Background: With the introduction of minimally invasive surgical techniques, the utilization of robotic surgery continues to rise. Providing good lung isolation and one lung ventilation can be particularly challenging in robotic thoracic surgery; given the unique positioning of the patient and limited airway access.Case Report: 69 year old male with a lung tumor presented for robotic assisted left lower lobe lobectomy. Since the DaVinci robot’s positioning will essentially cover the patient’s head and completely block the anesthesiologist access for airway security, we therefore, utilized the Vivasight™ (ET View Ltd, Misgav, Israel) video double lumen tube (VDLT) with an embedded camera to facilitate both placement and verification of the final position of the VDLT to ensure lung isolation.Discussion: Currently, placement of double lumen tubes (DLT) with fiberoptic bronchoscopy (FOB) confirmation is the standard of care in the United States. The positioning of the patient and robot, often make the airway inaccessible since the patient is in lateral position and the head may be turned 90-180 degrees away; making FOB challenging and awkward to perform.  Furthermore, following lateral repositioning or for evaluation of loss of lung isolation, the FOB is used to confirm and, if necessary, reacquire and maintain proper endobronchial tube placement. Unfortunately, many anesthesiologists lack the training and familiarity of tracheobronchial anatomy for adequate application of these techniques, leading to a high incidence (38%) of malposition. Technological advances in the miniaturization of video camera and light source offer a novel solution to the challenges faced by the anesthesiologist in these robotic cases.  Unlike the use of intermittent FOB visualization, the view provided by the VDLT allows for continuous real time visualization of the tracheal mucosa, primary carina, and proximal bronchial airways which facilitates rapid diagnosis and appropriate intervention; a critical factor in patients with low cardiopulmonary reserve in whom even transient disruption of ventilation may be detrimental. Using this novel solution, the anesthesiologist is able to forewarn the surgical team when the tube may become malpositioned and not rely necessarily on desaturation, changes in airway pressures, or surgeon noting lung inflation in the surgical field. That may offer another measure of patient safety as the continuous visualization of the airway can reduce complications from adverse airway events.
Although the VDLT can be used with or without the FOB, further study is warranted to evaluate issues such as cost and obstruction of camera lens by secretions.
Learning points: Continuous real time visualization via VDLT offers: rapid diagnosis and forewarning of malposition, verification of corrective maneuvers without requisite FOB use and enhances patient safety by potentially avoiding the harmful consequences of dislodgement.

Enhancing patient safety in robotic thoracic surgery with continuous real-time visualization via video double lumen tube