In the supine position, a double-lumen tube or bronchial blocker is placed for eventual single-lung ventilation.

On a deflatable beanbag, the patient is then positioned in the lateral decubitus position and strapped to the operating table with the upper arm placed in an arm sling positioned close over the forehead, the lower arm axilla on a soft axillary roll, and the arm up and lateral.

Once sufficiently arranged, the table is rotated 15 to 30 degrees posteriorly for upper and middle lobes and 15 to 30 degrees anteriorly for lower lobes. Patients with wide hips should have reverse mid-operating table flexion to provide sufficient chest exposure and range of motion of the robotic arms and videoport. Reverse Trendelenburg allows any of the minimal bleeding that occurs during the procedure to collect at the inferior aspect of the pleural space away from the operating location and allows for the subdiaphragmatic organs to fall away from the operative field, providing better access.

Using an indelible marker, a 4- to 5-cm circle is drawn just anterior to the tip of the scapula, with the center 2 to 3 cm from the tip; this is the target of the dissection.

Six puncture sites are then drawn onto the patient’s chest, differing in location for the upper and lower lobes.

For the upper and middle lobes, the videoport is placed in the seventh to eighth intercostal space, just lateral to the costal margin. From that port site a triangle is then drawn to the target serving as the base of the triangle. Then about 10 cm lateral to the right and left arm of the triangle, the two 8-mm robotic port sites are drawn to avoid later instrument collision. The two posterior sites are then drawn; the posterior-superior port site is at the level of the fourth intercostal space, just immediately adjacent to the longitudinal spinous muscle. The posterior inferior port site is located along the same parallel line, just immediately adjacent to the longitudinal spinous muscle at the lateral border of the 10th intercostal space. The final port site, the anterior superior site, is located at the fourth intercostal space in the midclavicular to lateral-third clavicular line.

For the lower lobes, the video port site is marked to be about 6 to 8 cm lateral to the longitudinal spinous muscle in the ninth intercostal space. Again, a triangle is drawn between the video port site and the target. The left and right robotic arms are then placed outside the triangle, each approximately 10 cm away from the video port site. The leftward robotic arm is just at or slightly medial to the lateral border of the longitudinal spinous muscle, and the rightward arm site is drawn at approximately the seventh to eighth intercostal space laterally. The posterior-superior port site and the anterior-superior port sites are in the same location as for the upper lobes. The anterior-inferior port site is placed at the sixth to seventh intercostal space 3 to 4 cm lateral to the costal margin.

The chest is then sterilely prepared in the usual fashion, and surgical drapes are applied.

The first incision made for either the upper or lower lobes is at the anterior-inferior port site. A small incision is made; then, using a tonsil clamp, the pleural space is entered after single-lung ventilation is initiated. A 10- to 12-mm thoracoport and the videoscope are then placed. The remaining ports will be placed under direct thoracoscopic vision to minimize injury to the intercostal bundle. First, the intrapleural location is verified and CO ₂ is infused slowly, increasing to achieve sufficient access and visibility and avoid hemodynamic compromise.

The two 8-mm robotic arms are placed, as well as the 10- to 12-mm thoracoports, aiming the direction of the thoracoports medially toward the hilum, where they will have the greatest function.

The robotic chassis is then rolled into position. For the upper and middle lobes, the robot is brought posteriorly and obliquely over the neck and shoulder so that the base of the chassis is in line with the target and videoport site. For the lower lobes, the chassis is brought obliquely from the anterior aspect of the head, aiming it toward the target and the videoscope. The positioning of the robot chassis base in relation to the operating room table is important to optimize robotic arm and instrument function. The robot arms and instruments function optimally when they are aimed toward the base of the robot chassis. This is determined, and the first joint of the video port arm is within 10 to 12 cm from the base of the chassis after the arm has been attached to the video thoracoport.

The videoscope arm is attached to the videoscope thoracoport, and the clutch button is used to guide the 0-degree scope into position to obtain visibility for the other arms to be placed.

The right and left robotic arms are then attached. Using the “setup joint” buttons, the arms are positioned to raise the arm base up and lateral as much as possible to achieve maximal maneuverability of the arms for the dissection.

In the left arm, a ProGrasp can be placed and in the right arm, a Harmonic scalpel. Using the clutch button, the arm instruments can be pushed into position so that the working parts can be visualized. Throughout the procedure, the instrument tips should be visible.