Surgical resection is the standard treatment for early- stage non-small cell lung cancer (NSCLC) and for incidentally detected anterior mediastinal masses. Video-assisted thoracoscopic surgery (VATS) has become a highly recommended surgical approach for resectable NSCLC after several trials demonstrated better short-term mortality [1,2] and similar long-term oncological outcomes [3] compared to thoracotomy. However, VATS is not routinely recommended for anterior mediastinal masses due to a lack of long-term clinical data. Nonetheless, VATS is considered a standard surgical approach for small anterior mediastinal masses, as several retrospective studies have shown comparable clinical outcomes for early-stage thymoma and thymic carcinoma relative to the transsternal approach [4]. Robotic-assisted thoracoscopic surgery (RATS) has expanded the possibilities for minimally invasive procedures, due to its 3-dimensional vision and multi-articulating forceps. However, its adoption has been limited in some countries and among certain patients due to its high cost. After the 2019 introduction of a novel articulating instrument for endoscopic surgery, termed ArtiSential (LIVSMED, Seongnam, Korea), some studies have reported its safety, efficacy, and cost-effectiveness in laparoscopic surgery [5,6]. Still, few reported clinical outcomes are available regarding the use of ArtiSential in thoracoscopic surgery. We report our early experience with VATS major pulmonary resection and thymectomy using ArtiSential articulating instruments.

Study population

The study protocol underwent review by the Seoul Metropolitan Government-Seoul National University Boramae Medical Center Review Board and received approval as a minimal-risk retrospective study (approval number: 20-2023-74), and the requirement for individual consent was waived. VATS procedures were performed by 2 surgeons (Y.W.S., H.J.M.) at the Seoul Metropolitan Government- Seoul National University Boramae Medical Center. From July 2020 to April 2023, a total of 500 patients underwent VATS pulmonary resection, and between January 2020 and April 2023, 43 patients underwent VATS thymectomy. For the VATS pulmonary resection cohort, after the exclusion of 157 wedge resections, 78 cases of benign disease, and 41 metastasectomies, 224 patients were included in the study. Of these, ArtiSential was utilized in 35 patients, while the remaining 189 patients underwent major VATS pulmonary resection without the use of ArtiSential. Regarding VATS thymectomy, after removing 3 cases of pericardial cysts and 2 incomplete resections from the analysis, 38 patients remained. ArtiSential was employed in 12 of these cases, and 26 patients underwent VATS thymectomy without ArtiSential (Fig. 1).

Figure 1. (A, B) Flow diagram of patient enrollment. VATS, video-assisted thoracoscopic surgery.

Operative techniques and strategy

For most cases of VATS pulmonary resection, a 3-port approach was employed. A 15-mm incision was made at the seventh intercostal space (ICS) on the midaxillary line to establish the instrument port for energy devices and endoscopic staplers. Subsequently, a 4-cm incision was made at the fifth ICS on the anterior axillary line to accommodate the utility port. A thoracoscope was inserted through this utility port. Finally, a 10-mm incision was placed at the sixth ICS below the scapular tip to establish the 8-mm ArtiSential instrument port. For VATS thymectomy, a lateral approach was utilized with patients in the supine position. The side of the approach was determined by reviewing preoperative computed tomography scans, and typically, 3 ports were employed. Patients were positioned with the approach side elevated, and the ipsilateral arm was adducted and positioned lower, in alignment with the method outlined by Seong et al. [7]. A 15-mm incision was made at the fifth ICS on the midaxillary line for the camera port, a 10-mm incision at the third ICS near the axilla for the 8-mm ArtiSential instrument port, and an 8-mm incision at the sixth ICS on the anterior axillary line for the 5-mm instrument port. All intercostal nerves at the VATS port sites received a preemptive injection of bupivacaine. During VATS thymectomy, carbon dioxide (CO₂) insufflation was applied at a pressure of 8 mm Hg. The surgeon initiated the use of ArtiSential when articulation was considered advantageous for dissection. ArtiSential forceps, measuring 25 cm in length and 8 mm in diameter, were employed. The ArtiSential system accommodates a variety of forceps, including fenestrated forceps, bipolar fenestrated forceps, Maryland dissectors, bipolar Maryland dissectors, bipolar precise dissectors, bipolar curved dissectors, needle holders, precise needle holders, clip appliers, and monopolar spatulas. For VATS major pulmonary resection, the Maryland dissector and bipolar precise dissector were used, while fenestrated forceps were selected for VATS thymectomy (Fig. 2).

Figure 2. (A) ArtiSential articulating instrument (LIVSMED, Seongnam, Korea). (B) Fenestrated forceps. (C) Maryland dissector. (D) Bipolar precise dissector. (E) Bipolar curved dissector. (F) Needle holder. (G) Precise needle holder. (H) Clip applier, medium large. (I) Monopolar spatula. (J) Monopolar hook.

Evaluation of early clinical outcomes

Staging for lung cancer was determined using the eighth edition of the tumor-node-metastasis classification system. The total hospital stay was defined as the duration of hospitalization from admission to discharge, while the hospital stay after surgery referred to the time from surgery to discharge. The 24-hour tube drainage volume was quantified as the volume (in mL) of drainage until postoperative day 1. The duration of chest tube placement was defined as the time from surgery (in days) until the removal of the chest tube. Because postoperative blood tests were routinely conducted only after VATS major pulmonary resection, comparisons of the increase in white blood cell (WBC) count (×10³/µL), hemoglobin (Hb) decrease (g/dL), and hematocrit (Hct) decrease (%) were not performed in the VATS thymectomy group. Postoperative complications were categorized according to the Clavien-Dindo classification system [8]. A chest tube duration exceeding 5 days was considered to indicate prolonged air leakage. Pulmonary complications encompassed all clinical scenarios in which pneumonia was suspected. Thus, the administration of intravenous broad-spectrum antibiotics, even without pathogen identification and including reintubation due to increased oxygen demand, was considered a pulmonary complication. Operative mortality was defined as any death occurring within 30 days following surgery.

Statistical analysis

Statistical analysis was conducted using IBM SPSS ver. 28.0 (IBM Corp., Armonk, NY, USA). Continuous variables were evaluated using the Mann-Whitney U test and are presented as medians with interquartile ranges. Categorical variables were assessed using the chi-square test and Fisher exact test and are reported as counts with percentages. All tests were 2-tailed, and a p-value of less than 0.05 was deemed to indicate statistical significance.

Preoperative characteristics

The preoperative characteristics of patients undergoing both VATS major pulmonary resection and thymectomy were comparable between the novel articulating instrument group and the conventional endoscopic instrument group (Table 1). In the VATS major pulmonary resection cohort, no significant differences were observed in median age (69 years versus 68 years, p=0.472), the proportion of male participants (71% versus 64%, p=0.398), median height (164.2 cm versus 162.9 cm, p=0.973), median weight (63.2 kg versus 63.9 kg, p=0.848), or the proportion of never smokers (34.3% versus 43.9%, p=0.290) between the 2 groups. Pulmonary function tests also yielded similar results; median forced expiratory volume in the first second (FEV1; 98% versus 101%, p=0.751), median forced vital capacity (FVC; 94% versus 96%, p=0.594), and median diffusing capacity for carbon monoxide (DLCO; 104% versus 100%, p=0.181) were comparable. Regarding neoadjuvant treatment, in the novel articulating instrument group, only 1 patient received chemotherapy. In contrast, in the conventional endoscopic instrument group, 4 patients received chemotherapy, 4 underwent concurrent chemoradiation therapy, and 1 received photodynamic therapy. Although the conventional endoscopic instrument group included a higher proportion of patients with advanced-stage lung cancer (stage 2: 5.7% versus 14.8%; stage 3: 11.4% versus 10.1%; stage 4: 0% versus 1.1%), this difference was not statistically significant (p=0.486).

Table 1 . Preoperative characteristics of VATS major pulmonary resection and VATS thymectomy.

Variable	Conventional	Novel articulating	p-value
VATS major pulmonary
No. of patients	189	35
Age (yr)	68 (62–74)	69 (58–74)	0.472
Sex			0.398
Male	121 (64)	25 (71)
Female	68 (36)	10 (29)
Height (cm)	162.9 (157.1–169.0)	164.2 (155.7–168.8)	0.973
Weight (kg)	63.9 (58.3–70.3)	63.2 (57.3–72.6)	0.848
Smoking			0.290
Never	83 (43.9)	12 (34.3)
Ever	106 (56.1)	23 (65.7)
Pulmonary function test
FEV1 (%)	101 (89–113)	98 (90–114)	0.751
FVC (%)	96 (89–106)	94 (86–107)	0.594
DLCO (%)	100 (86–112)	104 (91–122)	0.181
Neoadjuvant treatment			0.799
None	180 (95.2)	34 (97.1)
Chemotherapy	4 (2.1)	1 (2.9)
CCRT	4 (2.1)	0
Radiation therapy	0	0
PDT	1 (0.5)	0
Clinical stage			0.486
1	139 (73.5)	28 (80.0)
2	28 (14.8)	2 (5.7)
3	19 (10.1)	4 (11.4)
4	2 (1.1)	0
VATS thymectomy
No. of patients	26	12
Age (yr)	58 (47–70)	63 (57–68)	0.230
Sex			0.825
Male	14 (53.8)	6 (50.0)
Female	12 (46.2)	6 (50.0)
Height (cm)	165.6 (155.3–169.6)	159.9 (156.7–164.4)	0.387
Weight (kg)	64.7 (58.5–76.9)	67.9 (60.0–71.2)	0.802
Smoking			0.240
Never	20 (76.9)	7 (58.3)
Ever	6 (23.1)	5 (41.7)
Pulmonary function test
FEV1 (%)	106 (96–117)	100 (96–113)	0.593
FVC (%)	99 (88–110)	95 (88–103)	0.529
DLCO (%)	97 (91–107)	101 (94–115)	0.275
No. of myasthenia gravis	2 (7.7)	1 (8.3)	0.946

Values are presented as median (interquartile range) for continuous variables or number (%) for categorical variables..

VATS, video-assisted thoracoscopic surgery; FEV1, forced expiratory volume in the first second; FVC, forced vital capacity; DLCO, diffusing capacity for carbon monoxide; CCRT, concurrent chemoradiation therapy; PDT, photodynamic therapy..

In the comparison of VATS thymectomy outcomes, the groups showed no significant differences in median age (63 years versus 58 years, p=0.230), the proportion of male participants (50.0% versus 53.8%, p=0.825), median height (159.9 cm versus 165.6 cm, p=0.387), median weight (67.9 kg versus 64.7 kg, p=0.802), or the proportion of never smokers (58.3% versus 76.9%, p=0.240). Pulmonary function tests also yielded comparable results between the groups, with median FEV1 (100% versus 106%, p=0.593), median FVC (95% versus 99%, p=0.529), and median DLCO (101% versus 97%, p=0.275) showing no significant differences. Regarding preoperative diagnoses, 2 patients in the conventional endoscopic instrument group and 1 patient in the novel articulating instrument group were diagnosed with myasthenia gravis before undergoing surgery.

Operative data

No significant differences in operative data were observed between the novel articulating instrument and conventional endoscopic instrument groups for both VATS major pulmonary resection and thymectomy (Table 2). In the context of VATS major pulmonary resection, right upper lobe lobectomy was the most common procedure performed in both groups (40.0% versus 24.9%). The median tumor size (2.5 cm in both groups, p=0.604) and the median operation time (149 minutes versus 152 minutes, p=0.739) were comparable. The conventional endoscopic instrument group underwent 8 additional procedures. In the novel articulating instrument group, a greater number of lymph nodes were dissected (24 versus 21, p=0.028), and less blood loss occurred (100 mL versus 120 mL, p=0.009).

Table 2 . Operative data for VATS major pulmonary resection and VATS thymectomy.

Variable	Conventional	Novel articulating	p-value
VATS major pulmonary resection
No. of patients	189	35
Extent of surgical resection			0.224
Segmentectomy	30 (15.9)	3 (8.6)
Right upper lobectomy	47 (24.9)	14 (40.0)
Right middle lobectomy	12 (6.3)	1 (2.9)
Right lower lobectomy	40 (21.2)	6 (17.1)
Left upper lobectomy	39 (20.6)	5 (14.3)
Left lower lobectomy	16 (8.5)	6 (17.1)
Bi-lobectomy	5 (2.6)	0
Tumor size (cm)	2.5 (1.8–3.5)	2.5 (1.5–3.9)	0.604
No. of dissected LNs	21 (14–28)	24 (20–34)	0.028
Operation time (min)	152 (125–181)	149 (125–180)	0.739
Estimated blood loss (mL)	120 (70–250)	100 (50–200)	0.009
Additional procedure	8 (4.2)	0	0.215
Technical difficulty resulting in instrument change	-	0
VATS thymectomy
No. of patients	26	12
Approach			0.819
Right	19 (73.1)	8 (66.7)
Left	4 (15.4)	3 (25.0)
Bilateral	2 (7.7)	1 (8.3)
Subxiphoid	1 (3.8)	0
Operation time (min)	81 (60–110)	125 (74–155)	0.081
Estimated blood loss (mL)	50 (50–88)	50 (30–100)	0.783
Mass size (cm)	3.6 (2.8–5.3)	4.0 (2.9–6.3)	0.626
Additional procedure	8 (30.8)	1 (8.3)	0.130
Technical difficulty resulting in instrument change	-	0

Values are presented as number (%) for categorical variables or median (interquartile range) for continuous variables..

VATS, video-assisted thoracoscopic surgery; LN, lymph node..

For VATS thymectomy, the right-side approach was the most common in both the novel articulating instrument group and the conventional endoscopic instrument group (66.7% versus 73.1%, p=0.819). The median estimated blood loss was similar between the groups (50 mL for both, p=0.783). The mass was larger (4.0 cm versus 3.6 cm, p=0.626) and the operation time was longer (125 minutes versus 81 minutes, p=0.081) in the novel articulating instrument group, but these differences were not statistically significant. Eight additional procedures were performed in the conventional endoscopic instrument group, compared to 1 additional procedure in the novel articulating instrument group. No significant differences were found in pathological findings between the 2 groups for VATS major pulmonary resection or thymectomy (Supplementary Table 1). Additionally, we noted no instances of technical difficulty resulting in instrument change during either VATS major pulmonary resection or thymectomy.

Early clinical outcomes

No significant differences were found in early clinical outcomes between the novel articulating instrument group and the conventional endoscopic instrument group for either VATS major pulmonary resection or thymectomy (Table 3). In the case of VATS major pulmonary resection, the median duration of hospitalization (total: 7 days versus 8 days, p=0.375; median duration of hospitalization after surgery: 6 days for both groups, p=0.449), 24-hour tube drainage volume (180 mL versus 180 mL, p=0.985), median duration of chest tube placement (4 days versus 5 days, p=0.382), postoperative laboratory findings (WBC increase: 2.71×10³ μL versus 3.29×10³ μL, p=0.241; Hb loss: 1.1 g/dL versus 1.3 g/dL, p=0.170; Hct decrease: 2.9% versus 3.7%, p=0.398), and proportion of complications (42.9% versus 46.0%, p=0.615) were comparable between the 2 groups. For VATS thymectomy, the median number of hospital days (total: 4 versus 4, p=0.500; post-surgery: 2 versus 3, p=0.599), 24-hour tube drainage volume (30 versus 40, p=0.812), median duration of chest tube placement (1 day for both groups, p=0.060), and proportion of complications (8.3% versus 7.7%, p=0.946) were also similar between the 2 groups.

Table 3 . Early clinical outcomes of VATS pulmonary resection and VATS thymectomy.

Variable	Conventional	Novel articulating	p-value
VATS pulmonary resection
No. of patients	189	35
Hospital stay (day)
Total	8 (7–12)	7 (5–12)	0.375
After surgery	6 (5–10)	6 (4–11)	0.449
24-hr tube drainage (mL)	180 (110–260)	180 (100–300)	0.985
Chest tube duration (day)	5 (3–8)	4 (3–7)	0.382
Laboratory findings
WBC increase (×103 μL)	3.29 (1.58–4.93)	2.71 (1.24–4.11)	0.241
Hb loss (g/dL)	1.3 (0.7–1.8)	1.1 (0.4–1.6)	0.170
Hct decrease (%)	3.7 (1.9–5.3)	2.9 (0.9–5.5)	0.398
Complication	87 (46.0)	15 (42.9)	0.615
VATS thymectomy
No. of patients	26	12
Hospital stay (day)
Total	4 (3–4)	4 (3–6)	0.500
After surgery	3 (2–3)	2 (2–5)	0.599
24-hr tube drainage (mL)	40 (10–95)	30 (20–88)	0.812
Chest tube duration (day)	1 (1–2)	1 (1–1)	0.060
Complication	2 (7.7)	1 (8.3)	0.946

Values are presented as number (%) for categorical variables or median (interquartile range) for continuous variables..

VATS, video-assisted thoracoscopic surgery; WBC, white blood cell; Hb, hemoglobin; Hct, hematocrit..

Complications

No significant differences were found in the composition of complications between the novel articulating instrument group and the conventional endoscopic instrument group for VATS major pulmonary resection (Table 4). The incidence of prolonged air leakage was comparable between groups (37.1% versus 36.0%, p=0.895). The conventional endoscopic instrument group experienced more pulmonary complications, though the difference was not statistically significant (8.6% versus 14.8%, p=0.589). Within the entire cohort undergoing VATS major pulmonary resection, the operative mortality rate was 0.9% (2 of 224 patients). Within this cohort, the novel articulating instrument group recorded 1 death, resulting in a mortality rate of 2.9% (1 of 35 patients), while the conventional endoscopic instrument group also reported 1 death, corresponding to a mortality rate of 0.5% (1 of 189 patients). One patient in the novel articulating instrument group died from acute respiratory distress syndrome on postoperative day 28, while 1 patient in the conventional endoscopic instrument group died from postoperative pneumonia on postoperative day 22.

Table 4 . Complications of video-assisted thoracoscopic surgery major pulmonary resection.

Variable	Conventional	Novel articulating	p-value
No. of patients	189	35
Clavien-Dindo classification			0.878
1	27 (14.3)	3 (8.6)
2	35 (18.5)	7 (20.0)
≥3	25 (7.9)	5 (11.4)
Operative mortality	1 (0.5)	1 (2.9)	0.179
Pulmonary complication	28 (14.8)	3 (8.6)	0.589
Prolonged air leakage	68 (36.0)	13 (37.1)	0.895

Values are presented as number or number (%)..

Regarding VATS thymectomy, 1 complication was observed in the novel articulating instrument group and 2 complications in the conventional endoscopic instrument group (Table 3). The complication in the novel articulating instrument group involved a patient postoperatively diagnosed with type 2 respiratory failure, who subsequently underwent delayed left diaphragm plication. In the conventional endoscopic instrument group, 1 patient developed postoperative chylothorax, which improved with a low-fat diet, and another experienced left vocal fold palsy, which improved following injection laryngoplasty.

Following the introduction of robotic surgery for lung cancer [9] and anterior mediastinal masses [10], numerous studies have underscored its safety and efficacy. In a randomized trial, Huang et al. [11] reported early clinical outcomes of RATS that were comparable to thoracotomy, even among patients with clinical N2 stage NSCLC. Kneuertz et al. [12] found similar long-term clinical outcomes for RATS when compared to VATS and thoracotomy, including overall survival and recurrence-free survival. A parallel shift towards RATS, akin to its adoption in lung cancer surgery, has been observed in surgical procedures for anterior mediastinal masses. Seong et al. [7] demonstrated early clinical outcomes of RATS that were comparable to sternotomy after propensity score matching, while Kang et al. [13] reported similar recurrence-free survival for RATS compared to sternotomy, also after propensity score matching. Despite ongoing concerns about the long-term outcomes of VATS and RATS for anterior mediastinal masses, these techniques are now widely accepted as standard approaches for the surgical resection of thymic epithelial tumors and myasthenia gravis [14,15]. While these methods also display comparable clinical outcomes with sternotomy, thoracotomy, and VATS, their advantages also include those provided by the 3-dimensional vision and multi-articulating forceps. These forceps allow surgeons to perform dissection around pulmonary arteries with traction from any direction and to meticulously remove large mediastinal masses without damaging adjacent structures, such as the innominate vein and phrenic nerve. However, the high financial cost of RATS can be a barrier in some countries. Robot-assisted lobectomy and robot-assisted thymectomy have been shown to incur significantly higher costs than VATS [16,17]. Nevertheless, the benefits of multi-articulating forceps can be realized by incorporating ArtiSential articulating forceps into conventional endoscopic surgery (Fig. 3). Lee et al. [18] reported similar clinicopathologic and perioperative outcomes, as well as shorter operation time, in laparoscopic gastrectomy using ArtiSential forceps compared to robotic gastrectomy.

Figure 3. Video-assisted thoracoscopic surgery (VATS) lobectomy (A, B) and VATS thymectomy (C, D) utilizing the ArtiSential articulating instrument (LIVSMED, Seongnam, Korea). (A) Dissection of the pulmonary artery. (B) Precise traction was achievable from any direction. (C) Dissection of the left upper pole. (D) Maneuvering around a large thymoma.

To our knowledge, this study is among the first to evaluate the early clinical outcomes of VATS major pulmonary resection and thymectomy using ArtiSential articulating forceps. For VATS major pulmonary resection, the early clinical outcomes were generally comparable, apart from the number of dissected lymph nodes (LNs) and estimated blood loss, which appear to be incidental findings. We believe that the use of novel articulating forceps may enable deeper access to areas such as the subcarinal and paratracheal regions, potentially facilitating more extensive LN harvesting. However, due to selection bias and the small sample size involved, the conclusion that a significantly greater number of LNs were harvested using the novel articulating forceps should be regarded as an incidental finding. It could be argued that surgeons may have selectively used ArtiSential in low-risk patients and intentionally dissected more LNs in these cases. Nevertheless, no significant difference was found in postoperative pathologic data between the group operated upon using conventional endoscopic instruments and those who underwent surgery using the novel articulating instruments (Supplementary Table 1). Despite the absence of some data regarding preoperative comorbidities, no significant difference was found in age or preoperative pulmonary function tests, which are major components of preoperative risk assessment. Additionally, given the lack of a significant difference in postoperative Hb and Hct, we can infer that the significant difference in estimated blood loss may also be an incidental finding. Regarding VATS thymectomy, the operation time for thymectomy surgery was longer in the group operated upon using the novel instruments, though not significantly so. Since this study was not a randomized controlled trial, the decision to use the novel articulating forceps was made by the surgeon based on intraoperative findings. Consequently, the novel articulating forceps were selectively used in patients with masses that were more challenging to dissect with conventional forceps due to their size or location, despite the absence of significant differences in mass size between the 2 groups (Table 2).

ArtiSential articulated forceps can enable thoracic surgeons to perform with greater precision, safety, and efficacy. Lee et al. [18] reported that these forceps made it easier to dissect LNs located behind vascular structures such as hepatic arteries, portal veins, and splenic vessels by providing appropriate traction. This advantage is also relevant to VATS major pulmonary resection and VATS thymectomy. During VATS lobectomy, ArtiSential forceps can provide proper traction to safely dissect LNs from the pulmonary artery or vein. Similarly, during VATS thymectomy, the forceps can facilitate the dissection of an anterior mediastinal mass from the innominate vein or phrenic nerve. Unlike in RATS, surgeons do not require additional time to become accustomed to robot docking systems or port placements. Surgeons need only a few hours to adapt to the articulating movements by controlling their wrists [19]. At our institution, 2 surgeons (Y.W.S. and H.J.M.) performed VATS major pulmonary resection and VATS thymectomy using ArtiSential articulated forceps after just a few hours of practice in a dry-lab setting, demonstrating the intuitiveness and user-friendliness of the device (Supplementary Fig. 1). In this study, 8-mm-diameter forceps were used; however, the recent introduction of 5-mm-diameter ArtiSential 5 forceps is expected to further enhance the convenience and precision of thoracic surgery.

Limitations

This study has several limitations. First, it was conducted at a single center with a retrospective design and involved a small number of cases. Second, it compared only early clinical outcomes. Future research should focus on long-term clinical outcomes, such as overall survival and recurrence-free survival, which are of utmost importance for lung cancers and thymic epithelial tumors. Third, a cost- effectiveness analysis was not included in this study. Additional studies that compare the financial costs associated with RATS may be warranted.

Conclusions

VATS major pulmonary resection and VATS thymectomy performed with ArtiSential articulating forceps were found to be safe and effective. Early clinical outcomes were comparable to those achieved using conventional instruments.

Author contributions

Conceptualization: HJM, YWS. Data curation: SY. Formal analysis: JSC. Funding acquisition: YoWS. Investigation: SJO. Methodology: YJO. Project administration: JSC. Resources: HJM, YWS. Software: SJO. Supervision: YWS. Validation: YJO. Visualization: YJO. Writing–original draft: SY. Writing–review & editing: SY, YWS. Approval of final manuscript: all authors.

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.

Acknowledgments

This research received support in the form of a grant for the multi-institutional evaluation project for new domestically produced medical devices, in connection with the Korean Medical Society. The funding was provided by the Korea Health Industry Development Institute (KHIDI), under the auspices of the Ministry of Health & Welfare, Republic of Korea.

Supplementary materials

Supplementary materials can be found via https://doi.org/10.5090/jcs.23.161. Supplementary Table 1. Pathologic data of VATS major pulmonary resection and VATS thymectomy. Supplementary Fig. 1. Temporal trends in video-assisted thoracoscopic surgery major pulmonary resection using the ArtiSential articulating instrument.