and direct grasping, clamping, and retraction should be avoided at all costs.

Instead, surrounding structures should be retracted and dissected away from the

artery. While it may be tempting to avoid these critical structures during dissec-

right on the arterial wall in the subadventitial plane, can lead to a more precise

and quicker procedure.

bleeding. If additional retraction is required for the passage of the stapler, a ves-

sel loop placed around the vessel facilitates retraction and stapler advancement.

the mediastinum and both pulmonary veins. Alternatively, bulldog clamps can be

possible to avoid loss of vision from blood jet. The free arm should either hold

(green color) (Medtronic, Minneapolis, MN, USA) with an absorption time of

time, the use of a white stapler load is sufcient for these purposes. However, for

incomplete ssures, blue or even green loads might be required. In cases of com-

used. Staple line reinforcement can sometimes be benecial in patients with

approach all dissection with extra ssural technique. Developing plane in the

space between superior and inferior pulmonary vein leads the surgeon into the

tunnel over the interlobar PA and under the parenchymal bridge of the major s-

lobar vein exposes the tunnel under the minor ssure.

• Stapler Handling: While many surgeons successfully utilize handheld staplers,

this success is usually predicated on the availability of a consistent and experi-

to providing full control of the device by the console surgeon, the tissue com-

pression sensing SmartFire technology potentially can prevent some surgical

injury during this process. Ideally, the same area should be used consistently to

aid in developing muscle memory for the bedside assistant. The authors prefer to

remove specimens in a cut glove nger to prevent rupture, loss, and potential

be cinched, or bulldog clamps applied. However, if bleeding is massive or con-

of a surgeon’s level of skill, such complications will eventually occur with

increasing number of cases. Gown and gloves for the surgeon, as well as a

Finochietto retractor, should always be available on the table during any robotic

anatomic lung resection. The authors’ protocol for conversion is as follows:

• Console Surgeon:

• Circulating Nurse:

Multiple retrospective database analyses have been conducted to compare the early outcomes of RATS lobectomy to those of VATS.One comprehensive retro­spective study examined 774 patients with early-stage lung cancer, with 298 under­going RATS versus 476 undergoing VATS [65]. After matching the groups using propensity scores, the analysis revealed no signicant differences in operative time (RATS 147.91minutes versus VATS 149.23minutes; P=0.773), blood loss (RATS 50mL versus VATS 100mL; P=0.177), overall complications (RATS 17.9% ver­sus VATS 14.8%; P=0.340), and length of hospital stay (both RATS and VATS 4 days; P= 0.417) although RATS group had a signicantly higher number of lymph node stations dissected compared to VATS group, which is essential for accu­rate pathological staging and adjuvant therapy. Additionally, a meta-analysis com­pared postoperative outcomes of anatomical resections performed by RATS and VATS, including a subgroup analysis for both lobectomy and sublobar resections [32]. In the lobectomy group, RATS approach was associated with lower conversion rate (OR=0.50, 95% CI: 0.43–0.60, P<0.001), greater number of harvested lymph nodes and dissected stations (WMD=0.51, 95% CI: 0.15–0.86, P=0.005), shorter postoperative chest tube duration (WMD=−0.61, 95% CI: 0.78–0.44, P<0.001), lower overall complication rate (OR=0.90, 95% CI: 0.83–0.99, P=0.020), and reduced recurrence (OR=0.51, 95% CI: 0.36–0.72, P< 0.001). However, these differences were not signicant in the sublobar resection group. In another meta­analysis of 25 studies comparing the outcomes of RATS and VATS, a total of 50,404

Neoadjuvant treatment combined with perioperative immunotherapy is increas­ingly gaining prominence in the eld of thoracic oncology. A phase I trial examined the outcomes of 20 patients with stages I–IIIA lung cancer who received neoadju­vant nivolumab, and perioperative outcomes were analyzed [4]. Initially, a mini­mally invasive approach was attempted in 13 (65%) patients but was only successful in 46% of patients (3 VATS and 3 RATS). There was no perioperative mortality, and the morbidity rate was 50%, with atrial brillation being the most common compli­cation. The primary reasons for conversion were hemorrhage, dense adhesions, and inamed mediastinal and hilar nodal stations. A phase 2 study investigating neoad­juvant pembrolizumab in non-small cell lung cancer included 25 patients who underwent lung resections [56]. The majority (72%) had lobectomies. Of these patients, 92% initially underwent a minimally invasive approach, but 22% of these cases were converted to thoracotomy. An R0 resection was achieved in 88% of the patients. Another prospective randomized trial assessed perioperative outcomes of anatomic lung resections after neoadjuvant nivolumab (22 patients) or a combina­tion of nivolumab and ipilimumab (17 patients) [51]. Lobectomy was performed in