Because we use a four-arm technique, the robot must be driven in over the patient head on a 15–30° angle as shown in Fig. 8.2. This allows the third arm and the robotic arm next to it (for right-sided operation it is arm 2, for left-sided operation it is arm 1) ample room to prevent collisions between the robotic arms.

We prefer the CPRL-4 method [2]. As shown in Fig. 8.1, the pleural space is entered over the top of the eighth rib using a 5 mm port in the proposed camera port first. We have continued to evolve our technique to improve it, and recently we have started to place the camera port first instead of the most anterior port first. This avoids accidental entry into the abdomen. In order to do this, one must first carefully plan the most posterior port for robotic arm 3. Measurements using a ruler should be marked on the patient’s skin prior to any incisions. Once the marks are made, the camera incision is made first. A 5 mm VATS camera is used to ensure entry into the pleural space and warmed CO₂ is insufflated to drive the diaphragm inferiorly. The incisions are all carefully marked out with a pen and measured to ensure that there is at least 9 cm between it and the more posterior robotic arm and then 10 cm between it and robotic arm 3, which always serves as the most posterior robotic arm as shown in Fig. 8.3.

Robotic arm 3 is a 5 mm port, which is placed a few cm anterior to the spinous processes of the vertebral bodies. A paravertebral block is performed posteriorly using a local anesthetic and a 21 gauge needle from ribs 3 to 11. The needle is used to help select the ideal location for the second incision, the most posterior incision. The location chosen is two ribs below the major fissure and as far posterior in the chest as possible, just anterior to the spinal processes of the vertebral body. A small 5 mm incision is made and a 5 mm reusable metal da Vinci trocar is placed. This will be the position for robotic arm 3. The next few incisions are carefully planned and once again marked or remarked or changed on the skin prior to making them. Ten centimeters anteriorly to the most posterior incision and along the same rib (most commonly rib 8), a third incision is planned. It is an incision for an 8 mm port and its trocar is an 8 mm metal reusable da Vinci trocar that will be docked with robotic arm 2. A 12 mm plastic disposable port is used for the 12 mm camera and if the 8 mm camera is used, an 8 mm metal reusable trocar is placed. Prior to making these two incisions, a small 21 gauge needle is used to identify the most anteriorly inferior aspect of the chest that is just above the diaphragmatic fibers. This incision will have a 15 mm port and serve as the access port. A plastic disposable trocar is used. No robotic arms are attached to the trocar that is placed in this incision. This incision is carefully planned. It is made just above the diaphragm as anterior and inferior as possible and, importantly, in order to be in between the ports used for robotic arm 1 and the camera. The access port can be alternatively placed more posterior if anatomy dictates between the camera and robotic arm 2. It should be two or three ribs lower than these two ports. This affords room for the bedside assistant to work. Once these incisions are carefully planned and their location is confirmed, they are made and the appropriate trocars are placed. Finally, the initial 5 mm anterior port that was made first and used to introduce the VATS camera to identify the internal landmarks is then dilated to a 12 mm double cannulated port for robotic arm 1. The robot is driven over the patient’s shoulder on a 15° angle and attached to the four ports. In general, only four robotic instruments were used for all of these operations—the Cadiere grasper, a 5 mm bowel grasper (used exclusively through the most posterior port that is attached to robotic arm 3 which serves as a retractor of the lung), the Maryland forceps, and a cautery spatula.

Once the arms are in the chest under direct vision, we use a zero-degree camera to reduce pain and rubbing on the intercostal nerve and use it the entire operation usually.

First the pleural space is inspected and explored to ensure there are no metastatic lesions on the diaphragm or the parietal or visceral pleura. Dissection is started at the N2 mediastinal lymph nodes. If the lung deflates well, the nodes #9, #8, and & can be can be completely removed. If the lung does not deflate sufficiently, it is best to start at the #7 station and then move cephalad towards the trachea and remove #10R and separate the azygos vein off of the trachea. Removal of the lymph nodes first opens up the anatomy and affords visual inspection of the N2 nodes.LN# 9

The dissection is carried down between the hilar structures and the phrenic nerve. The phrenic nerve is gently swept down to remove the #10R lymph node avoiding the small phrenic vein that goes to the large #10R lymph node that is routinely found in this area. Develop the bifurcation between middle and upper lobe veins by bluntly dissecting it off of the underlying pulmonary artery. It can be encircled with the Cadiere forceps or curved bipolar dissector and a vessel loop. The #10R lymph node between the anterior–apical pulmonary artery branch and the superior pulmonary vein should be removed or swept up towards the lung. This exposes the anterior apical pulmonary artery branch. The dissection is continuing of the hilar tissue to cleanly expose the main pulmonary artery. Encircle the superior pulmonary vein with an 8 cm vessel loop and retract it off the pulmonary artery behind it. Using the vessel loop as a guide, the linear stapling device is passed across the right superior pulmonary vein and fired. Next the anterior apical trunk pulmonary artery branch is encircled with a vessel loop and transected with a linear stapler in the same fashion as the vein. In both cases the stapler is brought in from the assistant non-robotic port. Exposure might be improved by using the left-hand EndoWrist instrument to deflect the trachea downward and enable the tip of the stapler device to go above the trachea. The operation is now changed to a posterior approach in contrast to continue this anteriorly as done commonly via VATS lobectomy. The RUL bronchus’ anatomy is exposed. Its upper aspect is seen coming off the trachea. The dissection is continued inferiorly to expose the inferior edge of the RUL bronchus and free it from the bronchus intermedius. Once the anatomy is identified, a Cadiere forceps can be placed under the RUL bronchus to confirm complete dissection of it. Further lymph node dissection (10R and 11R, hilar and interlobar) is continued along the right main bronchus and the bifurcation between the bronchus intermedius with the upper lobe bronchus identified. Encircle the right upper lobe bronchus with a vessel loop and transect with a linear stapler (gold, green, or purple load). Care must be taken to apply only minimal retraction on the specimen to avoid tearing of any small remaining anterior PA branches.