Our usual set up (subxiphoid port, anterior camera port and 2 anterior utility ports) takes the same time as standard VATS cases and is quicker than robotics. The Maryland dissector can be easily manipulated to the ideal angle with simple wrist movements and the bipolar energy device facilitates coagulation of small vessels with less displacement of energy compared to monopolar devices. The ease of manipulation permits precise control during dissection, establishing the ideal tissue planes around the hilum. Supplementary Video 1 also demonstrates how easily instruments can be changed, for example to a sucker or standard diathermy, as the surgeon is at the bedside. Similarly, you can see the surgeon themselves, rather than an assistant, introducing the stapler around the inferior pulmonary vein. The specimen was removed through the subxiphoid port.

During this left upper lobectomy, the ability to angle the instruments to 90 degrees in all directions enabled accurate dissection of the pleura and vessels with the Maryland dissector and subsequently the fenestrated forceps. This feature is further appreciated when dissecting out the lymph nodes, with clear superiority to standard VATS instruments. The tactile feedback received from these instruments makes it possible for even the pointed Marylands to be used safely to dissect around the segmental pulmonary artery branch prior to stapling. We have also performed a right upper microlobectomy in a similar fashion.

Successful thymectomy via a minimally invasive approach relies on achieving a complete resection without harm to vital nearby structures. Again, the operator can achieve perfect angles with the Maryland dissector. Supplementary Video 3 demonstrates how subtle sweeping movements of the wristed instruments facilitate dissection of the fat between the innominate vein and the superior vena cava (SVC).

A left sided approach was necessary for a more complex thymectomy case with a left sided SVC (Supplementary Video 4). The orientation achieved with the wristed instruments suits the tissue planes perfectly.

This procedure showcases the dexterity of the fully articulated instruments during suturing. The needle holder can be used to grasp the needle exactly in the desired place, whilst the second wristed instrument can safely grasp or retract the tissue. In this case 10–12 horizontal mattress sutures are placed in an anterolateral to posteromedial position. Our normal practice is to tie outside the chest and use the Chitwood Knot Pusher (Scalan International, www.scanlaninternational.com). However, we demonstrate here that knot tying a Weston knot, with subsequent wristed instrument-tied throws, is incredibly straightforward.

When considering the use of wristed instruments, and drawing comparison to that of robotic thoracic surgery, the benefits can be broadly categorized into those impacting safety and cost. Many of the safety benefits of using these wristed instruments stem from having the lead surgeon at the bedside, rather than at a distance at a console. This enables visualization of the patient in their entirety, rather than from a digital isolated internal viewpoint. This allows for early management of any complications that may arise during the procedure, without the delay in waiting for the surgeon to “re-scrub.” This concept also acts to reduce potential barriers to communication between the healthcare team and the lead surgeon. The importance of such human factors has been particularly prudent during the COVID-19 pandemic, with personal protective equipment impacting on communication. Furthermore, from a technical standpoint, being positioned at the bedside ensures that the surgeon performs the key steps in the procedure, for example stapling, in comparison to most current robotic systems (with exception of the da Vinci® Xi Surgical System) that do not support stapling instruments. This notion is further improved by the tactile feedback gained through the use of wristed instruments, as opposed to robotics. In all, this contributes to increased precision when compared to VATS, due to the dexterity of a robotic instrument, with added tactile feedback. There are also ongoing attempts to develop technology for the integration of enhanced tactile sense (5). However, due to the wired articulating joint mechanism of the ArtiSential® wristed instruments, resistance from the tissue or tension during knot tying (6), can be sensed between the jaws of the instrument (5). This in contrast to the lack of haptic feedback exerted by the da Vinci® system.

As a center, elements which have been highlighted as key benefits include the added dexterity imparted by the wristed mechanism, which is above and beyond that of a rigid VATS instrument. This was particularly evident in the cases described. In addition, wristed instruments retain the flexibility and speed of VATS, especially when switching between instruments or ports. This increases the speed of the procedure when compared to undertaking the same process with a robot. Such flexibility is extended by the option to utilize both wristed and traditional instruments if desired. It may be that the surgeon wishes to exploit the increased dexterity of the ArtiSential® during a difficult case, when transitioning to the da Vinci® is simply unfeasible (5).

Aside from the technical benefits imparted by the use of such wristed instruments, they also replicate the advantages typically brought about by robotic instrumentation when compared to VATS techniques. The monetary investment required to run a robotics programme will be negated by the development of these new techniques, a vital consideration for those systems in which development of services is typically limited by scarce financial resources. The cost effectiveness of such wristed instruments is multifaceted when considering the wider financial cost of establishing a robotic programme. A key concept is the reduced training time required to initiate and run a wristed instrument programme (10–20 vs. 30 h for the robot), therefore increasing the number of staff competent in performing such cases, potentially improving the patient flow. Furthermore, even for those centers with an established robotic programme, it can be argued that the implementation of bedside wristed instrumentation brings about greater case throughput due to the lack of shared robotic sessions between specialties. The faster procedure time typically seen in VATS cases, when compared to robotics, further increases patient flow and reduces waiting times. With further technological advancement, additional cost saving methods may be imparted when using wristed instruments; namely, a robotic camera holder rendering an assist redundant (7). This is an element which may truly transform thoracic surgery, hybridizing the benefits of VATS and robotic surgery through the use of a three-dimensional surgeon-controlled camera, wristed instruments and tactile feedback with safety of the surgeon at the patient's bedside.

Despite the numerous aforementioned benefits, some challenges remain in relation to instigating practice with wristed instruments. Whilst the trocar pivot point and resistance of the chest wall restrict the degree of movement, which can result in localized trauma at the incision site or compression of the intercostal nerve, this is somewhat offset by the increased dexterity provided by the wrist mechanism. This results in a reduction in the need for extremes of movement that may be required using VATS instruments. Furthermore, the intuitiveness of operating with a robotic system is removed and the surgeon must adapt their technique, accounting for the fulcrum effect that VATS surgery imposes. This is arguably a minor challenge in the era of split practice between VATS and robotic surgery, whereby competency in both exists. This, however, raises an issue for surgeons who have not embraced robotic practice, in that the techniques required by wristed instruments demand a hybrid skill set. Studies have predictably demonstrated that experienced surgeons tend to obtain better results with traditional instruments in comparison to the same task using new surgical instruments (6). In order to adapt to diversifying practice, there is a need for a training period for the surgeon to attain the required competence.

Views currently remain dependent upon the quality of the camera, as well as the experience of the operating assistant. This is an aspect that is negated with a robotic system, as the views are entirely controlled by the lead surgeon. The procedure also benefits from the three-dimensional visualization at the console, enabling greater depth perception. In recognition of this, developers have strived to make a surgeon controlled “robotic” camera holder as well as a 3D VATS style camera.