From Central to Peripheral: A Novel Robotic Approach for Lobectomy in Patients with Incomplete Pulmonary Fissures

From Central to Peripheral: A Novel Robotic Approach for Lobectomy in Patients with Incomplete Pulmonary Fissures | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article From Central to Peripheral: A Novel Robotic Approach for Lobectomy in Patients with Incomplete Pulmonary Fissures Xu Hao, Chang Xiaoyan, Zhang Linyou This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7782382/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 01 Nov, 2025 Read the published version in Journal of Robotic Surgery → Version 1 posted 14 You are reading this latest preprint version Abstract Background Robotic-assisted thoracic surgery (RATS) is increasingly acknowledged for its efficacy in managing early-stage non-small cell lung cancer (NSCLC), owing to its distinct technical advantages. Nevertheless, individuals with pronounced incomplete interlobar fissures often face higher rates of conversion to alternative procedures and an increased likelihood of postoperative complications. This retrospective study introduces a novel robotic surgical technique tailored to the challenges posed by incomplete fissures, evaluating both its safety and therapeutic outcomes. Methods A retrospective analysis was performed on the clinical data of individuals who received robotic-assisted lobectomy for NSCLC at our center from March 2021 to September 2024. Altogether, 554 cases were incorporated and divided into two cohorts—those with fully developed fissures and those with partially developed fissures—based on the anatomical features of their lung fissures. Results Among the 554 patients analyzed, 302 were categorized as having complete fissures, while 252 were identified with incomplete fissures. Comparative evaluation revealed no statistically significant differences between these groups in terms of operative duration (p = 0.411), intraoperative blood loss (p = 0.822), chest tube retention time (p = 0.733), rate of prolonged air leakage (PAL, p = 0.805), or postoperative hospital stay (p = 0.962). Importantly, neither group exhibited cases of bronchopleural fistula, pneumonia, or perioperative death. Conclusion Incomplete fissures do not increase the procedural difficulty of lobectomy when employing this robotic surgical approach. This newly developed, robot-specific technique ensures both safety and efficacy for patients with incomplete fissures. Robotic-assisted thoracic surgery Lobectomy Incomplete fissure Lung cancer Introduction Lung cancer remains the leading cause of cancer-related mortality worldwide¹. For those found at an initial stage, surgery is still considered the most reliable curative treatment². Less invasive procedures, including video-assisted thoracic surgery (VATS) and robotic-assisted thoracic surgery (RATS), are highly suggested for qualified patients who do not have anatomical or operative contraindications, as long as key oncologic standards and proper dissection techniques are observed³. Undergoing VATS lobectomy is associated with better short-term results after surgery, such as less pain, shorter hospital stays, quicker recovery, and a lower incidence of complications, all without compromising oncologic outcomes. Similarly, RATS lobectomy has shown equivalent efficacy to conventional VATS techniques 4 , 5 . Notable benefits of RATS include high-definition three-dimensional visualization, the use of articulated and wristed instruments, decreased surgeon tremor, and improved ergonomic conditions 6 – 8 . The absence or incompleteness of pulmonary fissures (IFs) presents considerable technical challenges for thoracic surgeons performing lung resections 9 . Two primary methods are commonly used to manage incomplete fissures during pulmonary resection: the fissureless approach (also known as “fissure last”) and the tunnel approach (referred to as “fissure first”). The fissureless method in VATS lobectomy postpones the division of the fissure until the end of the operation, with the goal of minimizing the risk of prolonged air leakage (PAL) 10 , 11 . The tunnel technique represents an alternative strategy for managing IFs 12 , 13 . The management of IFs in RATS is scarcely addressed in the current literature, and existing approaches are predominantly adapted from those employed in VATS 14 – 16 . This retrospective study was designed to evaluate the safety and effectiveness of a newly developed, RATS-specific technique for managing incomplete pulmonary fissures during lobectomy. Patients and Methods In compliance with the Declaration of Helsinki (2013 revision), this retrospective study was approved by the Ethics Committee of the Second Affiliated Hospital of Harbin Medical University (approval number: KY2025-103). The committee also granted a waiver of individual informed consent for this research. Patients Between March 2021 and September 2024, 554 individuals who received robotic lobectomy at our center were retrospectively analyzed. The collected information included baseline characteristics, intraoperative details, and outcomes following surgery. Tumor staging was determined according to the eighth edition of the TNM system for malignant tumors 17 . Postoperative morbidity was classified based on the Clavien–Dindo grading system18. All operations were performed by a single specialized surgical team, supervised by an accomplished thoracic surgeon (Z.L.Y.), highly skilled in VATS. Operative methods In this study, all procedures were conducted using a total portal technique with three robotic arms (RPL-3) 19 . Following intravenous induction, patients underwent general anesthesia and were intubated with a double-lumen endotracheal tube. The Xi Da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA) was employed for all operations, utilizing three 8-mm robotic instrument ports and one 12-mm assistant port. The camera port (8-mm) was initially established at the eighth intercostal space (ICS), aligned with the anterior superior iliac spine. To lower the diaphragm, warmed and humidified CO₂ was insufflated into the thoracic cavity, maintaining a pressure of 8–10 mmHg. The posterior 8-mm port was placed at the same ICS, on the line of the inferior angle of the scapula, and positioned 8–10 cm from the camera port. The anterior 8-mm port was inserted in either the sixth or seventh ICS, also at the same level and 8–10 cm from the camera port. For specimen retrieval, the 12-mm assistant port was positioned in the fifth or sixth ICS along the midclavicular line and was enlarged after surgery 16 . The assessment of pulmonary fissure completeness was performed using a previously established anatomical classification system 20 . This system categorizes fissures into four grades: grade 1 indicates a completely separated fissure with distinct lobes; grade 2 describes a complete visceral cleft accompanied by parenchymal fusion at the fissure base; grade 3 refers to a visceral cleft that exists only in part of the fissure; and grade 4 denotes total fusion of the lobes without any discernible fissural line. Grades 1 and 2 were classified as complete fissures (CFs), whereas grades 3 and 4 were considered incomplete fissures (IFs). The newly developed surgical technique was specifically applied to patients with incomplete fissures. Central-to-Peripheral Approach Right Incomplete Minor Fissure The initial step involved locating the intersection of the horizontal and oblique fissures, a region characterized by a notably thin pleural layer. The pleura was delicately opened, permitting visualization of both the middle lobe branch of the pulmonary artery and the central venous structure. Careful dissection was performed along the central vein, following the anatomical plane in an anterior and caudal direction, until the anterior hilar pleura was encountered and divided. This maneuver resulted in the formation of a tunnel through the minor fissure ( Video 1 ). Upper Segment of the Right Incomplete Major Fissure Analogously, the procedure commenced with identification of the area where the horizontal and oblique fissures converge. Exposure of the dorsal arterial branch and the ascending artery was achieved. Dissection proceeded along the anatomical plane in a posterior and cranial direction, targeting the pleura overlaying the secondary carina. Division of the pleura at this location enabled creation of a tunnel traversing the upper portion of the incomplete right major fissure ( Video 2 ). Lower Segment of the Right Incomplete Major Fissure The junction between the horizontal and oblique fissures was first delineated, followed by exposure of the middle lobe pulmonary arterial branch and the basal pulmonary artery. Dissection continued along the anatomical plane in an anterior and inferior direction to reveal the middle lobe vein. Subsequent division of the pleura between the middle and lower lobe veins facilitated successful establishment of the tunnel ( Video 3 ). Upper Segment of the Left Incomplete Fissure Identification of the interlobar pulmonary artery preceded dissection along the main arterial trunk, enabling localization of both the dorsal artery and the segmental branch supplying segments 1 + 2c. The anatomical plane was mobilized posteriorly and superiorly to access the posterior hilar pleura (Video 4). Lower Segment of the Left Incomplete Fissure The interlobar pulmonary artery was identified at the outset. Dissection along its trunk permitted recognition of the lingular and anterior basal arterial branches. The anatomical plane was then advanced anteriorly and inferiorly to reach the pleura of the anterior hilum (Video 5). Following separation of the incomplete fissure, thorough dissection of the pulmonary arteries, veins, and bronchus serving the intended lobe was accomplished. Comprehensive mediastinal lymphadenectomy was performed in all cases. Upon completion of lobectomy, the lung was inflated under water to evaluate for air leakage. Any detected leaks were repaired using manual suturing, followed by reinflation under water to confirm resolution. Ultimately, a 28-Fr chest drain was inserted via the camera access site. Statistical Analysis All data are reported as means, medians, counts, or proportions, according to their nature. Clinical and operative characteristics were analyzed between the CFs and IFs cohorts. For categorical variables, results are expressed as numbers and percentages, while continuous data are presented as means or medians, based on distribution characteristics. Comparisons of continuous variables between groups utilized either the independent samples t-test or the Mann–Whitney U test, selected according to data normality. For categorical data, either Pearson’s chi-square or Fisher’s exact test was applied as appropriate. Statistical significance for all tests was defined by a two-tailed p -value less than 0.05. Results Patient Characteristics A total of 554 patients were analyzed, including 302 with complete fissures and 252 with incomplete fissures (Table 1 ). The baseline demographic profiles were comparable across the two groups. Male patients accounted for 37.4% in the CFs cohort and 41.3% in the IFs cohort (p = 0.355). The average age was 61.92 ± 8.44 years for the CFs group and 61.35 ± 8.94 years for the IFs group (p = 0.443). There were no statistically significant differences in height (163.59 ± 7.74 cm vs. 164.39 ± 7.21 cm, p = 0.220) or weight (63.77 ± 10.92 kg vs. 64.70 ± 10.58 kg, p = 0.314) between the cohorts. With respect to pulmonary function, individuals in the IFs group exhibited higher FEV1 values (2.44 ± 0.62 L compared to 2.31 ± 0.61 L, p = 0.015) and MVV (72.78 ± 24.98 L versus 68.06 ± 22.68 L, p = 0.021) than those in the CFs group. DLCO did not differ significantly between groups (5.89 ± 1.61 vs. 5.98 ± 1.61, p = 0.513). The prevalence of comorbid conditions was similar (56.95% vs. 52.38%, p = 0.281), with emphysema, diabetes mellitus, heart disease, coronary heart disease, and hypertension being the most frequently observed. Tumor features were likewise well matched. The mean tumor diameter measured by CT was 21.36 ± 10.97 mm in the CFs group and 22.87 ± 11.92 mm in the IFs group (p = 0.138). Adenocarcinoma represented the predominant histological subtype in both populations (85%), and there were no significant differences regarding the distribution of other histological types (p = 0.376) or pathological stages (p = 0.157). Table 1 Patients characteristics Variable Complete fissure (n = 302) Incomplete fissure (n = 252) p -value Sex 0.355 Male, n(%) 113(37.42) 104(41.27) Female, n(%) 189(62.58) 148(58.73) Age(years) 61.92 ± 8.44 61.35 ± 8.94 0.443 Height(cm) 163.59 ± 7.74 164.39 ± 7.21 0.220 Weight(kg) 63.77 ± 10.92 64.70 ± 10.58 0.314 Lung function FEV1 (L) 2.31 ± 0.61 2.44 ± 0.62 0.015 FEV1/FVC (%) 77.58 ± 9.18 78.69 ± 8.14 0.138 MVV 68.06 ± 22.68 72.78 ± 24.98 0.021 DLCO SB 5.89 ± 1.61 5.98 ± 1.61 0.513 DLCO/VA 1.29 ± 0.28 1.27 ± 0.26 0.356 Comorbidities, n(%) 172(56.95) 132(52.38) 0.281 Emphysema 4 1 Diabetes mellitus Heart disease 28 25 Coronary heart disease 32 17 Hypertension 90 59 Tumor size on CT 21.36 ± 10.97 22.87 ± 11.92 0.138 Tumor size (mm) 19.44 ± 12.58 20.31 ± 13.10 0.425 Histological type 0.376 Squamous cell carcinoma(%) 21(6.95) 10(3.97) Adenocarcinoma in situ(%) 16(5.30) 21(8.33) Adenocarcinoma(%) 257(85) 225(85.23) Large cell carcinoma(%) 3(0.99) 2(0.79) Small cell lung cancer 5(1.66) 4(1.59) The completeness of fissure Grade1 83 Grade2 219 Grade3 154 Grade4 98 Pathologic stage of lung cancer 0.157 0 16 21 IA1 48 38 IA2 138 113 IA3 48 35 IB 27 15 IIA 3 8 IIB 7 3 IIIA 13 18 IIIB 2 1 FEV1 = forced expiratory volume in 1 s; FVC = forced vital capacity; MVV = Maximum Ventilatory Volume; DLCO = diffuse diffusing capacity for carbon monoxide Table 2 presents the intraoperative results. No significant differences were observed between the CF and IF cohorts in terms of operative duration (102.80 ± 42.81 min versus 105.71 ± 39.66 min, p = 0.411) or intraoperative blood loss (87.45 ± 225.65 ml compared to 83.29 ± 204.72 ml, p = 0.822). The rate of substantial blood loss (≥ 500 ml) was comparable in both groups (2.32% vs. 2.78%, p = 0.731). Conversion to thoracotomy was required in two patients from each group (0.66% for CF and 0.79% for IF, p = 0.747). Complete tumor resection (R0) was achieved for all individuals. Importantly, the number of lymph node stations dissected was significantly higher in the IF group compared to the CF group (6.71 ± 0.99 vs. 6.39 ± 1.18, p = 0.001). Likewise, the total count of dissected lymph nodes was notably greater for the IF group (17.48 ± 7.21 versus 15.32 ± 6.92, p < 0.001). Table 2 Intraoperative results Variable Complete fissure (n = 302) Incomplete fissure (n = 252) p -value Operative time(min) 102.80 ± 42.81 105.71 ± 39.66 0.411 Blood loss(ml) 87.45 ± 225.65 83.29 ± 204.72 0.822 Blood loss(>500ml) 7(2.32%) 7(2.78%) 0.731 Conversion to thoracotomy 2(0.66%) 2(0.79%) 0.747 R0 resection 302(100%) 252(100%) - Dissected lymph nodes station,n 6.39 ± 1.18 6.71 ± 0.99 0.001 Dissected lymph nodes number,n 15.32 ± 6.92 17.48 ± 7.21 0.000 Table 3 summarizes the postoperative outcomes. The average duration of chest tube retention was similar between the CF and IF groups (2.88 ± 1.99 days versus 2.93 ± 1.76 days, p = 0.733). Postoperative hospital stays were also equivalent (4.36 ± 2.13 days for CF and 4.37 ± 1.79 days for IF, p = 0.962). No significant differences were found in drainage volumes on postoperative days 1, 2, and 3, nor in the total amount drained (all p > 0.1). There were no perioperative deaths in either cohort. Complication rates remained low and did not show a significant difference (5.96% for CF vs. 4.36% for IF, p = 0.401). Notably, no instances of bronchopleural fistula or empyema were reported. The frequency of prolonged air leak (PAL, > 5 days) was comparable (3.97% for CF and 3.57% for IF, p = 0.805), as was the occurrence of atelectasis (0.99% vs. 0%, p = 0.113). Cardiovascular events were infrequent, with a single case of atrial tachycardia (0.39%) in the IF group and one case of atrial fibrillation (0.33%) in the CF group; no myocardial infarctions were recorded. Pneumonia rates were low and did not differ significantly between the groups (0.66% vs. 0.39%, p = 0.672). Table 3 Postoperative mortality and complications Variable Complete fissure (n = 302) Incomplete fissure (n = 252) p -value Chest tube duration(days) 2.88 ± 1.99 2.93 ± 1.76 0.733 Postoperative hospital stay(days) 4.36 ± 2.13 4.37 ± 1.79 0.962 Postoperative drainage volume (ml) POD1 194.68 ± 168.54 205.14 ± 178.21 0.479 POD2 220.88 ± 155.35 213.25 ± 139.37 0.564 POD3 150.62 ± 118.22 131.62 ± 95.91 0.138 Total drainage volume 550.67 ± 510.54 537.19 ± 467.15 0.750 Perioperative mortality 0 0 Complications 18(5.96%) 11(4.36%) 0.401 Bronchopleural fistula 0 0 Prolonged air leakage(> 5 days) 12(3.97%) 9(3.57%) 0.805 Atelectasis 3(0.99%) 0 0.113 Cardiovascular complication Atrial tachycardia 0 1(0.39%) 0.382 Atrial fibrillation 1(0.33%) 0 0.361 Myocardial infarction 0 0 Pneumonia 2(0.66%) 1(0.39%) 0.672 Empyema 0 0 POD = Postoperative day Discussion Robotic thoracic surgery emerged in the early 2000s, with initial reports from Europe in 2002, followed by subsequent publications in the United States by 2006 21,22 . After the first lung resection performed with RATS, accumulating evidence has underscored its superiority compared to conventional VATS 23 . Notable advantages encompass three-dimensional imaging, enhanced maneuverability, wristed instrumentation for improved dexterity, mitigation of the fulcrum effect, tremor reduction, and better ergonomic support for surgeons. Numerous centers have substantiated that RATS is a viable and safe alternative to VATS in radical lung cancer surgery 24 . Moreover, meta-analyses suggest that RATS yields short-term results equivalent to those achieved with VATS, and may confer additional long-term survival benefits for patients undergoing anatomical lung resections 25 , 26 . IFs are commonly encountered in thoracic surgical procedures. The absence of the right minor fissure occurs in 7.1–45.2% of individuals, while incomplete formation is observed in 21–67% of cases; the oblique fissure is incompletely developed in 3–39.3% of right lungs and 10.6–46.6% of left lungs 27 , 28 . The existence of IFs correlates with increased operative duration, greater intraoperative hemorrhage, and a higher incidence of complications such as persistent air leaks 11 , 16 . To address incomplete fissures during lobectomy, two main surgical approaches are employed: the tunnel technique and the fissureless method. The tunnel technique allows for accurate identification of hilar structures and reduces the likelihood of accidental injury to pulmonary arterial branches 29 . In contrast, the fissureless technique involves complete division of the pulmonary parenchyma using endoscopic staplers as the final step, subsequent to the dissection and separation of hilar structures. This method, by avoiding direct manipulation of the interlobar parenchyma, has demonstrated superior efficacy in reducing the risk of prolonged air leaks 11 . Nevertheless, the fissureless approach is not without drawbacks; it may present safety challenges for surgeons lacking comprehensive knowledge of hilar anatomy. Specifically, during lower lobectomies, the pulmonary artery requiring resection lies posterior to the lower bronchus, which increases the potential for serious vascular injury when dividing the connective tissue between these structures 30 . Both techniques were initially developed for traditional open surgery or VATS. In RATS, the strategies for managing incomplete fissures generally mirror those utilized in VATS 14 – 16 . In this investigation, the management of incomplete fissures predominantly utilized the advanced three-dimensional visualization inherent to RATS, combined with the precise control of Maryland forceps via robotic instrumentation. This enabled careful dissection along the pulmonary vessel surfaces, resulting in a more straightforward, efficient, and secure division of incomplete fissures. When comparing patients with incomplete fissures to those with complete fissures, application of this technique did not lead to significant differences in operative duration or intraoperative blood loss ( p = 0.411 and p = 0.082, respectively). These outcomes indicate that this approach may effectively address the technical difficulties encountered during lobectomy for individuals with incomplete fissures. Furthermore, the rate of substantial intraoperative hemorrhage (≥ 500 mL) was similar between the incomplete and complete fissure groups (2.32% vs. 2.78%, p = 0.731), further supporting the safety profile of this method for such patients. Numerous investigations have recognized incomplete or fused fissures as notable contributors to the development of prolonged air leak (PAL). Employing fissureless surgical methods has been shown to lower the risk of PAL by reducing trauma to the pulmonary parenchyma. Unlike the fissure-first strategy, which unavoidably results in injury to the interlobar lung tissue, our method restricts such harm to the initial phase of pulmonary artery identification. After the artery is exposed, the integration of robotic three-dimensional visualization with meticulous dissection using Maryland forceps along the vessel surface further limits parenchymal damage. Comparative analysis revealed no significant differences between groups regarding average chest tube duration ( p = 0.733), postoperative hospital stay length ( p = 0.962), drainage volume after surgery ( p > 0.1), or rates of postoperative complications ( p = 0.401) including PAL incidence ( p = 0.805). These findings suggest that our technique is both effective for treating incomplete fissures and for reducing the likelihood of prolonged air leak. Lymph node removal represents a pivotal aspect of lung cancer surgery, functioning as a key parameter for evaluating the oncological effectiveness of the operation. Relative to the tunnel technique, the fissureless method may present limitations for individuals with N1 lymph node involvement, primarily due to the potential for inadequate interlobar lymph node clearance 31 . In our research, the quantity of lymph nodes excised in the IFs cohort was notably greater than in the CFs group. This outcome likely results from the enhanced three-dimensional visualization at high magnification afforded by RATS, which allows for more accurate identification and removal of lymph nodes located near vessels and within interlobar fissures when addressing incomplete fissures. These observations further reinforce the oncological advantages of this surgical technique. This investigation is subject to several limitations. Primarily, its single-center nature may restrict the applicability of the findings to broader patient populations. Additionally, the retrospective design and reliance on limited evaluation criteria could have introduced certain biases. Future prospective, randomized trials are necessary to confirm these observations. Nonetheless, to our knowledge, this work constitutes the largest cohort thus far examining the effectiveness and safety of a robotic-assisted thoracic surgery (RATS) technique specifically tailored for the management of incomplete pulmonary fissures during lobectomy. In summary, anatomical lung resection performed with this RATS-specific approach appears to offer a safe and effective option for individuals presenting with incomplete fissures. Declarations Author Disclosures Drs. Xu Hao, Chang Xiaoyan, and Zhang Linyou have no conflicts of interest or financial ties to disclose. References Siegel RL, Giaquinto AN, Jemal A. Cancer statistics, 2024. 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Surg Today. 2025 Feb 17. doi: 10.1007/s00595-025-03000-6 Liang H, Liang W, Zhao L, Chen D, Zhang J, Zhang Y, Tang S, He J. Robotic Versus Video-assisted Lobectomy/Segmentectomy for Lung Cancer: A Meta-analysis. Ann Surg. 2018;268(2):254–259. doi: 10.1097/SLA.0000000000002346. PMID: 28628562. Zhang J, Feng Q, Huang Y, Ouyang L, Luo F. Updated Evaluation of Robotic- and Video-Assisted Thoracoscopic Lobectomy or Segmentectomy for Lung Cancer: A Systematic Review and Meta-Analysis. Front Oncol. 2022;12:853530. doi: 10.3389/fonc.2022.853530 George BM, Nayak SB, Marpalli S. Morphological variations of the lungs: a study conducted on Indian cadavers. Anat Cell Biol. 2014;47(4):253–8. doi: 10.5115/acb.2014.47.4.253 Bostanci K, Ozyurtkan MO, Polat MO, Batirel H, Lacin T, Yuksel M, Stamenovic D. Variations in pulmonary fissural anatomy: a medicolegal autopsy study of 256 cases. ANZ J Surg. 2020;90(4):608–611. doi: 10.1111/ans.15553 Yutaka Y, Tanaka S, Yamada Y, Ohsumi A, Nakajima D, Hamaji M, Menju T, Date H. Fissure-last technique for left upper lobe lung cancer with interlobar invasion: how to do it? Gen Thorac Cardiovasc Surg. 2022;70(9):828–831. doi: 10.1007/s11748-022-01841-3 Zhang Y, Xin W, Xu C, Yuan M, Yang G, Cheng K, Luo D. Thoracoscopic lobectomy through the pulmonary hilum approach for the treatment of congenital lung malformation. Surg Endosc. 2021 Feb 16. doi: 10.1007/s00464-021-08339-8 . Gómez-Caro A, Calvo MJ, Lanzas JT, Chau R, Cascales P, Parrilla P. The approach of fused fissures with fissureless technique decreases the incidence of persistent air leak after lobectomy. Eur J Cardiothorac Surg. 2007;31(2):203–8. doi: 10.1016/j.ejcts.2006.11.030. Epub 2006 Dec 18. Additional Declarations No competing interests reported. Supplementary Files Video1.RightIncompleteMinorFissure.mp4 Video1. Right Incomplete Minor Fissure Video2.UpperSegmentoftheRightIncompleteMajorFissure.mp4 Video2. Upper Segment of the Right Incomplete Major Fissure Video3.LowerSegmentoftheRightIncompleteMajorFissure.mp4 Video3. Lower Segment of the Right Incomplete Major Fissure Video4.UpperSegmentoftheLeftIncompleteFissure.mp4 Video4. Upper Segment of the Left Incomplete Fissure Video5.LowerSegmentoftheLeftIncompleteFissure.mp4 Video5. Lower Segment of the Left Incomplete Fissure Cite Share Download PDF Status: Published Journal Publication published 01 Nov, 2025 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Revision requested 17 Oct, 2025 Reviews received at journal 16 Oct, 2025 Reviews received at journal 16 Oct, 2025 Reviewers agreed at journal 14 Oct, 2025 Reviewers agreed at journal 13 Oct, 2025 Reviewers agreed at journal 13 Oct, 2025 Reviewers agreed at journal 12 Oct, 2025 Reviewers agreed at journal 12 Oct, 2025 Reviewers agreed at journal 11 Oct, 2025 Reviewers agreed at journal 11 Oct, 2025 Reviewers invited by journal 11 Oct, 2025 Editor assigned by journal 06 Oct, 2025 Submission checks completed at journal 06 Oct, 2025 First submitted to journal 04 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7782382","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":531423434,"identity":"631069de-7199-4a4e-a736-c710ba5bb77e","order_by":0,"name":"Xu Hao","email":"","orcid":"","institution":"The Second Hospital Affiliated to Harbin Medical University","correspondingAuthor":false,"prefix":"","firstName":"Xu","middleName":"","lastName":"Hao","suffix":""},{"id":531423435,"identity":"1703000a-6179-47cd-a3fd-85c7be71e53e","order_by":1,"name":"Chang Xiaoyan","email":"","orcid":"","institution":"The Second Hospital Affiliated to Harbin 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Right Incomplete Minor Fissure\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Video1.RightIncompleteMinorFissure.mp4","url":"https://assets-eu.researchsquare.com/files/rs-7782382/v1/89b8053b70117536968be309.mp4"},{"id":94383315,"identity":"bac95cbb-9205-4ab1-b8a2-47c9ca4f43b9","added_by":"auto","created_at":"2025-10-27 13:45:52","extension":"mp4","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":3035674,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVideo2. Upper Segment of the Right Incomplete Major Fissure\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Video2.UpperSegmentoftheRightIncompleteMajorFissure.mp4","url":"https://assets-eu.researchsquare.com/files/rs-7782382/v1/4cecae5ae67457cae2001ef7.mp4"},{"id":94382502,"identity":"fca1b05c-b6f7-4e27-a437-33bff5c4f0aa","added_by":"auto","created_at":"2025-10-27 13:45:14","extension":"mp4","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":2900303,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVideo3. Lower Segment of the Right Incomplete Major Fissure\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Video3.LowerSegmentoftheRightIncompleteMajorFissure.mp4","url":"https://assets-eu.researchsquare.com/files/rs-7782382/v1/08b43c27f2bfece0215d0475.mp4"},{"id":94382651,"identity":"a4412f63-7bf5-4b09-a763-6471c4affc4d","added_by":"auto","created_at":"2025-10-27 13:45:26","extension":"mp4","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":9980626,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVideo4. Upper Segment of the Left Incomplete Fissure\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Video4.UpperSegmentoftheLeftIncompleteFissure.mp4","url":"https://assets-eu.researchsquare.com/files/rs-7782382/v1/d381f94f1be3cd69539d3f92.mp4"},{"id":94383331,"identity":"5ef68e61-bfbd-4109-82bd-7a1f2b5542dd","added_by":"auto","created_at":"2025-10-27 13:45:55","extension":"mp4","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":3696800,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eVideo5. Lower Segment of the Left Incomplete Fissure\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Video5.LowerSegmentoftheLeftIncompleteFissure.mp4","url":"https://assets-eu.researchsquare.com/files/rs-7782382/v1/891f98e62da37c4701ed3b8f.mp4"}],"financialInterests":"No competing interests reported.","formattedTitle":"From Central to Peripheral: A Novel Robotic Approach for Lobectomy in Patients with Incomplete Pulmonary Fissures","fulltext":[{"header":"Introduction","content":"\u003cp\u003eLung cancer remains the leading cause of cancer-related mortality worldwide\u0026sup1;. For those found at an initial stage, surgery is still considered the most reliable curative treatment\u0026sup2;. Less invasive procedures, including video-assisted thoracic surgery (VATS) and robotic-assisted thoracic surgery (RATS), are highly suggested for qualified patients who do not have anatomical or operative contraindications, as long as key oncologic standards and proper dissection techniques are observed\u0026sup3;. Undergoing VATS lobectomy is associated with better short-term results after surgery, such as less pain, shorter hospital stays, quicker recovery, and a lower incidence of complications, all without compromising oncologic outcomes. Similarly, RATS lobectomy has shown equivalent efficacy to conventional VATS techniques\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e,\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e. Notable benefits of RATS include high-definition three-dimensional visualization, the use of articulated and wristed instruments, decreased surgeon tremor, and improved ergonomic conditions\u003csup\u003e\u003cspan additionalcitationids=\"CR7\" citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe absence or incompleteness of pulmonary fissures (IFs) presents considerable technical challenges for thoracic surgeons performing lung resections\u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. Two primary methods are commonly used to manage incomplete fissures during pulmonary resection: the fissureless approach (also known as \u0026ldquo;fissure last\u0026rdquo;) and the tunnel approach (referred to as \u0026ldquo;fissure first\u0026rdquo;). The fissureless method in VATS lobectomy postpones the division of the fissure until the end of the operation, with the goal of minimizing the risk of prolonged air leakage (PAL)\u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e,\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. The tunnel technique represents an alternative strategy for managing IFs\u003csup\u003e\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e,\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e. The management of IFs in RATS is scarcely addressed in the current literature, and existing approaches are predominantly adapted from those employed in VATS\u003csup\u003e\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. This retrospective study was designed to evaluate the safety and effectiveness of a newly developed, RATS-specific technique for managing incomplete pulmonary fissures during lobectomy.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003e In compliance with the Declaration of Helsinki (2013 revision), this retrospective study was approved by the Ethics Committee of the Second Affiliated Hospital of Harbin Medical University (approval number: KY2025-103). The committee also granted a waiver of individual informed consent for this research.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003ePatients\u003c/h2\u003e\u003cp\u003eBetween March 2021 and September 2024, 554 individuals who received robotic lobectomy at our center were retrospectively analyzed. The collected information included baseline characteristics, intraoperative details, and outcomes following surgery. Tumor staging was determined according to the eighth edition of the TNM system for malignant tumors\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e. Postoperative morbidity was classified based on the Clavien\u0026ndash;Dindo grading system18. All operations were performed by a single specialized surgical team, supervised by an accomplished thoracic surgeon (Z.L.Y.), highly skilled in VATS.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eOperative methods\u003c/h3\u003e\n\u003cp\u003eIn this study, all procedures were conducted using a total portal technique with three robotic arms (RPL-3)\u003csup\u003e19\u003c/sup\u003e. Following intravenous induction, patients underwent general anesthesia and were intubated with a double-lumen endotracheal tube. The Xi Da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA) was employed for all operations, utilizing three 8-mm robotic instrument ports and one 12-mm assistant port. The camera port (8-mm) was initially established at the eighth intercostal space (ICS), aligned with the anterior superior iliac spine. To lower the diaphragm, warmed and humidified CO₂ was insufflated into the thoracic cavity, maintaining a pressure of 8\u0026ndash;10 mmHg. The posterior 8-mm port was placed at the same ICS, on the line of the inferior angle of the scapula, and positioned 8\u0026ndash;10 cm from the camera port. The anterior 8-mm port was inserted in either the sixth or seventh ICS, also at the same level and 8\u0026ndash;10 cm from the camera port. For specimen retrieval, the 12-mm assistant port was positioned in the fifth or sixth ICS along the midclavicular line and was enlarged after surgery\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThe assessment of pulmonary fissure completeness was performed using a previously established anatomical classification system\u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. This system categorizes fissures into four grades: grade 1 indicates a completely separated fissure with distinct lobes; grade 2 describes a complete visceral cleft accompanied by parenchymal fusion at the fissure base; grade 3 refers to a visceral cleft that exists only in part of the fissure; and grade 4 denotes total fusion of the lobes without any discernible fissural line. Grades 1 and 2 were classified as complete fissures (CFs), whereas grades 3 and 4 were considered incomplete fissures (IFs). The newly developed surgical technique was specifically applied to patients with incomplete fissures.\u003c/p\u003e\n\u003ch3\u003eCentral-to-Peripheral Approach\u003c/h3\u003e\n\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eRight Incomplete Minor Fissure\u003c/h2\u003e\u003cp\u003eThe initial step involved locating the intersection of the horizontal and oblique fissures, a region characterized by a notably thin pleural layer. The pleura was delicately opened, permitting visualization of both the middle lobe branch of the pulmonary artery and the central venous structure. Careful dissection was performed along the central vein, following the anatomical plane in an anterior and caudal direction, until the anterior hilar pleura was encountered and divided. This maneuver resulted in the formation of a tunnel through the minor fissure (\u003cb\u003eVideo 1\u003c/b\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eUpper Segment of the Right Incomplete Major Fissure\u003c/h3\u003e\n\u003cp\u003eAnalogously, the procedure commenced with identification of the area where the horizontal and oblique fissures converge. Exposure of the dorsal arterial branch and the ascending artery was achieved. Dissection proceeded along the anatomical plane in a posterior and cranial direction, targeting the pleura overlaying the secondary carina. Division of the pleura at this location enabled creation of a tunnel traversing the upper portion of the incomplete right major fissure (\u003cb\u003eVideo 2\u003c/b\u003e).\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eLower Segment of the Right Incomplete Major Fissure\u003c/h2\u003e\u003cp\u003eThe junction between the horizontal and oblique fissures was first delineated, followed by exposure of the middle lobe pulmonary arterial branch and the basal pulmonary artery. Dissection continued along the anatomical plane in an anterior and inferior direction to reveal the middle lobe vein. Subsequent division of the pleura between the middle and lower lobe veins facilitated successful establishment of the tunnel (\u003cb\u003eVideo 3\u003c/b\u003e).\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eUpper Segment of the Left Incomplete Fissure\u003c/h3\u003e\n\u003cp\u003eIdentification of the interlobar pulmonary artery preceded dissection along the main arterial trunk, enabling localization of both the dorsal artery and the segmental branch supplying segments 1\u0026thinsp;+\u0026thinsp;2c. The anatomical plane was mobilized posteriorly and superiorly to access the posterior hilar pleura \u003cb\u003e(Video 4).\u003c/b\u003e\u003c/p\u003e\n\u003ch3\u003eLower Segment of the Left Incomplete Fissure\u003c/h3\u003e\n\u003cp\u003eThe interlobar pulmonary artery was identified at the outset. Dissection along its trunk permitted recognition of the lingular and anterior basal arterial branches. The anatomical plane was then advanced anteriorly and inferiorly to reach the pleura of the anterior hilum \u003cb\u003e(Video 5).\u003c/b\u003e\u003c/p\u003e\u003cp\u003eFollowing separation of the incomplete fissure, thorough dissection of the pulmonary arteries, veins, and bronchus serving the intended lobe was accomplished. Comprehensive mediastinal lymphadenectomy was performed in all cases. Upon completion of lobectomy, the lung was inflated under water to evaluate for air leakage. Any detected leaks were repaired using manual suturing, followed by reinflation under water to confirm resolution. Ultimately, a 28-Fr chest drain was inserted via the camera access site.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eAll data are reported as means, medians, counts, or proportions, according to their nature. Clinical and operative characteristics were analyzed between the CFs and IFs cohorts. For categorical variables, results are expressed as numbers and percentages, while continuous data are presented as means or medians, based on distribution characteristics. Comparisons of continuous variables between groups utilized either the independent samples t-test or the Mann\u0026ndash;Whitney U test, selected according to data normality. For categorical data, either Pearson\u0026rsquo;s chi-square or Fisher\u0026rsquo;s exact test was applied as appropriate. Statistical significance for all tests was defined by a two-tailed \u003cem\u003ep\u003c/em\u003e-value less than 0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003ePatient Characteristics\u003c/h2\u003e\u003cp\u003eA total of 554 patients were analyzed, including 302 with complete fissures and 252 with incomplete fissures (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The baseline demographic profiles were comparable across the two groups. Male patients accounted for 37.4% in the CFs cohort and 41.3% in the IFs cohort (p\u0026thinsp;=\u0026thinsp;0.355). The average age was 61.92\u0026thinsp;\u0026plusmn;\u0026thinsp;8.44 years for the CFs group and 61.35\u0026thinsp;\u0026plusmn;\u0026thinsp;8.94 years for the IFs group (p\u0026thinsp;=\u0026thinsp;0.443). There were no statistically significant differences in height (163.59\u0026thinsp;\u0026plusmn;\u0026thinsp;7.74 cm vs. 164.39\u0026thinsp;\u0026plusmn;\u0026thinsp;7.21 cm, p\u0026thinsp;=\u0026thinsp;0.220) or weight (63.77\u0026thinsp;\u0026plusmn;\u0026thinsp;10.92 kg vs. 64.70\u0026thinsp;\u0026plusmn;\u0026thinsp;10.58 kg, p\u0026thinsp;=\u0026thinsp;0.314) between the cohorts.\u003c/p\u003e\u003cp\u003eWith respect to pulmonary function, individuals in the IFs group exhibited higher FEV1 values (2.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62 L compared to 2.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.61 L, p\u0026thinsp;=\u0026thinsp;0.015) and MVV (72.78\u0026thinsp;\u0026plusmn;\u0026thinsp;24.98 L versus 68.06\u0026thinsp;\u0026plusmn;\u0026thinsp;22.68 L, p\u0026thinsp;=\u0026thinsp;0.021) than those in the CFs group. DLCO did not differ significantly between groups (5.89\u0026thinsp;\u0026plusmn;\u0026thinsp;1.61 vs. 5.98\u0026thinsp;\u0026plusmn;\u0026thinsp;1.61, p\u0026thinsp;=\u0026thinsp;0.513). The prevalence of comorbid conditions was similar (56.95% vs. 52.38%, p\u0026thinsp;=\u0026thinsp;0.281), with emphysema, diabetes mellitus, heart disease, coronary heart disease, and hypertension being the most frequently observed.\u003c/p\u003e\u003cp\u003eTumor features were likewise well matched. The mean tumor diameter measured by CT was 21.36\u0026thinsp;\u0026plusmn;\u0026thinsp;10.97 mm in the CFs group and 22.87\u0026thinsp;\u0026plusmn;\u0026thinsp;11.92 mm in the IFs group (p\u0026thinsp;=\u0026thinsp;0.138). Adenocarcinoma represented the predominant histological subtype in both populations (85%), and there were no significant differences regarding the distribution of other histological types (p\u0026thinsp;=\u0026thinsp;0.376) or pathological stages (p\u0026thinsp;=\u0026thinsp;0.157).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePatients characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComplete fissure (n\u0026thinsp;=\u0026thinsp;302)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIncomplete fissure (n\u0026thinsp;=\u0026thinsp;252)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.355\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMale, n(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e113(37.42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e104(41.27)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale, n(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e189(62.58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e148(58.73)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge(years)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e61.92\u0026thinsp;\u0026plusmn;\u0026thinsp;8.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e61.35\u0026thinsp;\u0026plusmn;\u0026thinsp;8.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.443\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHeight(cm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e163.59\u0026thinsp;\u0026plusmn;\u0026thinsp;7.74\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e164.39\u0026thinsp;\u0026plusmn;\u0026thinsp;7.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.220\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eWeight(kg)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e63.77\u0026thinsp;\u0026plusmn;\u0026thinsp;10.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64.70\u0026thinsp;\u0026plusmn;\u0026thinsp;10.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.314\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLung function\u003c/p\u003e\u003cp\u003eFEV1 (L)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.31\u0026thinsp;\u0026plusmn;\u0026thinsp;0.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.44\u0026thinsp;\u0026plusmn;\u0026thinsp;0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.015\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFEV1/FVC (%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e77.58\u0026thinsp;\u0026plusmn;\u0026thinsp;9.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e78.69\u0026thinsp;\u0026plusmn;\u0026thinsp;8.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.138\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMVV\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e68.06\u0026thinsp;\u0026plusmn;\u0026thinsp;22.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e72.78\u0026thinsp;\u0026plusmn;\u0026thinsp;24.98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.021\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDLCO SB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5.89\u0026thinsp;\u0026plusmn;\u0026thinsp;1.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.98\u0026thinsp;\u0026plusmn;\u0026thinsp;1.61\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.513\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDLCO/VA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.29\u0026thinsp;\u0026plusmn;\u0026thinsp;0.28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.27\u0026thinsp;\u0026plusmn;\u0026thinsp;0.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.356\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComorbidities, n(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e172(56.95)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e132(52.38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.281\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmphysema\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDiabetes mellitus\u003c/p\u003e\u003cp\u003eHeart disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCoronary heart disease\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHypertension\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTumor size on CT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21.36\u0026thinsp;\u0026plusmn;\u0026thinsp;10.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.87\u0026thinsp;\u0026plusmn;\u0026thinsp;11.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.138\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTumor size (mm)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e19.44\u0026thinsp;\u0026plusmn;\u0026thinsp;12.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20.31\u0026thinsp;\u0026plusmn;\u0026thinsp;13.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.425\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHistological type\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.376\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSquamous cell carcinoma(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e21(6.95)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e10(3.97)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdenocarcinoma in situ(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16(5.30)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21(8.33)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAdenocarcinoma(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e257(85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e225(85.23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLarge cell carcinoma(%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(0.99)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2(0.79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSmall cell lung cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5(1.66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4(1.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThe completeness of fissure\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrade1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrade2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e219\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrade3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e154\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGrade4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e98\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePathologic stage of lung cancer\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.157\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIA1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIA2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e138\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e113\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIA3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIIA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIIB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIIIA\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIIIB\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003eFEV1\u0026thinsp;=\u0026thinsp;forced expiratory volume in 1 s; FVC\u0026thinsp;=\u0026thinsp;forced vital capacity; MVV\u0026thinsp;=\u0026thinsp;Maximum Ventilatory Volume; DLCO\u0026thinsp;=\u0026thinsp;diffuse diffusing capacity for carbon monoxide\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the intraoperative results. No significant differences were observed between the CF and IF cohorts in terms of operative duration (102.80\u0026thinsp;\u0026plusmn;\u0026thinsp;42.81 min versus 105.71\u0026thinsp;\u0026plusmn;\u0026thinsp;39.66 min, p\u0026thinsp;=\u0026thinsp;0.411) or intraoperative blood loss (87.45\u0026thinsp;\u0026plusmn;\u0026thinsp;225.65 ml compared to 83.29\u0026thinsp;\u0026plusmn;\u0026thinsp;204.72 ml, p\u0026thinsp;=\u0026thinsp;0.822). The rate of substantial blood loss (\u0026ge;\u0026thinsp;500 ml) was comparable in both groups (2.32% vs. 2.78%, p\u0026thinsp;=\u0026thinsp;0.731). Conversion to thoracotomy was required in two patients from each group (0.66% for CF and 0.79% for IF, p\u0026thinsp;=\u0026thinsp;0.747). Complete tumor resection (R0) was achieved for all individuals. Importantly, the number of lymph node stations dissected was significantly higher in the IF group compared to the CF group (6.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99 vs. 6.39\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18, p\u0026thinsp;=\u0026thinsp;0.001). Likewise, the total count of dissected lymph nodes was notably greater for the IF group (17.48\u0026thinsp;\u0026plusmn;\u0026thinsp;7.21 versus 15.32\u0026thinsp;\u0026plusmn;\u0026thinsp;6.92, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eIntraoperative results\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComplete fissure (n\u0026thinsp;=\u0026thinsp;302)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIncomplete fissure (n\u0026thinsp;=\u0026thinsp;252)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOperative time(min)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e102.80\u0026thinsp;\u0026plusmn;\u0026thinsp;42.81\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e105.71\u0026thinsp;\u0026plusmn;\u0026thinsp;39.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.411\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood loss(ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e87.45\u0026thinsp;\u0026plusmn;\u0026thinsp;225.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e83.29\u0026thinsp;\u0026plusmn;\u0026thinsp;204.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.822\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBlood loss(\u0026gt;500ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e7(2.32%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7(2.78%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.731\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConversion to thoracotomy\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(0.66%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2(0.79%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.747\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eR0 resection\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e302(100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e252(100%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e-\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDissected lymph nodes station,n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e6.39\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDissected lymph nodes number,n\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e15.32\u0026thinsp;\u0026plusmn;\u0026thinsp;6.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17.48\u0026thinsp;\u0026plusmn;\u0026thinsp;7.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.000\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e summarizes the postoperative outcomes. The average duration of chest tube retention was similar between the CF and IF groups (2.88\u0026thinsp;\u0026plusmn;\u0026thinsp;1.99 days versus 2.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.76 days, p\u0026thinsp;=\u0026thinsp;0.733). Postoperative hospital stays were also equivalent (4.36\u0026thinsp;\u0026plusmn;\u0026thinsp;2.13 days for CF and 4.37\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79 days for IF, p\u0026thinsp;=\u0026thinsp;0.962). No significant differences were found in drainage volumes on postoperative days 1, 2, and 3, nor in the total amount drained (all p\u0026thinsp;\u0026gt;\u0026thinsp;0.1). There were no perioperative deaths in either cohort. Complication rates remained low and did not show a significant difference (5.96% for CF vs. 4.36% for IF, p\u0026thinsp;=\u0026thinsp;0.401). Notably, no instances of bronchopleural fistula or empyema were reported. The frequency of prolonged air leak (PAL, \u0026gt;\u0026thinsp;5 days) was comparable (3.97% for CF and 3.57% for IF, p\u0026thinsp;=\u0026thinsp;0.805), as was the occurrence of atelectasis (0.99% vs. 0%, p\u0026thinsp;=\u0026thinsp;0.113). Cardiovascular events were infrequent, with a single case of atrial tachycardia (0.39%) in the IF group and one case of atrial fibrillation (0.33%) in the CF group; no myocardial infarctions were recorded. Pneumonia rates were low and did not differ significantly between the groups (0.66% vs. 0.39%, p\u0026thinsp;=\u0026thinsp;0.672).\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003ePostoperative mortality and complications\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eComplete fissure (n\u0026thinsp;=\u0026thinsp;302)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eIncomplete fissure (n\u0026thinsp;=\u0026thinsp;252)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003ep\u003c/em\u003e-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChest tube duration(days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2.88\u0026thinsp;\u0026plusmn;\u0026thinsp;1.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.93\u0026thinsp;\u0026plusmn;\u0026thinsp;1.76\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.733\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative hospital stay(days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4.36\u0026thinsp;\u0026plusmn;\u0026thinsp;2.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.37\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.962\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePostoperative drainage volume (ml)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePOD1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e194.68\u0026thinsp;\u0026plusmn;\u0026thinsp;168.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e205.14\u0026thinsp;\u0026plusmn;\u0026thinsp;178.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.479\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePOD2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e220.88\u0026thinsp;\u0026plusmn;\u0026thinsp;155.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e213.25\u0026thinsp;\u0026plusmn;\u0026thinsp;139.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.564\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePOD3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e150.62\u0026thinsp;\u0026plusmn;\u0026thinsp;118.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e131.62\u0026thinsp;\u0026plusmn;\u0026thinsp;95.91\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.138\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTotal drainage volume\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e550.67\u0026thinsp;\u0026plusmn;\u0026thinsp;510.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e537.19\u0026thinsp;\u0026plusmn;\u0026thinsp;467.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.750\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePerioperative mortality\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eComplications\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e18(5.96%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11(4.36%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.401\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBronchopleural fistula\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eProlonged air leakage(\u0026gt;\u0026thinsp;5 days)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12(3.97%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e9(3.57%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.805\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAtelectasis\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(0.99%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.113\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCardiovascular complication\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAtrial tachycardia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1(0.39%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.382\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAtrial fibrillation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1(0.33%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.361\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMyocardial infarction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePneumonia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2(0.66%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1(0.39%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e0.672\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmpyema\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"4\"\u003ePOD\u0026thinsp;=\u0026thinsp;Postoperative day\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eRobotic thoracic surgery emerged in the early 2000s, with initial reports from Europe in 2002, followed by subsequent publications in the United States by 2006 \u003csup\u003e21,22\u003c/sup\u003e. After the first lung resection performed with RATS, accumulating evidence has underscored its superiority compared to conventional VATS \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e. Notable advantages encompass three-dimensional imaging, enhanced maneuverability, wristed instrumentation for improved dexterity, mitigation of the fulcrum effect, tremor reduction, and better ergonomic support for surgeons. Numerous centers have substantiated that RATS is a viable and safe alternative to VATS in radical lung cancer surgery \u003csup\u003e\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e\u003c/sup\u003e. Moreover, meta-analyses suggest that RATS yields short-term results equivalent to those achieved with VATS, and may confer additional long-term survival benefits for patients undergoing anatomical lung resections \u003csup\u003e\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e,\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIFs are commonly encountered in thoracic surgical procedures. The absence of the right minor fissure occurs in 7.1\u0026ndash;45.2% of individuals, while incomplete formation is observed in 21\u0026ndash;67% of cases; the oblique fissure is incompletely developed in 3\u0026ndash;39.3% of right lungs and 10.6\u0026ndash;46.6% of left lungs \u003csup\u003e\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e,\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e\u003c/sup\u003e. The existence of IFs correlates with increased operative duration, greater intraoperative hemorrhage, and a higher incidence of complications such as persistent air leaks \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e,\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. To address incomplete fissures during lobectomy, two main surgical approaches are employed: the tunnel technique and the fissureless method. The tunnel technique allows for accurate identification of hilar structures and reduces the likelihood of accidental injury to pulmonary arterial branches \u003csup\u003e\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e\u003c/sup\u003e. In contrast, the fissureless technique involves complete division of the pulmonary parenchyma using endoscopic staplers as the final step, subsequent to the dissection and separation of hilar structures. This method, by avoiding direct manipulation of the interlobar parenchyma, has demonstrated superior efficacy in reducing the risk of prolonged air leaks \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Nevertheless, the fissureless approach is not without drawbacks; it may present safety challenges for surgeons lacking comprehensive knowledge of hilar anatomy. Specifically, during lower lobectomies, the pulmonary artery requiring resection lies posterior to the lower bronchus, which increases the potential for serious vascular injury when dividing the connective tissue between these structures \u003csup\u003e\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e\u003c/sup\u003e. Both techniques were initially developed for traditional open surgery or VATS. In RATS, the strategies for managing incomplete fissures generally mirror those utilized in VATS \u003csup\u003e\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eIn this investigation, the management of incomplete fissures predominantly utilized the advanced three-dimensional visualization inherent to RATS, combined with the precise control of Maryland forceps via robotic instrumentation. This enabled careful dissection along the pulmonary vessel surfaces, resulting in a more straightforward, efficient, and secure division of incomplete fissures. When comparing patients with incomplete fissures to those with complete fissures, application of this technique did not lead to significant differences in operative duration or intraoperative blood loss (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.411 and \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.082, respectively). These outcomes indicate that this approach may effectively address the technical difficulties encountered during lobectomy for individuals with incomplete fissures. Furthermore, the rate of substantial intraoperative hemorrhage (\u0026ge;\u0026thinsp;500 mL) was similar between the incomplete and complete fissure groups (2.32% vs. 2.78%, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.731), further supporting the safety profile of this method for such patients.\u003c/p\u003e\u003cp\u003eNumerous investigations have recognized incomplete or fused fissures as notable contributors to the development of prolonged air leak (PAL). Employing fissureless surgical methods has been shown to lower the risk of PAL by reducing trauma to the pulmonary parenchyma. Unlike the fissure-first strategy, which unavoidably results in injury to the interlobar lung tissue, our method restricts such harm to the initial phase of pulmonary artery identification. After the artery is exposed, the integration of robotic three-dimensional visualization with meticulous dissection using Maryland forceps along the vessel surface further limits parenchymal damage. Comparative analysis revealed no significant differences between groups regarding average chest tube duration (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.733), postoperative hospital stay length (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.962), drainage volume after surgery (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.1), or rates of postoperative complications (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.401) including PAL incidence (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.805). These findings suggest that our technique is both effective for treating incomplete fissures and for reducing the likelihood of prolonged air leak.\u003c/p\u003e\u003cp\u003eLymph node removal represents a pivotal aspect of lung cancer surgery, functioning as a key parameter for evaluating the oncological effectiveness of the operation. Relative to the tunnel technique, the fissureless method may present limitations for individuals with N1 lymph node involvement, primarily due to the potential for inadequate interlobar lymph node clearance\u003csup\u003e\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u003c/sup\u003e. In our research, the quantity of lymph nodes excised in the IFs cohort was notably greater than in the CFs group. This outcome likely results from the enhanced three-dimensional visualization at high magnification afforded by RATS, which allows for more accurate identification and removal of lymph nodes located near vessels and within interlobar fissures when addressing incomplete fissures. These observations further reinforce the oncological advantages of this surgical technique.\u003c/p\u003e\u003cp\u003eThis investigation is subject to several limitations. Primarily, its single-center nature may restrict the applicability of the findings to broader patient populations. Additionally, the retrospective design and reliance on limited evaluation criteria could have introduced certain biases. Future prospective, randomized trials are necessary to confirm these observations. Nonetheless, to our knowledge, this work constitutes the largest cohort thus far examining the effectiveness and safety of a robotic-assisted thoracic surgery (RATS) technique specifically tailored for the management of incomplete pulmonary fissures during lobectomy.\u003c/p\u003e\u003cp\u003eIn summary, anatomical lung resection performed with this RATS-specific approach appears to offer a safe and effective option for individuals presenting with incomplete fissures.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eAuthor Disclosures\u003c/h2\u003e\u003cp\u003eDrs. Xu Hao, Chang Xiaoyan, and Zhang Linyou have no conflicts of interest or financial ties to disclose.\u003c/p\u003e\u003c/div\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eSiegel RL, Giaquinto AN, Jemal A. Cancer statistics, 2024. CA Cancer J Clin. 2024 Jan-Feb;74(1):12\u0026ndash;49. doi: 10.3322/caac.21820IF: 503.1 Q1. Epub 2024 Jan 17. Erratum in: CA Cancer J Clin. 2024 Mar-Apr;74(2):203. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3322/caac.21830\u003c/span\u003e\u003cspan address=\"10.3322/caac.21830\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHowington JA, Blum MG, Chang AC, Balekian AA, Murthy SC. Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. 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Epub 2006 Dec 18.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Robotic-assisted thoracic surgery, Lobectomy, Incomplete fissure, Lung cancer","lastPublishedDoi":"10.21203/rs.3.rs-7782382/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7782382/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eRobotic-assisted thoracic surgery (RATS) is increasingly acknowledged for its efficacy in managing early-stage non-small cell lung cancer (NSCLC), owing to its distinct technical advantages. Nevertheless, individuals with pronounced incomplete interlobar fissures often face higher rates of conversion to alternative procedures and an increased likelihood of postoperative complications. This retrospective study introduces a novel robotic surgical technique tailored to the challenges posed by incomplete fissures, evaluating both its safety and therapeutic outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA retrospective analysis was performed on the clinical data of individuals who received robotic-assisted lobectomy for NSCLC at our center from March 2021 to September 2024. Altogether, 554 cases were incorporated and divided into two cohorts\u0026mdash;those with fully developed fissures and those with partially developed fissures\u0026mdash;based on the anatomical features of their lung fissures.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eAmong the 554 patients analyzed, 302 were categorized as having complete fissures, while 252 were identified with incomplete fissures. Comparative evaluation revealed no statistically significant differences between these groups in terms of operative duration (p\u0026thinsp;=\u0026thinsp;0.411), intraoperative blood loss (p\u0026thinsp;=\u0026thinsp;0.822), chest tube retention time (p\u0026thinsp;=\u0026thinsp;0.733), rate of prolonged air leakage (PAL, p\u0026thinsp;=\u0026thinsp;0.805), or postoperative hospital stay (p\u0026thinsp;=\u0026thinsp;0.962). Importantly, neither group exhibited cases of bronchopleural fistula, pneumonia, or perioperative death.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eIncomplete fissures do not increase the procedural difficulty of lobectomy when employing this robotic surgical approach. This newly developed, robot-specific technique ensures both safety and efficacy for patients with incomplete fissures.\u003c/p\u003e","manuscriptTitle":"From Central to Peripheral: A Novel Robotic Approach for Lobectomy in Patients with Incomplete Pulmonary Fissures","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-25 09:23:23","doi":"10.21203/rs.3.rs-7782382/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-17T22:15:28+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-17T02:38:57+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-16T09:59:33+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"268046165712722091951581963132175046538","date":"2025-10-14T15:09:40+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"53412144503604387259358700369326469204","date":"2025-10-13T19:12:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"90606757820033088369093618706234620869","date":"2025-10-13T10:13:59+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"101875331164450669410070323562674571626","date":"2025-10-12T10:40:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"220686003520608541835476191230065761054","date":"2025-10-12T09:40:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"124071286364282813726248816570443996872","date":"2025-10-12T03:11:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"164529958208214970288858645594748663308","date":"2025-10-12T01:01:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-11T21:07:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-06T19:32:43+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-06T05:17:30+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2025-10-05T02:27:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"344ce0a1-d012-45c9-bd32-2e3c6c60198a","owner":[],"postedDate":"October 25th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-03T16:02:36+00:00","versionOfRecord":{"articleIdentity":"rs-7782382","link":"https://doi.org/10.1007/s11701-025-02930-0","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2025-11-01 15:58:14","publishedOnDateReadable":"November 1st, 2025"},"versionCreatedAt":"2025-10-25 09:23:23","video":"","vorDoi":"10.1007/s11701-025-02930-0","vorDoiUrl":"https://doi.org/10.1007/s11701-025-02930-0","workflowStages":[]},"version":"v1","identity":"rs-7782382","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7782382","identity":"rs-7782382","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}