In theory, the IMLNs are equally distributed in the intercostal space and behind the costal cartilage. Intercostal biopsy without costal cartilage resection may miss lymph nodes. Reports of thoracoscopic surgery for IMLN resection have also been reported.[4,12–15] This method is easy for right IMLN chain resection. However, because of the location of the heart and the pivot effect of the rigid long straight instrument, it is difficult to remove the left IMLNs, limiting the application and development of this technique.
The 3D imaging system and the larger magnification of the Da Vinci robotic surgical equipment can provide a clearer vision compared with open surgery or traditional laparoscopic surgery. The operating instrument with the special internal joint design (EndoWrist) has 7 degrees of freedom, which is beyond the human hand's limit and therefore is conducive to the completion of more detailed operations. Meanwhile, the vibration reduction system and the action calibration system of the robot system can effectively protect the blood vessels and nerves, further improving the safety of the surgery.
The main disadvantage of robotic surgery is increased cost and operation time. A recent cost analysis of robotic surgery based on medical costs in the United States showed that the robotic system extended the operative time and disposables costs, thus contributing to an increase in operative costs.[16,17] Cost can be minimized by the multidisciplinary use, especially in an institutional practice. In addition, lack of haptic feedback is another concern. Novice surgeons may find the absence of haptic feedback a difficulty. The visual clues must be relied to assess the surgical field.
The surgical results of this case show that except for the duration of operation preparation and docking, the operation lasted for only 1.5 hours. Blood loss was only 10 mL, and 9 IMLNs were removed. The patient's postoperative recovery was fast, and her post-traumatic stress reaction was mild. With 10 months of follow-up after the operation, the patient showed good recovery, without surgical complications.
We thank Ling Zhong for helping with the images collection and Junlan Liu for critical reading of the manuscript.
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