We appreciate Dr. Oh’s thoughtful and constructive comments on our recent article entitled “Three-arm robot-assisted thoracoscopic surgery for locally advanced N2 non-small cell lung cancer”. There are several points in his comments that we would like to echo. (I) As Dr. Oh mentioned, our approach is a RAL-3 technique according to the new American Association for Thoracic Surgery (AATS) consensus on robotic-assisted thoracic surgery (RATS) nomenclature (1). The simple 4-unit naming system contains critical details of the surgery, in our case, R for robot, A for assisted, L for lobectomy and 3 for 3-arm technique. This new nomenclature marks a big step forward and the era of using one name (RATS) to represent all procedures. We strongly recommend all robotic surgeries to be recorded using the new naming system. (II) Lung flips in a robotic approach is generally easier than that in a traditional thoracoscopic approach. Although we attempt to avoid unnecessary flips, during the resection of some challenging cases, it is common to approach the lobectomy from various routes. (III) As Dr. Oh pointed, we prefer posterior approach, also termed as “bronchus first”, for right upper lobectomy not only because it is less likely to injure the truncus but also because it is easier to control bleeding if accidental bleeding occurs (2).
In addition to our 3-arm approach, Dr. Oh briefly introduced the 4-arm approach to the new X and Xi platforms. Although we have little experience in these new robots, some technical advances should certainly ease the operation. For instance, the additional arm will allow better control by the surgeon and less reliance on the assistant so that the surgery can be performed by a complete portal approach under capnothorax. The flexible robotic stapler can minimize retraction of the vessel. All such technical improvement should significantly reduce the difficulty of robotic surgery and hasten the conversion from video-assisted thoracoscopic surgery (VATS) to RATS. The real power of the robot is that it provides unlimited possibilities for improvements which will eventually be translated to surgical outcomes. Therefore, although fierce debates remain in this area, robotic surgeons should have faith and carry on.
Again, we thank Dr. Oh for his comments on our article.
Funding: This work was supported by the Shanghai Hospital Development Center Grant (SHDC12016113) and Science and Technology Commission of Shanghai Municipality (18441901500).
Conflicts of Interest: The authors have no conflicts of interest to declare.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
- Cerfolio R, Louie BE, Farivar AS, et al. Consensus statement on definitions and nomenclature for robotic thoracic surgery. J Thorac Cardiovasc Surg 2017;154:1065-9. [Crossref] [PubMed]
- Li Z, Li Y, Wang L, et al. Management of calcified hilar lymph nodes during thoracoscopic lobectomies: avoidance of conversions. J Thorac Dis 2019;11:657-63. [Crossref] [PubMed]