The introduction of surgical robotic systems around the turn of the millennium marked a significant transformation in the end instruments of minimally invasive surgery [1]. The general disadvantages of conventional video-assisted thoracic surgery (VATS) include the limited 2-dimensional view and the restricted maneuverability of the instruments and end effectors. Therefore, during thoracoscopic lobectomy or thymectomy, it can sometimes be challenging to perform vascular and mediastinal dissection in a precise and anatomically correct manner with conventional video- endoscopic instruments [2,3]. In contrast to the classic straight laparoscopic and thoracoscopic instruments (straight sticks), which were introduced as early as the 1980s, the new hand- guided articulating ArtiSential instruments (LIVSMED, Seongnam, Korea) are flexible [4]. The articulation of the end effector or the tip of the instrument increases the range of motion by 2 degrees of freedom, thereby improving the surgical accessibility of structures in narrow anatomical spaces, such as within the thorax, during lymphadenectomy, or in vascular preparation, and especially during dissection in the mediastinum as part of thymectomy. Previous attempts to introduce articulation into standard laparoscopic/thoracoscopic instruments were unsuccessful due to various factors, including immature and non-ergonomic designs and a lack of consensus on the optimal technical execution to meet the surgeons’ needs [5]. In 2019, the articulating instrument system (ArtiSential) was introduced, featuring a complete arsenal of single-use wristed instruments with a freely (360°) articulating end effector, similar to those found in surgical robotic systems [4]. Recent publications, including some by our group, have reported on clinical experiences with these articulating instruments in various surgical disciplines [6-8].

This well-prepared and detailed study examined the use of articulated instruments in VATS major pulmonary resections and VATS thymectomies and compared the results with a control group operated on using conventional VATS instruments [9]. ArtiSential forceps were used in 35 patients out of 224 patients in the VATS major pulmonary resection group and in 12 patients out of 38 in the VATS thymectomy group. There were no differences in patient preparation, the surgical procedure, or the minimally invasive placement of port sites between the conventional VATS group and the novel articulating instrument VATS group. The surgeons employed ArtiSential when it was determined that articulation would improve the dissection.

The retrospective analysis showed no significant differences in clinical parameters, such as operation time, complication rate, or duration of hospitalization, between the novel articulating instrument group and the conventional endoscopic instrument group.

Interestingly, during major pulmonary VATS resections, significantly more lymph nodes were resected during radical lymphadenectomy in the novel articulating instrument group (24 versus 21, p=0.028) than in the conventional instrument group. Of course, as the authors concluded, the observation of a significantly higher number of resected lymph nodes in the articulated VATS group can be considered an incidental finding due to potential selection bias and a small sample size. This is a cautious and absolutely legitimate assessment and interpretation by the authors. Nonetheless, current data from robotic-assisted thoracoscopic surgery also show a significantly higher number of resected lymph nodes in robotically-articulated radical lymphadenectomy during anatomical lung resections, thus supporting the importance of articulated instrumentation [10]—either robotic or hand-held articulation, as in the current study. Our group has been using the articulating ArtiSential instruments for over 3 years now and has also observed significantly higher numbers of resected lymph nodes in the articulated VATS group than in the conventional VATS group in a preliminary data analysis of VATS anatomical pulmonary resections (publication in preparation). These findings additionally confirm the results of the current study.

These consistent results regarding higher lymph node yield appear to be related to articulated instrumentation and improved accessibility of anatomical structures when dissecting around vessels and during lymphadenectomy in confined spaces in the thoracic cavity, providing proper traction from different directions to dissect lymph nodes from the pulmonary artery, vein, bronchus, esophagus, or vagus nerve more safely.

The results regarding the significantly lower intraoperative blood loss in the novel articulating instrument group should be interpreted in a similar way (100 mL versus 120 mL, p=0.009).

The authors also pointed out other possible advantageous aspects—for instance, compared to robotically assisted lobectomy or thymectomy, the flexible use of hand-held articulating instruments might be more cost-effective, does not involve additional time due to complex docking and port placement, and the learning curve to achieve intuitive mastery of the instruments is shorter.

The evaluation of only early clinical results from a single center, the retrospective nature of the study, the absence of randomization, and the omission of a cost-effectiveness analysis might have introduced biases here. The authors also acknowledged the challenges in patient selection, raising questions about the generalizability of the findings.

Furthermore, this study had limited statistical power due to a small sample size, which may lead to false-negative errors. Conducting a study on a larger patient cohort could reveal significant differences with more statistical power concerning parameters such as the number of harvested lymph nodes, complications, oncological outcomes, and the conversion-to-open rate between conventional instrument VATS and novel articulating instrument VATS groups.

The conclusion that VATS major pulmonary resection and VATS thymectomy can be performed safely and effectively with the new articulating instruments, and that early clinical outcomes are comparable to those achieved with conventional instruments, is ultimately the most important finding of the present study. It also serves as a foundation and a guide for future larger, prospective studies, which should focus on long-term clinical outcomes, such as overall survival and recurrence-free survival.

In summary, this study acknowledges the ongoing debate about the use of articulation-assisted approaches in minimally invasive thoracic surgery and emphasizes the possible advantages of hand-held articulated instrumentation for patients’ outcomes. Moreover, it highlights the complexity of patient selection and underscores the importance of future (prospective) studies to evaluate this new approach.

Author contributions

All the work was done by Alexander Kern.

Conflict of interest

No potential conflict of interest relevant to this article was reported.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.