Major Pulmonary Resection Research Articles

The road to ultimate minimal invasiveness.

Singe-port video-assisted thoracic surgery (SPVATS) has become increasingly popular among thoracic surgeons in recent years. Generally, major pulmonary resection is performed through a single incision (3–5 cm), with the goal of causing potentially less pain, while achieving similar oncologic control compared with conventional VATS procedures (1). The article by Dr. Kim and colleagues (2) describes a successful tri-segmentectomy for a small lesion located in the left upper lobe via a single 2-cm incision.

Non-intubated (tubeless) uniportal video-assisted thoracoscopic lobectomy.

During the last decade, there have been important developments in new minimally invasive surgical techniques for major pulmonary resections (1). Advances in anesthesiology include a lack of general anesthesia in thoracic operations, by maintaining spontaneous ventilation, and minimal sedation of patients. The choice of a single-incision technique combined with the lack of general anesthesia further minimize the invasiveness of the procedure (2). Moreover, a ‘tubeless’ concept can be perfectly applied to these procedures. This involves the complete absence of a tracheal tube or even laryngeal mask, central line, urinary catheter or epidural. We present a video showing three cases of non-intubated (tubeless) uniportal video-assisted thoracoscopic surgery (VATS) major pulmonary resections (Video 1). Video 1 Non-intubated (tubeless) uniportal video-assisted thoracoscopic lobectomy.

Video-assisted thoracoscopic surgery lobectomy for lung cancer versus thoracotomy: a less decrease in sVEGFR2 level after surgery.

Angiogenic and anti-angiogenic factors play an important role in tumor biology and tumor recurrence after surgical resection. Antiangiogenic factors such as vascular endothelial growth factor (VEGF)-receptor 1 (sVEGFR1) and sVEGFR2, two soluble form receptor proteins of VEGF, are critical for angiogenesis. VEGF can be sequestered by soluble forms of these receptors, which result in decreasing VEGF amount available to bind to its receptor on vascular endothelial cell surface. This study aimed to investigate the influences of video-assisted thoracoscopic surgery (VATS) lobectomy and open by thoracotomy for early stage non-small cell lung cancer (NSCLC) on postoperative circulating sVEGFR1 and sVEGFR2 levels. Forty-eight lung cancer patients underwent lobectomy through either VATS (n=26) or thoracotomy (n=22). Blood samples were collected from all patients preoperatively and postoperatively on days 1, 3 and 7. ELISA analysis was used to determine the plasma levels of sVEGFR1 and sVEGFR2. Data are reported as means and standard deviations, and were assessed with the Wilcoxon signed-Rank test (P<0.05). For all patients undergoing lobectomy, postoperative sVEGFR1 levels on days 1 and 3 were markedly increased, while postoperative sVEGFR2 levels on days 1 and 3 were significantly decreased. Moreover, VATS group had significantly higher plasma level of sVEGFR2 postoperative in comparison with open thoracotomy (OT) on day 1 (VATS 6,953±1,535 pg/mL; OT 5,874±1,328 pg/mL, P<0.05). Major pulmonary resection for early stage NSCLC resulted in the increased sVEGFR1 and decreased sVEGFR2 productions. VATS is associated with enhanced anti-angiogenic response with higher circulating sVEGFR2 levels compared with that with OT. Such differences in anti-angiogenic response may have an important effect on cancer biology and recurrence after surgery.

Nonintubated uniportal video-assisted thoracic surgery course-live surgery.

"Uniportal video-assisted thoracic surgery (VATS) course-live surgery" was held on 23rd of November 2015 in Lithuania, The Hospital of Lithuanian University of Health Sciences Kaunas Clinics. This international event has attracted many thoracic surgeons, doctors anesthesiologists-reanimatologists, operative theatre nurses and other medical specialists from Lithuania, Latvia, Estonia and Poland. The special guests of the conference were thoracic surgeon Dr. Diego Gonzalez-Rivas and doctor anesthesiologist Dr. Humberto Aymerich Cano. Since the first uniportal VATS lobectomy was performed on 29th of July, 2010, this innovative minimally invasive surgical technique has been adopted in many countries of the world. The first nonintubated VATS for lobectomy was initially described in 2007, although general anesthesia with intubation and one lung ventilation was traditionally considered to be necessary for major thoracoscopic pulmonary resections. During this course, right upper and left upper uniportal VATS lobectomies were performed for nonintubated patients, diagnosed with non-small cell lung cancer. These successful examples demonstrate a minimally invasive surgical technique-uniportal VATS lobectomy for a nonintubated patient.

Surgical team turnover and operative time: An evaluation of operating room efficiency during pulmonary resection

ObjectiveHealth care resources are costly and should be used judiciously and efficiently. Predicting the duration of surgical procedures is key to optimizing operating room resources. Our objective was to identify factors influencing operative time, particularly surgical team turnover. MethodsWe performed a single-institution, retrospective review of lobectomy operations. Univariate and multivariate analyses were performed to evaluate the impact of different factors on surgical time (skin-to-skin) and total procedure time. Staff turnover within the nursing component of the surgical team was defined as the number of instances any nurse had to leave the operating room over the total number of nurses involved in the operation. ResultsA total of 235 lobectomies were performed by 5 surgeons, most commonly for lung cancer (95%). On multivariate analysis, percent forced expiratory volume in 1 second, surgical approach, and lesion size had a significant effect on surgical time. Nursing turnover was associated with a significant increase in surgical time (53.7 minutes; 95% confidence interval, 6.4-101; P = .026) and total procedure time (83.2 minutes; 95% confidence interval, 30.1-136.2; P = .002). ConclusionsActive management of surgical team turnover may be an opportunity to improve operating room efficiency when the surgical team is engaged in a major pulmonary resection.

Pain control of thoracoscopic major pulmonary resection: is pre-emptive local bupivacaine injection able to replace the intravenous patient controlled analgesia?

The aim of this open-label, non-inferiority trial was to evaluate whether pre-emptive local bupivacaine injection (PLBI) can replace intravenous patient controlled analgesia (IV PCA) in video-assisted thoracic surgery (VATS) major pulmonary resection. A total of 86 patients scheduled for VATS segmentectomy/lobectomy were randomly assigned into two groups. The PLBI group (n=42) received 0.5% bupivacaine wound infiltration before skin incision, and the IV PCA group (n=44) received a continuous infusion of fentanyl with a basal rate of 10 µg/mL/h. Visual analogue scale (VAS; range, 0-10) was measured as the primary endpoint. The secondary endpoint was an additional use of analgesics and drug induced side effects. Both groups showed no difference in terms of age, sex, disease entity, operation time, chest tube indwelling time, and hospital stay. Serial pain scores between the PLBI and IV PCA groups demonstrated no statistical differences (non-inferiority margin; ΔVAS =1.0) (Recovery room: 8.3±2.1 vs. 8.5±1.7; Day 0: 5.1±1.6 vs. 5.2±1.4; Day 1: 3.5±1.6 vs. 3.3±1.2; Day 2: 2.7±1.3 vs. 2.5±1.2; Day 3: 2.3±1.3 vs. 2.1±1.5; 1 week after discharge: 3.0±1.7 vs. 2.8±1.5; 1 month: 1.9±1.2 vs. 2.3±1.4 and 2 months: 1.5±1.2 vs. 1.3±1.2; 95% confidential interval (CI) of ΔVAS <1.0; P>0.05). The mean one-additional usage of IV analgesics was needed in the PLBI group (3.3±2.1 vs. 2.3±1.3; P=0.03). The occurrence of nausea/vomiting was higher in the IV PCA group (12.5% vs. 38.9%; P=0.026) and 41.7% of IV PCA patients experienced drug side effects that required IV PCA removal within postoperative day (POD) 1. PLBI is a simple, safe, effective, and economical method, which is not inferior to IV PCA in VATS major pulmonary resection.

Muscle-Sparing Thoracotomy: A Systematic Literature Review and the “AVE” Classification

Background: To synthesize the concept of muscle-sparing thoracotomies for major pulmonary resections and to explore the relationship between Kraissl’s lines and skin incisions perpendicular to them.

A Predictive Score for Bronchopleural Fistula Established Using the French Database Epithor

Bronchopleural fistula (BPF) remains a rare but fatal complication of thoracic surgery. The aim of this study was to develop and validate a predictive model of BPF after pulmonary resection and to identify patients at high risk for BPF. From January 2005 to December 2012, 34,000 patients underwent major pulmonary resection (lobectomy, bilobectomy, or pneumonectomy) and were entered into the French National database Epithor. The primary outcome was the occurrence of postoperative BPF at 30 days. The logistic regression model was built using a backward stepwise variable selection. Bronchopleural fistula occurred in 318 patients (0.94%); its prevalence was 0.5% for lobectomy (n = 139), 2.2% for bilobectomy (n = 39), and 3% for pneumonectomy (n = 140). The mortality rate was 25.9% for lobectomy (n = 36), 16.7% for bilobectomy (n = 6), and 20% for pneumonectomy (n = 28). In the final model, nine variables were selected: sex, body mass index, dyspnea score, number of comorbidities per patient, bilobectomy, pneumonectomy, emergency surgery, sleeve resection, and the side of the resection. In the development data set, the C-index was 0.8 (95% confidence interval: 0.78 to 0.82). This model was well calibrated because the Hosmer-Lemeshow test was not significant (χ(2) = 10.5, p = 0.23). We then calculated the logistic regression coefficient to build the predictive score for BPF. This strong model could be easily used by surgeons to identify patient at high risk for BPF. This score needs to be confirmed prospectively in an independent cohort.

Experimental left pneumonectomy in pigs: procedure and management

BackgroundBecause there is no detailed description of procedures and perioperative management of major pulmonary resections in swine, we reviewed our experience to delineate the most effective practice in performing left pneumonectomy. Materials and methodsAnalysis of 11 consecutive left pneumonectomies. Animal data, operative reports, anesthesia records, and perioperative facts were evaluated. Follow-up information until postoperative day 60, methods of care-taking, therapy administration, and all the stabling aspects were systematically assessed. The investigation was aimed at highlighting those procedural steps or details which make the difference in optimizing the available resources (animals, instruments, and personnel). No statistical analysis was performed considering data characteristics and the descriptive nature of information. ResultsSurgery requires a median time of 2 h and 16 min; two operators and one anesthesiologist represent the basic team. Circulators' number depends on goals to accomplish. The most straightforward procedure requires careful dissection of the pulmonary ligament (limited view), pulmonary veins (low variability), pulmonary artery (delicate), and finally bronchus (no variability observed). The key factors for good anesthesia management have been identified: sedation by caregivers, preoxygenation before induction of general anesthesia, high respiratory rates with low tidal volume after pneumonectomy, and noninvasive ventilation after extubation. Antibiotic prophylaxis has been performed. Postoperative care must be continuous until animals are able to stand up, afterward “preventive noncurative,” and always animal friendly. Ideas for minimally stressful therapy administration are helpful. ConclusionsAfter the delineation of this methodology, the compliance to a routine practice allowed us to reduce time, stress, and cost; quality and quantity of possible research increased.

Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery?

Thanks to the experience gained through the improvement of video-assisted thoracoscopic surgery (VATS) technique, and the enhancement of surgical instruments and high-definition cameras, most pulmonary resections can now be performed by minimally invasive surgery. The future of the thoracic surgery should be associated with a combination of surgical and anaesthetic evolution and improvements to reduce the trauma to the patient. Traditionally, intubated general anaesthesia with one-lung ventilation was considered necessary for thoracoscopic major pulmonary resections. However, thanks to the advances in minimally invasive techniques, the non-intubated thoracoscopic approach has been adapted even for use with major lung resections. An adequate analgesia obtained from regional anaesthesia techniques allows VATS to be performed in sedated patients and the potential adverse effects related to general anaesthesia and selective ventilation can be avoided. The non-intubated procedures try to minimize the adverse effects of tracheal intubation and general anaesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and postoperative nausea and vomiting. Anaesthesiologists should be acquainted with the procedure to be performed. Furthermore, patients may also benefit from the efficient contraction of the dependent hemidiaphragm and preserved hypoxic pulmonary vasoconstriction during surgically induced pneumothorax in spontaneous ventilation. However, the surgical team must be aware of the potential problems and have the judgement to convert regional anaesthesia to intubated general anaesthesia in enforced circumstances. The non-intubated anaesthesia combined with the uniportal approach represents another step forward in the minimally invasive strategies of treatment, and can be reliably offered in the near future to an increasing number of patients. Therefore, educating and training programmes in VATS with non-intubated patients may be needed. Surgical techniques and various regional anaesthesia techniques as well as indications, contraindications, criteria to conversion of sedation to general anaesthesia in non-intubated patients are reviewed and discussed.

Lung cancer surgery in patients aged 80years or older: an analysis of risk factors, morbidity, and mortality.

As the population ages, the age of patients undergoing thoracic surgery increases, and elderly patients often have more comorbidities than younger patients. This retrospective study observed preoperative comorbidities, surgical procedures and postoperative morbidity and mortality after lung cancer surgery in patients 80 years of age or older. The medical records of lung cancer patients 80 years of age or older who underwent surgery from January 2003 to December 2012 were reviewed. There were 49 patients (27 males, 22 females), with a median age of 83 years. Thirty patients underwent major pulmonary resection and 18 patients underwent limited pulmonary resection. The median Charlson comorbidity index was 3. Although approximately two-thirds of the patients (20 patients; 40.8%) experienced some kind of postoperative morbidity, more than 80% of the complications were grade 1 or 2 according to the Clavien-Dindo classification. Cerebrovascular disease and chronic obstructive pulmonary disease were significantly associated with moderate-to-severe complications. Postoperative death was observed in two cases (4.1%). In addition, an increased American Society of Anesthesiologists classification score and past history of myocardial infarction, congestive heart failure and/or diabetes mellitus with end-organ damage were significantly associated with mortality. The overall survival rate was 79.6% at 3 years and 53.1% at 5 years. Thoracic surgery shows acceptable morbidity and mortality in patients 80 years of age or older. Patients 80 years of age or older should be offered the best treatments, including surgery, with careful patient evaluation and selection.

Complications after major pulmonary resections for lung cancer: A prospective study

Aim-Background The aim of this study was to evaluate the complications after major pulmonary resections for lung cancer and identify the risk factors associated with the occurrence of complications. We studied risk factors related to both clinical and laboratory characteristics of patients and those related to tumour stage, histology and type of surgery.

Uniportal video-assisted thoracoscopic left upper lobectomy under spontaneous ventilation.

Intubated general anesthesia with one-lung ventilation was traditionally considered necessary for thoracoscopic major pulmonary resections. However, non-intubated thoracoscopic lobectomy can be performed by using conventional and uniportal video-assisted thoracoscopic surgery (VATS). These non-intubated procedures try to minimize the adverse effects of tracheal intubation and general anesthesia but these procedures must only be performed by experienced anesthesiologists and skilled thoracoscopic surgeons. Here we present a video of a uniportal VATS left upper lobectomy in a non-intubated patient, maintaining the spontaneous ventilation.

Role of 3-Dimentional Computed Tomography Scan in Video Assisted Major Pulmonary Resection in Patient with Situs Inversus Totalis

The aim of this case report is to raise awareness about the use of 3-Dimentional Computed Tomography (3D-CT) virtual reality imaging as a routine pre-operative tool for evaluation of unusual anatomy such as Situs Inversus Totalis (SIT). We present a case of presumed lung cancer in a 58 years old lady with SIT successfully treated by VATS lobectomy via an anterior approach. She presented with an incidental solitary pulmonary nodule in her right lower lobe, which had moderate FDG uptake on the PET scan. The nodule was too deep to permit safe wedge biopsy, due to proximity of a large pulmonary arterial branch. 3D-CT images were invaluable in pre-operative assessment of the anatomy and were the key to safe completion of right VATS lower lobectomy. Sectioning the lung after retrieval of the specimen suggested a chondroid hamartoma; therefore, systemic nodal dissection (SND) was not contemplated. The final histology confirmed the diagnosis of chondroid hamartoma. In an unusual anatomy such as SIT, 3D-CT allows construction of virtual reality models that can be viewed and manipulated before and during the operation to understand the anatomy better, highlight caveats around target structures and enable localisation of lesions unlikely to be palpated intra-operatively.

Beneficial effects of perioperative statins for major pulmonary resection

Statins improve overall outcomes after noncardiac surgery. The primary aim of the study was to determine whether use of perioperative atorvastatin reduced the rate of postoperative complications in patients undergoing pulmonary resection. This was a prospective, randomized, placebo-controlled, double-blind trial of patients undergoing elective pulmonary resection who received atorvastatin (40 mg daily) or placebo beginning 1 week before surgery and continued for 1 week postoperatively. Patient characteristics and postoperative complications were recorded. Plasma inflammatory markers were sampled at baseline, in the post-anesthesia care unit, and on postoperative day 3. Because of difficulty enrolling statin-naive patients, the study was stopped at the interim analysis. Postoperative complications occurred in 16 of 72 patients (22%) receiving placebo and in 8 of 65 patients (12%) receiving atorvastatin (P = .13). For patients undergoing major anatomic resection, there were 24 complications in 15 of 45 placebo-treated patients and 8 complications in 7 of 43 atorvastatin-treated patients (P = .04). Plasma levels of C-reactive protein, tumor necrosis factor-α, and myeloperoxidase did not differ between the 2 treatment arms during the study. After a 2-week perioperative course of atorvastatin (40 mg) in statin-naïve patients undergoing major pulmonary resection, we found evidence of a reduction in the number of clinically important cardiovascular and pulmonary complications compared with placebo. These promising results merit evaluation in a larger, perhaps multicenter study.

The feasibility of single-incision video-assisted thoracoscopic major pulmonary resection performed by surgeons experienced with a two-incision technique.

This study evaluated the safety and feasibility of a single-incision video-assisted thoracoscopic surgery (VATS) major pulmonary resection performed by surgeons experienced with the two-incision technique. Consecutive patients who underwent single-incision VATS major pulmonary resection from March 2012 to May 2013 were included. The fifth intercostal space was incised (3-5 cm) at the anterior or posterior axillary line according to the tumour location. In total, 60 patients (39 men, 21 women; median age, 61 years; interquartile range, 53-69 years) were included in this study. Malignant lung disease was diagnosed preoperatively in 56 patients (93%) and benign disease in 4 (7%) patients. Lobectomy was performed in the majority of patients (n = 55), bilobectomy in 1, sleeve lobectomy in 1 and segmentectomy in 3. Four patients (7%) required a second incision, and conversion to thoracotomy was required in 2 (3%). In 50 lung cancer cases completed using a single-incision technique, the median surgical duration was 145 min (interquartile range, 90-182 min), and the total number of dissected lymph nodes per patient was 22 (interquartile range, 10-28 min). The chest tube was removed 5 days (interquartile range, 3-6 days) postoperatively, and there were no cases involving major perioperative morbidity or mortality. Single-incision VATS major pulmonary resection is feasible, and following a two-incision technique learning period, may yield results similar to those obtained with conventional VATS lobectomy.

Technique of uniportal VATS major pulmonary resections.

The surgical approach to lung resections is evolving constantly. Since the video-assisted thoracoscopic surgery (VATS) anatomic lobectomy for lung cancer was described two decades ago, many units have successfully adopted this technique. The VATS lobectomy can be defined as the individual dissection of veins, arteries and bronchus, with a mediastinal lymphadenectomy, using a videothoracoscopic approach visualized on screen and involving 2 to 4 incisions or ports, with no rib spreading. However, the surgery can be performed by only one incision with similar outcomes. Since 2010, when the uniportal approach was introduced for major pulmonary resections, the technique has been spreading worldwide. This technique provides a direct view of the target tissue. The parallel instrumentation achieved during the single-port approach mimics the maneuvers performed during open surgery. It represents a less invasive approach than the multiport technique, and minimizes the compression of the intercostal nerve. As the surgeon's experience with the uniportal VATS lobectomy grows, more complex cases can be performed by using this approach, thus expanding the indications for single-incision thoracoscopic lobectomy.

From open surgery to uniportal VATS: asturias experience.

Uniportal video-assisted thoracic surgery (VATS) resections are of increasing interest in many thoracic surgery departments. This study shows our initial experience in uniportal VATS anatomical resections in direct transition from posterolateral thoracotomy. We retrospectively reviewed the 82 files of patients on whom anatomical pulmonary resection via uniportal VATS was attempted in our department by a single surgeon experienced in VATS for almost all purposes except major pulmonary resections. Demographic data of patients, smoking habits, chronic obstructive pulmonary disease (COPD), presence of cardiopulmonary comorbidities, general characteristics of pulmonary lesions, preoperative FEV1, intraoperative findings, operative time, postoperative-drain-time, hospital-stay-time, successfully completed or converted to thoracotomy, intraoperative and postoperative complications and 30-day mortality were recorded. The patients were chronologically divided into two groups for analysis (A: operated on in the first year; B: operated on after the first year). We compare our results with the largest published experience in anatomical resections by uniportal VATS started from multiport technique and anterior thoracotomy in order to identify the feasibility of this transition. From January 2012 to January 2014, 82 uniportal VATS anatomical pulmonary resections were attempted. Of these 82 resections attempted, 74 (90.2%) were completely carried out. The median drain-time and hospital-stay-time were 3 days, and 4 days for the first year of experience and 2 and 3 days for the second year of experience respectively. The most frequent intraoperative complication was bleeding in 10 (12.1%), of these 8 occurred in the first year of experience (group A). In 8 (9.75%) cases conversion to thoracotomy widening the incision was needed for different reasons, of these 6 occurred in group A. The most frequent minor complication was chest tube reinsertion in 12 (14.6%) patients. There were no major complications or mortality in the first year of experience (group A). Two cases of mortality in the 8(th) and 15(th) postoperative day respectively occurred in group B in two patients with serious comorbidities. Uniportal VATS for anatomical resections is a feasible and safe technique with good results even if experience is started in direct transition from open surgery, on condition that general recommendations for an initial VATS program were observed. Specific training courses with experts are also necessary. Patient selection is crucial. The number of procedures necessary to obtain appropriate experience may be similar to those reported for transition from open surgery to multiport technique.

B-type natriuretic peptide following thoracic surgery: a predictor of postoperative cardiopulmonary complications.

B-type natriuretic peptides (BNPs) are secreted by the human heart in response to ventricular wall stretch or myocardial ischaemia, and predict adverse cardiovascular events and death in the general population. Following non-cardiac surgical procedures, there is growing evidence supporting BNP measurement as a powerful independent predictor of death and perioperative complications. However, the clinical implication of elevated BNP measurements after pulmonary resection has not been completely defined. This study aimed to evaluate the role of BNP in predicting adverse cardiopulmonary events after thoracic surgery. A prospective, short-term, observational cohort study was conducted in a tertiary care hospital, including consecutive patients undergoing scheduled pulmonary resection between April 2012 and October 2013. Baseline clinical details were obtained; serum BNP levels were measured at baseline and on postoperative days 1 and 4. We enrolled 294 consecutive patients, median age 66 [interquartile range (IQR): 57-73], 67% male. There were 2 perioperative deaths, and 52 patients experienced one or more cardiopulmonary complications. The baseline median BNP value was normal (29.5 pg/ml, IQR: 16-57.2), and showed significant postoperative increase, peaking on day 1. Patients who developed postoperative complications had a significantly greater BNP increase (P < 0.0001) when compared with those without complications. A postoperative day 1 BNP measurement of ≥118.5 [receiver operating characteristic area: 0.654; 95% confidence interval (CI): 0.57-0.74; P = 0.001] was associated with a 3-fold risk of developing postoperative cardiopulmonary complications [odds ratio (OR): 2.94; 95% CI: 1.32-6.57; P = 0.008]. Logistic regression analysis showed major pulmonary resections (lobectomies or pneumonectomies), BNP ≥ 118.5 and age ≥ 65 to be the only independent predictive variables. In the subset of patients undergoing lobectomy or pneumonectomy (n = 226), BNP was the strongest independent predictor of complications (OR: 3.49; 95% CI: 1.51-8.04). Our results show that BNP elevation, measured in the first days after thoracic surgery, is independently associated with postoperative adverse events. In patients undergoing major pulmonary resections, a postoperative BNP elevation is the strongest independent predictor of cardiopulmonary complications.

Experimental Robotic Pulmonary Lobectomy With the TELELAP/ALFX System in the Ovine Model.

A new robotic telesurgical device (TELELAP/ALFX) is used for the first time to execute an anatomical pulmonary resection (lobectomy) plus mediastinal lymph node dissection in the ovine model. This integrated operative system has 2 innovative peculiarities: (a) tactile perception (engineered to give the operator a tactile feedback similar to that experienced when handling thoracoscopy instruments) and (b) eye-tracking (immediate synchronization of the surgeon's eyes movements with that of the robotic camera). Herein, we report a lower right pulmonary lobectomy under complete robotic assistance (TELELAP/ALFX). Standard endoscopic staplers were used in all the major maneuvers (bronchial as well as vascular resections and fissural completion) introduced through a utility 4-cm-sized incision. The specimen was placed in an endoscopic retrieval bag and removed through a service minithoracotomy. With the limitations because of interspecies differences in anatomical landmarks, a mediastinal lymph nodal dissection was also completed. The operative time was acceptable (~180 minutes) with blood loss of 100 mL. In conclusion, according to this first all experimental experience we may deem the TELELAP/ALFX system completely apt to perform major anatomic pulmonary resections and the regulatory process to run trials in humans are under way.