title: Initial consecutive experience of completely portal robotic pulmonary resection with 4 arms.
abstract: BACKGROUND
  Many general thoracic surgeons are learning robotic pulmonary resection.
  
  
  METHODS
  We retrospectively compared results of completely portal robot lobectomy with 4 arms (CPRL-4) against propensity-matched controls and results after technical changes to CPRL-4.
  
  
  RESULTS
  In 14 months, 168 patients underwent robotic pulmonary resection: 7 had metastatic pleural disease, 13 had conversion to open procedures, and 148 had completion robotically (106 lobectomies, 26 wedge resections, 16 segmentectomies). All patients underwent R0 resection and removal of all visible lymph nodes (median of 5 N2, 3 N1 nodal stations, 17 lymph nodes). The 106 patients who underwent CPRL-4 were compared with 318 propensity-matched patients who underwent lobectomy by rib- and nerve-sparing thoracotomy. The robotic group had reduced morbidity (27% vs 38%; P = .05), lower mortality (0% vs 3.1%; P = .11), improved mental quality of life (53 vs 40; P < .001), and shorter hospital stay (2.0 vs 4.0 days; P = .02). Results of CPRL-4 after technical modifications led to reductions in median operative time (3.7 vs 1.9 hours; P < .001) and conversion (12/62 vs 1/106; P < .001). Technical improvements were addition of fourth robotic arm for retraction, vessel loop to guide the stapler, tumor removal above the diaphragm, and carbon dioxide insufflation.
  
  
  CONCLUSIONS
  The newly refined CPRL-4 is safe and yields an R0 resection with complete lymph node removal. It has lower morbidity, mortality, shorter hospital stay, and better quality of life than rib- and nerve-sparing thoracotomy. Technical advances are possible to shorten and improve the operation.
authors.affiliation: Division of Cardiothoracic Surgery, University of Alabama at Birmingham, Birmingham, AL 35294, USA. rcerfolio@uab.edu
authors.forename: Robert J
authors.initials: RJ
authors.lastname: Cerfolio
authors.forename: Ayesha S
authors.initials: AS
authors.lastname: Bryant
authors.forename: Loki
authors.initials: L
authors.lastname: Skylizard
authors.forename: Douglas James
authors.initials: DJ
authors.lastname: Minnich
mesh_terms: D000328:Adult; D000368:Aged; D000407:Alabama; D002289:Carcinoma, Non-Small-Cell Lung / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016022:Case-Control Studies; D016009:Chi-Square Distribution; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007902:Length of Stay; D016015:Logistic Models; D008175:Lung Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D008197:Lymph Node Excision; D008297:Male; D008875:Middle Aged; D011013:Pneumonectomy / Q000009:adverse effects / Q000379:methods* / Q000401:mortality; D057216:Propensity Score; D011788:Quality of Life; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012371:Robotics; D025321:Surgery, Computer-Assisted / Q000009:adverse effects / Q000401:mortality; D013908:Thoracotomy / Q000009:adverse effects / Q000401:mortality; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult