thoracic surgeryCyberKnife RadiosurgeryNovac 7 RadiosurgeryRobodoc OrthopedicsNeuromate Neurosurgery

Video 1. The surgeon sits at the master console located at a dis-tance from the patient with eyes focused downwards toward theoperative field which appears as an open surgical technique and arobotic unit provides a ‘tele-presence’ within the chest for themanipulation of micro-instruments.

Photo 1. Motion scaling. (Reprinted with permission from IntuitiveSurgical Inc, CA, USA.)In terms of motion, the mechanical wrists of the instruments have6 degrees of freedom. Tip articulations mime the up/down (‘pitch’)and the side-to-side (‘yaw’) flexibility of the human wrist.

major lung resections (video robotic lobectomy (VRL)in NSCLC-stage I patients) w11–15x.

Method

Compared to conventional surgery and VATS, robotsurgery demands a new set of manual skills and eye–hand coordination. The transition from traditional sur-gery to advanced totally robotic surgery is notimmediate. Just as it was necessary to follow certainprecise organizational and didactic routes in passingfrom open surgery to minimally-invasive technique,here too, the same process is necessary. It is essentialto be familiar with the device and that all members ofthe surgical team (surgeons, scrub nurses, and tech-nicians) have undergone specific training. The learningcurve is relatively short since the surgeons have a sol-id background in conventional and thoracoscopicsurgery.

Robot-system in the operating room

The system employed to perform video robot lobec-tomy (VRL) is the da Vinci� Robotic System(MMCTSLink 17).

It is a complete robot device which comprehends amaster remote console, a computer controller and athree-arms surgical manipulator with fixed remotecentre kinematics connected via electrical cables andoptic fibres (Video 1).

The master console is connected to a surgical manip-ulator with two instrument-arms and a central arm toguide the endoscope. Two master handles at the sur-geon’s console are manipulated by the user. The posi-tion and the orientation of the surgeon’s hands on thehandles trigger highly-sensitive motion sensors whichtransfer the surgeon’s movements to the tip of theinstrument at a remote location.

The surgical arm cart provides three degrees of free-dom (pitch, yaw, insertion). Attached to the robot armis the surgical instrument, the tip of which is providedby a mechanical cable-driven wrist (EndoWrist�,MMCTSLink 31). This adds four more degrees offreedom (internal pitch, internal yaw, rotation andgrip).To increase precision, the system uses down-scaling from the motion of the handles to that of thesurgical arms. In addition, unintended movementscaused by human tremor are filtered by a 6-Hz motionfilter (Photo 1).

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Video 2. The robot’s arms are draped in special disposable nyloncovers (for the sterile operating field) which contain the microchipsto connect the arms to the robotic instruments. The insertion ofelectronic microcircuit plates establishes a connection with otherrobotic instruments.

Video 3. In order to avoid collisions between the mechanical arms,the correct placement of the robot arm cart and of the trocars isessential. The trocars must be positioned at a greater distance fromeach other than they normally would be in standard thoracoscopicprocedures. Physical orientation and optimal working anglesbetween the instruments are important issues which must beconsidered.

Table 2. Selection criteria

Size -4 cm (max diameter)Stage Clinical stage I NSCLCAnatomical features Absence of chest wall involvement

Absence of pleural symphysisComplete or near complete interlobarfissures

In order to perform robotic surgery in a safe andstraightforward manner, it is necessary to standardizeprocedures and establish operative schemes. Thisrobotic device requires meticulous preparation interms of set-up of the system and its placement atthe operating table (Video 2).

The main body of the machine (robot cart) and therobotic arms are placed in relation to the side of thelesion. When the robotic cart has been positioned andthe patient placed in the chosen position, the roboticarms are brought into the operative field (Video 3).

Operative techniqueMany of the robotic procedures can be carried out bya single operator. This is true for procedures which

require few accurate manoeuvres – dissection/coag-ulation – in a restricted and well-defined field: enucle-ation of condroma, excisions of mediastinal masses,thymectomies. On the contrary, during major resec-tions such as lobectomies, some manoeuvres mustnecessarily be performed by the assistant surgeon,given the need of a fourth arm. In fact, maintaining acorrect position with appropriate tension of the lungparenchyma is a top priority for identifying and dis-secting the hilum structures (vessels and bronchus),as is suction, passing the sutures in the chest cavity,and appropriate positioning of the stapler. In order toperform these manoeuvres the role of the assistantsurgeon is mandatory, and he must always be at handat the operating table.

Like VATS, few absolute contraindications are applic-able to this surgical procedure (Table 2).

During the video robotic lobectomy, a single-lunganaesthesia is achieved via a double lumen endotra-cheal tube. Patients are prepared and draped for aposterior lateral thoracotomy so that the procedurecan be converted in the event of intraoperative com-plications or in case a video robot lobectomy is notpossible (Video 4).

Instruments

Few robotic instruments are used during roboticlobectomy. To handle the lung parenchyma safely aCadiere forcep (MMCTSLink 32) is advisable becauseit is an a-traumatic instrument. In contrast, otherrobotic grasps are too small to handle the lung. Dis-section of structures is performed with a combinationof electrocautery and Debakey forceps (MMCTSLink32) mounted on the robotic arms. Accessory endo-scopic instruments handled by an assistant surgeonat the operative site are inserted through the mini-thoracotomy (‘service entrance’) or through anadditional small incision (5 mm), when necessary(Video 5).

Incisions

The location of the incisions is critical for the suc-cessful identification and dissection of the interlobarartery – technically the most difficult aspect of videorobot lobectomy. The best positioning of the systemand of the robotic arms are established in relation tothe side of the lesion in order to have an excellent,unobstructed view of the chest cavity without armimpingement and interference. However, the exactposition of the operating ports is best assessed dur-ing the operation when suitable points of entry in rela-

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Table 3. Clinical features of patients undergoing robotic lobectomy

Age Preoperative Procedure Pathological Postoperative Dicharge Remarks(yr)/sex conditions findings course p.o

64/F Diabetes RL lobectomy Adenocarcinoma Uneventful 5T1N0

41/M Unremarkable LL lobectomy Typical carcinoid Uneventful 466/M Unremarkable LL lobectomy Typical carcinoid Sputum 6

(converted) retention70/M Prostatism/ LL lobectomy Sq. carcinoma Uneventful 5 Retained in

hypertension T1N0 unit (angina)66/M Cough RL lobectomy Sq. carcinoma Sputum 6

(converted) T1N0 retention64/F Unremarkable LL lobectomy Adenocarcinoma Uneventful 4

T1N060/M Hypertension LL lobectomy Adenocarcinoma Uneventful 4

T1N161/F Unremarkable RL lobectomy Adenocarcinoma Air leaks 10

T1N061/M Unremarkable LL lobectomy Sq. carcinoma Uneventful 5

T1N069/M Hypertention LL lobectomy Adenocarcinoma Acute kidney Dead XII p.o.

T1N0 failure IV p.o65/M Unremarkable LL lobectomy Sq. carcinoma Uneventful 4

T1N066/F Diabetes M lobectomy Sq. carcinoma Atrial 5

T1N1 fibrillation58/F Unremarkable LR lobectomy Adenocarcinoma Uneventful 4

T1N067/M Cough LR lobectomy Atypical carcinoid Sputum 5

T1N0 retention70/M Sigmoid colectomy M lobectomy Sq. carcinoma Sputum 6

2 years before T1N0 retention69/F Unremarkable UR lobectomy Sq. carcinoma Uneventful 5

T1N069/M Unremarkable LR lobectomy Adenocarcinoma Air leaks 6

T1N074/M Cough/hemoptysis LL lobectomy Sq. carcinoma Uneventful 4

T1N065/F Unremarkable LR lobectomy Adenocarcinoma Uneventful 4

T1N059/M Unremarkable LR lobectomy Adenocarcinoma Uneventful 5

T1N067/F Cough M lobectomy Sq. carcinoma Sputum 6

T1N0 retention71/M Unremarkable LL lobectomy Sq. carcinoma Uneventful 4

T1N060/M Hypertension LL lobectomy Adenocarcinoma Uneventful 5

T1N0

Video 4. The patient is placed in the lateral position with generalanaesthesia and single-lung ventilation

tion to the shape of each patient’s chest cavity aremade.

The standard layout is the following: the first port isplaced at the 7th or 8th space in the mid-axillary line(for the 08 3-D scope), the other at the 6th or 7th inter-costal space in the post-axillary line (for the left robot-ic arm), a ‘service entrance’ is made at the 4th or 5th

intercostal space in the anterior axillary line (where theright robot arm is placed). An additional small incisionis made (between the ‘service entrance’ and the 3-Dscope) for the assistant surgeon to insert conventional

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Video 5. The robotic instruments currently used during the VRL areCadiere and Debakey forceps, electrocautery and micro scissors(EndoWrist�, MMCTSLink 31). In addition, thoracoscopic instru-ments and a full thoracotomy instrument set is opened and kept onhand, in case of preoperative complications.

Video 6. The first incision is made at the 7th space in the mid-axillaryline to verify the feasibility of the robot procedure using a standardendoscopic optic.

Photo 2. Chest incisions.Incision layout during a robot left lower lobectomy.

Photo 3. CT scan.A computed tomogram of the chest demonstrating a speculatedmass in the lower lobe of the left side.

endoscopic instruments only when strictly necessary(Video 6).

The routine VATS exploration prior to the operationcould yield important information that would markedlyalter the treatment strategy.

If there is no contraindication to proceed, the mini-thoracotomy ‘service entrance’ (approximately 4 cmin length) is placed over the 4th or 5th intercostal space

(in the anterior axillary line). It provides an easy directaccess to the hilum; to insert standard endoscopicinstruments when the robotic instruments are notsuitable; moreover, it is wider than the posteriorspace and facilitates later retrieval of the specimen(Photo 2).

Surgical steps

Video robotic lobectomy follows the standard surgicalsteps of open thoracic surgery and implies the isola-tion and resection of the vascular and bronchial hilarelements. Usually the artery is dealt with before thevein and eventually the bronchus is resected. How-ever, priorities are not strictly set. Frequently, as is thecase of open thoracic surgery, due to surgical strat-egies the ligature of the vein precedes that of theartery. In some cases it is preferable to resect thebronchus before resecting the artery branch.

Here below is described a robot-left lower lobectomyin a 64-year-old female. She was a non-smoker withsmall lung mass without mediastinal lymphadenopa-thy on CT scan, with normal bronchoscopic appear-ances, judged to have clinical stage I (positivecytology for adenocarcinoma at needle aspiration/CT-guide) (Photo 3).

Arterial phase

Dissecting around the pulmonary vessel is basicallythe same as in conventional open surgery.

The Cadiere forceps and robot electrocautery(MMCTSLink 32), connected to the robot arms, are

Video-robotic left lower lobectomy

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Video 7. The dissection of the fissure with robotic instruments toexpose the interlobar artery.

Video 8. After dissection of the fissure, the pulmonary arterybranches are carefully identified and isolated.

Video 9. A sling is passed to lift the vessels separately to obtain asafer ligation.

Video 10. The vessels are taken separately and tied with Linen 2.5.Due to their rough texture, linen as well as silk are ideal becausethe ligation does not come undone.

Video 11. A double tie is advisable in all cases, even in small calibrevessels to ensure a safe ligation. A resection is made between thetwo ligations by micro scissors (EndoWrist� , MMCTSLink 31).

introduced through the minithoracotomy and posteriorincision for the dissection of the hilum and the fissure.A standard endoscopic holding forceps (Babcock5BB, MMCTSLink 33) can be introduced by the assis-tant surgeon through the service entrance or (rarely)through an additional incision. This provides appro-

priate traction of the lung parenchyma and helps thesurgeon to position the lobes so that the hilum andthe vessels can be easily accessed.

If the interlobar fissure is complete or nearly complete,the incision of the visceral pleura with robotic electro-cautery or blunt dissection with a pledget mounted onthe Cadiere forceps (EndoWrist� , MMCTSLink 31),allows the pulmonary artery to be easily identified. Inthis case, the electrocautery at a low setting is usefuland safe (Videos 7 and 8).

When the fissure is incomplete the upper lobe isretracted upward and forward, the artery appearsfrom the posterior aspect of the lung root. The arteryis then identified within the fissure by careful dissec-tion and a sling is passed between the two points ofthe arterial access to elevate the fused posterior fis-sure, which is divided by stapling. The same proce-dure is carried out for the resection of the anteriorfissure. The mechanical stapler (Endopath ATB45,MMCTSLink 34) is used by the assistant surgeonthrough one of the other two ports (depending on thealignment).

Currently the apical and main-stem lower vessels aretaken separately and tied with Linen 2.5 (Videos 9, 10and 11).

Instead of a double tie with Linen, conventional endo-scopic clips (MMCTSLink 35) can be used on the dis-tal part of the artery. However, this technique is notvery safe because these endoscopic clips must beapplied at the operating site by the assistant surgeon,who has a bi-dimensional vision and does not havesufficient coordination. On the other hand, theavailable robotic clips are too small to be used forpulmonary vessels. In this regard, a possible compli-cation is that the clips can lacerate the vessel duringthe surgery or that they can slip off (Video 12).

Vein phase

Usually the surgical time sequence implies treatingthe vein as a second step. The pulmonary ligament is

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Video 12. This is an example of the laceration of a pulmonary arterydue to the imprecise positioning of the clips solved by further iso-lating the artery peripherally and placing additional clips.

Video 13. The vein is cleared and separated from the lymph node,which is removed, by using electrocautery and the Cadiere forceps(MMCTSLink 32). A blunt dissection can be useful.

Video 14. After isolation, a sling is passed and the vein is doubletied with Linen 2.5 and resected between the ligations.

Video 15. The bronchus is isolated and cleaned by dissectionmanoeuvres. Here too, a sling is used to better isolate the bronchusand to position the stapler correctly.

Video 16. The resected lobe is removed in sterile plastic bagsthrough the ‘service entrance’.

incised and the lower vein cleared from the surround-ing tissues and divided (Videos 13 and 14). When it isparticularly thick it is advisable to use a mechanicalstapler, although this increases the cost. Another wayof handling the vein is to place a vascular clamp

through a 4th incision, when it is made, and stitch itby using the robot Debakey forceps and a large nee-dle holder (EndoWrist�, MMCTSLink 31) (Polypropyl-ene Monofilament 4/0). This is more difficult and notsafe, considering that both the stapler and the clamphave to be placed by the assistant surgeon (at handat the operating table), whose hand–eye orientation(bi-dimensional vision) is less precise compared to thesurgeon who, at the console, has a different depthperception and optical resolution. Consequently poorcoordination between the surgeon and the assistantcan jeopardize the success of the operation.

Bronchus phase

The last step consists of isolation and resection of thelobar bronchus by using the stapler (Endopath ATB45,MMCTSLink 34), necessarily performed by the assis-tant surgeon. This is the only possible way to resectand suture the bronchus with this approach.

Although the robot wrists are able to simulate evenfine physiological movements, the surgeon cannotmake a running stitch when dealing with the bronchusas the robotic instruments in current use are too smallto handle such a thick structure (Video 15).

Blunt dissection is particularly useful when dissectingand for sweeping tissue along the lobar bronchusperipheral to the line of intended bronchial division sothat all the lobar bronchial nodes can be included inthe operative specimen.

The lobectomy specimen is placed in a sterile plasticbag and removed through the minithoracotomy. Thebronchial stump is then tested under water for airleaks with 20 cm of positive airway pressure (Video16).

At the end of the operation all the accessible nodalstations are systematically sampled to ensure properstaging of the lung cancer. Currently the lymph-nodesamplings are made at stations that are more likelyinvolved for tumours originating from a particular lobe

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Table 4. Mean data ("SD) of robotic lobectomy

Operative time (h) 3.2 ("0.6)Operative blood loss (ml) 103 ("28.1)Post-operative morphine consumption (mg/h) 0.47 ("0.1)Postoperative (VAS) pain score 1.3 ("0.7)first 24 h (mm:range 0–100)

Chest tube (days) 2 ("1.4)Hospital stay (days) 5 ("1.3)

w16x: the right upper lobe (prevascular and retro tra-cheal N3 and lower paratracheal N4R), the middlelobe (N3 and subcarinal N7), the right lower lobe (N7),the left upper lobe (sub-aortic N5 and para-aortic N6),the left lower lobe (N7). If a complete lymph node dis-section is considered necessary it should be donethrough a thoracotomy. Unlike VATS approach, thereare no limitations regarding accurate lymph-nodesampling, given that this is carried out at the end ofthe operation when a part of the lung has beenremoved. In fact, there is no need to move the entirepulmonary parenchyma in order to access all lymph-node stations.

Two 24 French chest drains (through the previouscamera and instrument ports) and closure of the mini-thoracotomy wound complete the operation.

Personal experience

Since February 2001 we have used a robotic systemto operate 85 patients with a range of thoracic dis-eases. There were 54 men and 31 females aged 19–71 years (mean age 61). We applied the da Vinci�Robotic System (MMCTSLink 17) to perform variousthoracic operations, ranging from the simplest pro-cedures, such as benign tumour enucleations/excisions, to very complex ones, such as major pul-monary resections.

Video robotic lobectomies (VRL) were performed in 23good-risk patients selected by pre-operative investi-gations. There were 15 men and 8 females aged 41to 78 years (mean age 64.4). The patients werereferred to our Department with a pulmonary opacityon chest radiographs and normal bronchoscopicappearances. In accordance with our then normalpractice for small lesions without mediastinal lym-phadenopathy on the CT scan, mediastinoscopy wasnot undertaken. These patients were judged to haveclinical stage I (NSCLC). Arterial blood gases wherewithin normal limits, and pulmonary function demon-strated adequate pulmonary reserve to undergo aplanned lobectomy (forced expiratory volume in 1 s(FEV1) )1.5 l). Specific consent was obtained forattempted robotic resection. The lobes resected were

the lower left (ns11), the lower right (ns9), the middlelobe w3x, the upper right (ns1).

Results

Details of patients who underwent robotic lobectomyare summarized in Table 4. In this highly selectedgroup of good-risk patients no technical operativemishaps related to manoeuvres of the instrument-arms occurred. None of the patients had problemsrelated to operative bleeding. All patients tolerated theprocedure well and the post-operative course wassatisfactory, requiring less analgesic compared toconventional surgery. In two patients the procedurewas converted to a minimal thoracotomy. In thesecases we began the lobectomies by isolating andstitching the transected lower vein with the robot.However, we had to complete the operations usingthe ‘service entrance’ (enlarged by about 2 cm) dueto hilar calcified lymph nodes, since these renderedthe dissecting of the pulmonary artery unsafe. Inanother two patients we had air leaks. In both casesmechanical staplers were used to complete the fis-sure. There was one death on the 12th p.o. day (notrelated to the surgical technique) due to pulmonaryembolus. After an initial excellent postoperativerecovery the patient had acute kidney failure on the4th p.o. day which led to a worsening of the clinicalconditions.

Chest tubes were removed in mean 2 p.o. days andthe patients were discharged in mean 5 postoperativedays.

Operative time varied between 2.5 to 5 h, of which 1 hwas used to do the self-test of the machine andinstrument set-up. This time was considerably longerthan that for standard open surgery or VAT procedure,but it decreased with experience so that the last cas-es averaged 3 h.

All patients were discharged in good condition andreturned to preoperative levels of physical activitywithin 10 days of the operation.

Comments and controversies

As far as is known, few video-assisted robotic lobec-tomies are performed, consequently few surgeonshave experience in this field w11–16x. Currently, manyof the limitations of robotics surgery are related to theimperfections of the system. At present the greatestdifficulties of the VRL are associated with the availablearm instruments, which are designed for cardiac orgeneral surgery and are not adequate for thoracic sur-gery. Consequently some procedures become more

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complicated especially for the lung major resection.This accounts for the extreme difficulty in performingupper lobectomies, which can only be carried out withthe aid of the assistant surgeon, who is in a differentergonomic position. In our experience we performedonly one upper right lobectomy and no upper leftlobectomy. This is because a fourth arm would haveto be available to allow the surgeon to easily accessthe hilum of the upper lobe and to handle the pul-monary parenchyma. Therefore, lower-lobe lobecto-mies, especially left lower lobectomy – also inconventional thoracic surgery – are technically themost straight-forward resection to carry out.

Other limitations are system-related. At present,blocking of the robotic arms or working against strongresistance is experienced at the console. The surgeondoes not receive information on the amount of forceapplied to tissue or sutures, and therefore is depend-ent on visual feedback. This is sufficient in the major-ity of the manoeuvres, but not when it comes tosuturing delicate structures and tying knots, or whenthe surgeon wants to distinguish tissue characteris-tics. This poor tactility impairs the surgeon’s ability tojudge the amount of tension applied during themanoeuvres of suture/ligation tensioning w10x.

Considering all these limitations, robotic proceduresmay be technically feasible only in highly selectedcases and in the hands of an experienced thoracicsurgeon. Like the VAT, this new surgical techniqueshould only be undertaken by surgeons trained in tho-racic surgery w17x. Besides a perfect knowledge oftopographical anatomy and broad experience in con-ventional surgery, training in specific thoracoscopicskills is required.

Nonetheless, we believe that many of the current lim-itations can be overcome in the near future, and that,as the da Vinci System is improved and its instru-ments better adapted to thoracic surgery, their appli-cation will be extended to a wider range of operations.

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