Surgeon's Dexterity Research Articles

Augmented dexterity: How robots can enhance human surgical skills.

Advances in AI and robotics have the potential to enhance the dexterity of human surgeons.

Handheld robotic device for endoscopic neurosurgery: system integration and pre-clinical evaluation.

The Expanded Endoscopic Endonasal Approach, one of the best examples of endoscopic neurosurgery, allows access to the skull base through the natural orifice of the nostril. Current standard instruments lack articulation limiting operative access and surgeon dexterity, and thus, could benefit from robotic articulation. In this study, a handheld robotic system with a series of detachable end-effectors for this approach is presented. This system is comprised of interchangeable articulated 2/3 degrees-of-freedom 3 mm instruments that expand the operative workspace and enhance the surgeon's dexterity, an ergonomically designed handheld controller with a rotating joystick-body that can be placed at the position most comfortable for the user, and the accompanying control box. The robotic instruments were experimentally evaluated for their workspace, structural integrity, and force-delivery capabilities. The entire system was then tested in a pre-clinical context during a phantom feasibility test, followed up by a cadaveric pilot study by a cohort of surgeons of varied clinical experience. Results from this series of experiments suggested enhanced dexterity and adequate robustness that could be associated with feasibility in a clinical context, as well as improvement over current neurosurgical instruments.

Delayed Repair of E2 Bile Duct Injury With Robotic Roux-en-Y Hepaticojejunostomy.

Bile duct injury is a rare complication in the modern era of minimally invasive laparoscopic and robotic surgery; however, it can lead to serious short- and long-term consequences. Repair of bile duct injury with Roux-en-Y hepaticojejunostomy is a technically complex operation, especially when undertaken laparoscopically. Newer robotic technology improves surgeon's dexterity for fine suturing tasks such as in creating a delicate hepaticojejunostomy, which overcomes technical limitations of conventional laparoscopic approach. As surgeons accumulate more experience in minimally invasive bile duct surgery for benign and malignant diseases, the accepted surgical approaches gradually transition from open to robotic technique. In this video, we describe our robotic technique for delayed repair of an E2 bile duct injury.

Tissue palpation in endoscopy using EIT and soft actuators.

The integration of soft robots in medical procedures has significantly improved diagnostic and therapeutic interventions, addressing safety concerns and enhancing surgeon dexterity. In conjunction with artificial intelligence, these soft robots hold the potential to expedite autonomous interventions, such as tissue palpation for cancer detection. While cameras are prevalent in surgical instruments, situations with obscured views necessitate palpation. This proof-of-concept study investigates the effectiveness of using a soft robot integrated with Electrical Impedance Tomography (EIT) capabilities for tissue palpation in simulated in vivo inspection of the large intestine. The approach involves classifying tissue samples of varying thickness into healthy and cancerous tissues using the shape changes induced on a hydraulically-driven soft continuum robot during palpation. Shape changes of the robot are mapped using EIT, providing arrays of impedance measurements. Following the fabrication of an in-plane bending soft manipulator, the preliminary tissue phantom design is detailed. The phantom, representing the descending colon wall, considers induced stiffness by surrounding tissues based on a mass-spring model. The shape changes of the manipulator, resulting from interactions with tissues of different stiffness, are measured, and EIT measurements are fed into a Long Short-Term Memory (LSTM) classifier. Train and test datasets are collected as temporal sequences of data from a single training phantom and two test phantoms, namely, A and B, possessing distinctive thickness patterns. The collected dataset from phantom B, which differs in stiffness distribution, remains unseen to the network, thus posing challenges to the classifier. The classifier and proposed method achieve an accuracy of and on phantom A and B, respectively. Classification results are presented through confusion matrices and heat maps, visualising the accuracy of the algorithm and corresponding classified tissues.

Analysis of the Robotic-Based In Situ Bioprinting Workflow for the Regeneration of Damaged Tissues through a Case Study.

This study aims to critically analyse the workflow of the in situ bioprinting procedure, presenting a simulated neurosurgical case study, based on a real traumatic event, for collecting quantitative data in support of this innovative approach. After a traumatic event involving the head, bone fragments may have to be removed and a replacement implant placed through a highly demanding surgical procedure in terms of surgeon dexterity. A promising alternative to the current surgical technique is the use of a robotic arm to deposit the biomaterials directly onto the damaged site of the patient following a planned curved surface, which can be designed pre-operatively. Here we achieved an accurate planning-patient registration through pre-operative fiducial markers positioned around the surgical area, reconstructed starting from computed tomography images. Exploiting the availability of multiple degrees of freedom for the regeneration of complex and also overhanging parts typical of anatomical defects, in this work the robotic platform IMAGObot was used to regenerate a cranial defect on a patient-specific phantom. The in situ bioprinting process was then successfully performed showing the great potential of this innovative technology in the field of cranial surgery. In particular, the accuracy of the deposition process was quantified, as well as the duration of the whole procedure was compared to a standard surgical practice. Further investigations include a biological characterisation over time of the printed construct as well as an in vitro and in vivo analysis of the proposed approach, to better analyse the biomaterial performances in terms of osteo-integration with the native tissue.

Transcranial Surgery for Pituitary Tumors: A "Community Neurosurgery Experience".

Despite the evolution of endoscopic techniques, large pituitary adenomas with unfavorable characteristics and irregular anatomical configurations continue to pose a challenge for the dexterity, skills, and patience of endoscopic surgeons. Transcranial surgery retains a significant role in these situations where the tumor access, hemostasis, and dissection around adjoining neurovascular tissues can be controlled efficaciously. In this report, we describe our experience with transcranial surgery for pituitary adenomas highlighting its safety and versatility in peripheral centers. We accessed the case files and imaging records of pituitary tumors operated between 2001 and 2019 at a private hospital in a major Indian city. The records were analyzed with emphasis on postoperative clinical course, visual, and endocrinological outcomes. The data was analyzed with respect to differences between transcranial and transsphenoidal procedures. Categorical variables were compared with Chi-square test/Fischer's exact test and difference in means evaluated with Welch's t-test. A total of 178 procedures were performed in 173 patients with pituitary adenoma, who were the subjects of this study. Ninety-eight (56.7%) patients were treated by transsphenoidal excision whereas 80 (46.2%) underwent transcranial procedures (75 primary and five secondary). In the patients operated transcranially, we observed three deaths and nine patients suffered from significant morbidity. Visual outcomes were similar to the group operated transsphenoidally. However, incidence of panhypopituitarism was significantly higher in transcranial procedures; the extent of resection was poorer than transsphenoidal surgeries owing to more extensive nature of tumors. In low-volume centers, the endoscopic skills required for transsphenoidal resection of large and complex pituitary adenomas may be scarce. Transcranial surgery, dependent on familiar microsurgical techniques and equipment, may still be viable, safe, and an effective option.

Assessment of the da Vinci Single Port Robotic Platform on Cholecystectomy in Adolescents

Background: The new da Vinci single port (SP) robotic platform has great appeal for pediatric surgery. To assess its efficacy and identify potential challenges, 7 adolescents underwent SP cholecystectomy. Materials and Methods: The surgeon controls three fully wristed elbowed instruments, and the first fully wristed da Vinci endoscope through a single 2.5 cm cannula. Instruments can reach 24 cm deep and triangulate distally. Instruments can also reach anatomy anywhere within 360° of port placement. A vertical incision was made through the umbilicus for port access. The cystic duct and cystic artery were dissected, clipped, divided, and hook cautery was used to remove the gallbladder. Patient characteristics and outcomes were collected and analyzed. Results: Patients were American Society of Anesthesiologists (ASA) classes I, II, and III; mean age was 17 years; mean weight was 72 kg; and 6 of 7 patients were female. There were no fatalities, and there were no returns to the operating room. Mean estimated blood loss was 2 mL and mean case duration was 126 minutes. Five out of seven patients were treated as outpatients, and none of them required narcotics on discharge. One patient reported bilateral shoulder pain 1 day postoperatively and was taking hydrocodone/acetaminophen at the time of 13-day follow-up. Conclusions: SP robotic platform cholecystectomy in adolescents appears to be safe and effective. The wristed movement of the robotic instruments improves surgeon dexterity, and the single incision hidden in the contour of the umbilicus provides good cosmesis. This series sets an exciting precedent and provides a glimpse of what is possible in pediatric robotic surgery. Clinical Trial Registration number 2014-0396.

One-Year Outcomes of the First Human Trial on Robot-Assisted Lymphaticovenous Anastomosis for Breast Cancer-Related Lymphedema.

Lymphaticovenous anastomosis, a supermicrosurgical technique, creates bypasses between the lymphatic and venous systems. The quality of lymphaticovenous anastomosis depends on the surgeon's dexterity and precision, and is subject to imperfections caused by the physiologic tremor of the human hand. A dedicated robot for microsurgery has been created to overcome these limitations (MUSA, MicroSure, Eindhoven, The Netherlands). This study describes 1-year clinical outcomes of the first-in-human trial of robot-assisted and manual lymphaticovenous anastomosis in patients with breast cancer-related lymphedema. In this prospective pilot study, women with breast cancer-related lymphedema were randomized into the robot-assisted or manual lymphaticovenous anastomosis group. Outcomes were quality of life, arm circumference, conservative treatment frequency, arm dermal backflow stage, and anastomosis patency. Twenty women were included, of whom eight underwent robot-assisted lymphaticovenous anastomosis surgery and 12 underwent manual surgery. In both groups, quality of life significantly improved at 12 months (robot-assisted surgery, p = 0.045; manual surgery, p = 0.001). Arm circumference did not decrease (robot-assisted surgery, p = 0.094; manual surgery, p = 0.240). Daily use of compression garments decreased by 61.9 percent (robot-assisted surgery) and 70.2 percent (manual surgery). The frequency of manual lymphatic drainage remained similar compared with baseline. Arm dermal backflow stage was reduced in one patient in the robot-assisted group and in five cases in the manual group. Overall, 76.5 percent of the anastomoses were patent (robot-assisted surgery, 66.6 percent; manual surgery, 81.8 percent). After evaluating 1-year follow-up data, this study confirms the feasibility of robot-assisted lymphaticovenous anastomosis surgery. Clinical outcomes were comparable between robot-assisted and manual lymphaticovenous anastomosis. This encourages further research using the new microsurgical robot MUSA for lymphaticovenous anastomosis and other (super)microsurgical procedures. Therapeutic, II.

A Single Institution's Experience With Robotic Minor and Major Hepatectomy.

Minimally invasive liver resection is gradually becoming the preferred technique to treat liver tumors due its salutary benefits when compared with traditional "open" method. While robotic technology improves surgeon dexterity to better perform complex operations, outcomes of robotic hepatectomy have not been adequately studied. We therefore describe our institutional experience with robotic minor and major hepatectomy. We prospectively study all patients undergoing robotic hepatectomy from 2016 to 2020. A total of 220 patients underwent robotic hepatectomy. 138 (63%) were major hepatectomies while 82 (37%) were minor hepatectomies. Median age was 63 (62 ± 13) years, 118 (54%) were female. 168 patients had neoplastic disease and 52 patients had benign disease. Lesion size in patients who had undergone minor hepatectomy was 2 (3 ± 2.5) cm, compared to 5 (5 ± 3.0) cm in patients who undergone major hepatectomy (P < .001). 97% of patients underwent R0 resections while none of the patients had R2 resection. Operative duration was 226 (260 ± 122.7) vs 282 (299 ± 118.7) minutes (P ≤ .05); estimated blood loss was 100 (163 ± 259.2) vs 200 (251 ± 246.7) mL (P ≤ .05) for minor and major hepatectomy, respectively. One patient had intraoperative bleeding requiring "open" conversion. Nine (4%) patients had experienced notable postoperative complications and 2 (1%) patients died postoperatively. Length of stay was 3 (5 ± 4.6) vs 4 (5 ± 2.8) days for minor vs major hepatectomy (P = .84). Reoperation and readmission rate for minor vs major hepatectomy was 1% vs 3% (P = .65) and 9% vs 10% (P = .81), respectively. Robotic major hepatectomy is safe, feasible, and efficacious with excellent postoperative outcomes.

Analysis of performance factors in 240 consecutive cases of robot-assisted flexible ureteroscopic stone treatment.

Flexible ureteroscopy is the keystone of modern kidney stone treatment. Although a simple surgical technique achieves good clinical results and a low complication rate, there are high demands on the surgeon's dexterity and ergonomic restrictions. Robotic-assisted flexible ureteroscopy (rfURS) could overcome these limitations. After 4years of use of rfURS at a tertiary stone center, performance factors were analyzed to define the role of rfURS in kidney stone management. A rfURS system was installed in August 2014 at the SLK Kliniken (Heilbronn, Germany). Treatment data of N = 240 consecutive patients undergoing rfURS were prospectively collected and analyzed. The patient cohort represents typical stone formers. N = 240 renal units containing 443 stones with an average stone load of 1798mm3 were treated. Surgical parameters as well as the peri- and postoperative complications were recorded, analyzed and compared to the current data in the literature. OR time 91min, stone treatment time 55min, stone treatment efficacy 33mm3/min; perioperative complications 5.4%; robot times: preparation 5min, docking 5min, console time to stone contact 6min, console time 75min; postoperative complications 6.7%; postoperative length of stay 1.5days; stone-free rate (residuals < 2mm) 90% and re-treatment rate 8.75%. This consecutive series represents real-life data about the utilization of rfURS. The detailed analysis of performance factors revealed the successful utilization of the first generation of robotic systems in endourologic stone surgery, and indicates that the robot performs comparably to conventional flexible URS. Optimal ergonomics maintain the surgeon's endurance in long-lasting surgeries.

Institutional experience of robotic liver resection: outcome comparisons with nsqip data

Background: Minimally invasive techniques have significantly changed many aspects of Surgery, more specifically length of stay and postoperative complications. Robotic surgery has improved visualization and dexterity of surgeons especially in complex operations. This study was undertaken to examine our institutional results of robotic liver resections compared to those predicted by NSQIP risk calculator, and reported in the NSQIP database. Methods: With IRB approval, 76 patients were prospectively followed. Demographic data, operative duration, estimated blood loss (EBL), complications, length of stay (LOS), readmission within 30 days, return to OR, and discharge disposition were collected and analyzed. We used the ACS NSQIP Surgical Risk Calculator to achieve a predicted outcome and compared our data to the NSQIP database. Data were analyzed with a student’s t-test. For illustrative purposes data are expressed as median (mean + SD) when appropriate. Results: 76 patients underwent robotic liver resections, 87% occurring between 2015–2018: 45 partial hepatectomies, 15 right hepatectomies, 13 left hepatectomies, and 3 trisegmentectomies (table). Patients’ age was 63 (62 + 14.3) years and BMI 27 (29 + 9.6) kg/m2. Operative duration was 232 (267+ 109.6) mins, EBL was 150 (265 + 319.9) mL, and LOS was 3 (5 + 4.6) days. EBL variations include: 100 (295 + 412.0)mL for partial hepatectomy, 250 (334 + 267.0) mL for right hepatectomies, 100 (159 + 145.0) mL for left hepatectomies, and 400 (583 + 645.0) mL for trisegmentectomies. Robotic partial hepatectomies took 240 (347 ± 482.0) minutes, robotic right lobectomies took 306 (311 ± 107.0) minutes, robotic left hepatectomies took 225 (229 ± 61.0) minutes, and robotic trisegmentectomies took 275 (229 ± 110.0) minutes. Postoperative complications include 3 (4%) patients with bile leaks, 1 (1%) patient with pleural effusion, 1 (1%) patient with intra abdominal fluid collection, 1 (1%) patient with UTI , and 1 (1%) patient with enterocutaneous fistula, renal failure, and subsequently died due to sepsis. 7 patients were readmitted within 30 days of operation, but none required return to the OR. No patients suffered liver failure or hemorrhage, and only one patient required a nursing or rehab facility upon discharge. Conclusion: Our patients were similar to those in the NSQIP database, they were not a select group.We had less complications when compared to the national average, which are primarily ‘open’ resections. Our experience has shown robotic liver resections are as safe as open resections reported by NSQIP with less complications.

Totally Robotic Transhiatal Esophagectomy: Step-by-Step Approach

Abstract Introduction: Transhiatal esophagectomy is among the most complex and challenging laparoscopic operations.1–3 Owing to limitations of laparoscopic instruments, robotic systems may improve the observation, surgeon dexterity, and resectability of esophageal cancers.4–7 This video depicts a robotic transhiatal esophagectomy in a step-by-step manner. The initial results from an initial pilot study at a single institution are presented as well. Materials and Methods: This video presents a step-by-step approach to a total robotic transhiatal esophagectomy procedure performed on a 76-year-old man with an adenocarcinoma arising from the middle part of the esophagus (T3N1). Neoadjuvant treatment was given to the patients with cisplatine, 5-fluoruracil, and radiotherapy. The Da Vinci robotic surgical system model Si (Intuitive Surgical, Sunnyvale, CA) was used for this procedure. Initially, the patient was placed in a 20° reverse-Trendelenburg position with legs apart. After achieving a pneumoperitoneum wi...

Current status of robotic surgery in urology.

As a result of ergonomics, optimal magnification of the operative field, surgeon dexterity, and precision of surgical manipulation, robotic technology has been shown to overcome many difficulties associated with pure laparoscopy. With the recent expansion of robot-assisted surgery in the field of urology and following the success of robot-assisted prostatectomy and robot-assisted partial nephrectomy, robot-assisted surgery is being applied to treat many other genitourinary diseases, such as bladder cancer and ureteropelvic junction obstruction. The aim of the present review is to discuss the role of robotic surgery in urology and summarize recent developments in the field of urologic robotic surgery.

Miniaturized Instruments for the da Vinci Research Kit: Design and Implementation of Custom Continuum Tools

The da Vinci Surgical System is a commercially available surgical robotics platform used to perform more than 450,000 surgeries annually, primarily for gynecological and urological procedures [1]. This technology enhances the surgeon's dexterity through the use of a multiarm robot with wristed instruments that enter a patient's body through small incisions. However, the size of existing instruments (5-8 mm in shaft diameter) has prevented the adoption of the da Vinci system in areas such as neurosurgery, head and neck surgery, and pediatrics [2], [3]. These applications require high dexterity in small, confined workspaces, and, therefore, new miniaturized tools are needed [4].

Minimal abdominal incisions

Minimally invasive procedures aim to resolve the disease with minimal trauma to the body, resulting in a rapid return to activities and in reductions of infection, complications, costs and pain. Minimally incised laparotomy, sometimes referred to as minilaparotomy, is an example of such minimally invasive procedures. The aim of this study is to demonstrate the feasibility and utility of laparotomy with minimal incision based on the literature and exemplifying with a case. The case in question describes reconstruction of the intestinal transit with the use of this incision. Male, young, HIV-positive patient in a late postoperative of ileotiflectomy, terminal ileostomy and closing of the ascending colon by an acute perforating abdomen, due to ileocolonic tuberculosis. The barium enema showed a proximal stump of the right colon near the ileostomy. The access to the cavity was made through the orifice resulting from the release of the stoma, with a lateral-lateral ileo-colonic anastomosis with a 25mm circular stapler and manual closure of the ileal stump. These surgeries require their own tactics, such as rigor in the lysis of adhesions, tissue traction, and hemostasis, in addition to requiring surgeon dexterity – but without the need for investments in technology; moreover, the learning curve is reported as being lower than that for videolaparoscopy. Laparotomy with minimal incision should be considered as a valid and viable option in the treatment of surgical conditions.

Risk factors' analysis of transient and permanent hypoparathyroidism after thyroidectomy

This review evaluates those main risk factors that can affect patients undergoing thyroidectomy, to reach a better pre- and post-operative management of transient and permanent hypoparathyroidism. The transient hypoparathyroidism is a potentially severe complication of thyroidectomy, including a wide range of signs and symptoms that persists for a few weeks. The definitive hypoparathyroidism occurs when a medical treatment is necessary over 12 months. Risk factors that may influence the onset of this condition after thyroidectomy include: pre- and post-operative biochemical factors, such as serum calcium levels, vitamin D blood concentrations and intact PTH. Other involved factors could be summarized as follow: female sex, Graves' or thyroid neoplastic diseases, surgeon's dexterity and surgical technique. The medical treatment includes the administration of calcium, vitamin D and magnesium sometimes. Although biological and biochemical factors could be related to iatrogenic hypoparathyroidism, the surgeon's experience and the used surgical technique still maintain a crucial role in the aetiology of this important complication.

Lessons learned over a decade of pediatric robotic ureteral reimplantation.

The da Vinci robotic system has improved surgeon dexterity, ergonomics, and visualization to allow for a minimally invasive option for complex reconstructive procedures in children. Over the past decade, robot-assisted laparoscopic ureteral reimplantation (RALUR) has become a viable minimally invasive surgical option for pediatric vesicoureteral reflux (VUR). However, higher-than-expected complication rates and suboptimal reflux resolution rates at some centers have also been reported. The heterogeneity of surgical outcomes may arise from the inherent and underestimated complexity of the RALUR procedure that may justify its reclassification as a complex reconstructive procedure and especially for robotic surgeons early in their learning curve. Currently, no consensus exists on the role of RALUR for the surgical management of VUR. High success rates and low major complication rates are the expected norm for the current gold standard surgical option of open ureteral reimplantation. Similar to how robot-assisted laparoscopic surgery has gradually replaced open surgery as the most utilized option for prostatectomy in prostate cancer patients, RALUR may become a higher utilized surgical option in children with VUR if the adoption of standardized surgical techniques that have been associated with optimal outcomes can be adopted during the second decade of RALUR. A future standard of RALUR for children with VUR whose parents seek a minimally invasive surgical option can arise if widespread achievement of high success rates and low major complication rates can be obtained, similar to the replacement of open surgery with robot-assisted laparoscopic radical prostectomy as the new strandard for men with prostate cancer.

Surgical Skill Assessment Using Motion Quality and Smoothness

This article presents a quantitative technique to assess motion quality and smoothness during the performance of micromanipulation tasks common to surgical maneuvers. The objective is to investigate the effectiveness of the jerk index, a derivative of acceleration with respect to time, as a kinetostatic measure for assessment of surgical performance. A surgical forceps was instrumented with a position tracker and accelerometer that allowed measurement of position and acceleration relative to tool motion. Participants were asked to perform peg-in-hole tasks on a modified O'Connor Dexterity board and a Tweezer Dexterity pegboard (placed inside a skull). Normalized jerk index was calculated for each individual task to compare smoothness of each group. This study was conducted at Project neuroArm, Cumming School of Medicine, the University of Calgary. Four groups of participants (surgeons, surgery residents, engineers, and gamers) participated in the tests. Results showed that the surgeons exhibited better jerk index performance in all tasks. Moreover, the residents experienced motions closer to the surgeons compared to the engineers and gamers. One-way analysis of variance test indicated a significant difference between the mean values of normalized jerk indices among 4 groups during the performance of all tasks. Moreover, the mean value of the normalized jerk index significantly varied for each group from one task to another. Normalized jerk index as an independent parameter with respect to time and amplitude is an indicator of motion smoothness and can be used to assess hand motion dexterity of surgeons. Furthermore, the method provides a quantifiable metrics for trainee assessment and proficiency, particularly relevant as surgical training shifts toward a competency-based paradigm.

A magnetic levitation robotic camera for minimally invasive surgery: Useful for NOTES?

Minimally invasive surgery (MIS) is rising in popularity generating a revolution in operative medicine during the past few decades. Although laparoscopic techniques have not significantly changed in the last 10 years, several advances have been made in visualization devices and instrumentation. Our team, composed of surgeons and biomedical engineers, developed a magnetic levitation camera (MLC) with a magnetic internal mechanism dedicated to MIS. Three animal trials were performed. Porcine acute model has been chosen after animal ethical committee approval, and laparoscopic cholecystectomy, nephrectomy and hernioplastic repair have been performed. MLC permits to complete efficiently several two-port laparoscopy surgeries reducing patients' invasiveness and at the same time saving surgeon's dexterity. We strongly believe that insertable and softly tethered devices like MLS camera will be an integral part of future surgical systems, thus improving procedures efficiency, minimizing invasiveness and enhancing surgeon dexterity and versatility of visions angles.

Robot-assisted thoracoscopic bronchoplasty.

Robotic systems have been used to enhance the surgeon's dexterity and visualization in endoscopic surgery and thus facilitate refined dissection, suturing, and knot tying. We describe use of the da Vinci surgical system for robotic-assisted thoracoscopic bronchoplasty in patient with centrally located lung cancer. We used three robotic ports (a 12-mm trocar for the 30°-down camera and two 8-mm trocars for the robotic instrument arms) and one utility incision for assistance and specimen retrieval. Lung isolation were achieved using double-lumen endotracheal tube without carbon dioxide inflation. The bronchoplasty was performed by using 4/0 polydioxanone suture (PDS). Three cases of robotic-assisted thoracoscopic bronchoplasty (n=3) were performed. Case 1: right upper lobe lobectomy with right main bronchus primary closure; case 2: right upper lobe lobectomy with the anterior wall of the right main bronchus re-anastomosis; case 3: left upper lobe sleeve lobectomy. The surgery and post-operative course were smooth without complication. We suggest that robotic-assisted thoracoscopic surgery offers specific advantages over conventional thoracoscopic surgery with accuracy and safety when doing bronchoplasty.