[Abstract】：Objective To summarize the experience of diaphragmatic hernia repair via thorax using the da Vinci Surgical System. Methods Under adequate preoperative preparation, a patient with diaphragmatic hernia underwent transthoracic diaphragmatic hernia repair with the da Vinci Surgical System under general anesthesia via tracheal intubation, the hernia contents were returned, and the diaphragmatic defect was closed with silk sutures. The operation was completed successfully in 1 hour and 20 minutes, and there was no collateral damage to the lung, heart and thoracic aorta during the operation. The patient had no postoperative complications such as fever, pus and hemothorax, and was discharged on the 7th day after the operation. Conclusion After adequate preoperative preparation, the da Vinci Surgical System can successfully complete transthoracic diaphragmatic hernia repair surgery with minimal surgical trauma, rapid postoperative recovery, and high safety. Keywords: da Vinci Surgical System, diaphragmatic hernia, minimally invasive The birth of da Vinci Surgical Systems is another minimally invasive improvement in surgery after the lumpectomy system, and has been used in more and more surgical fields. We have recently completed a case of transthoracic diaphragmatic hernia repair performed under the da Vinci Surgical System, which is the first case in China and has not been reported in detail internationally. The patient was discharged from the hospital with abdominal pain, which was suddenly aggravated 5 years ago, and was admitted to the local hospital for transthoracic diaphragmatic hernia repair for more than 1 year. In the past 1 year, chest tightness often occurred, and a chest X-ray was taken in the outpatient clinic, and an occupancy was seen in the left chest. 1.2 Methods 1.2.1 Preoperative examinations were improved, especially imaging examinations, so that the morphology and location of the diaphragmatic hernia could be understood in detail based on imaging data. Figure 1: Chest X-ray showed that the mass was located at the bottom of the left thoracic cavity Figure 2: Chest CT showed that the left anterolateral chest was occupied Figure 3: Coronal CT scan showed the location of the diaphragmatic defect Figure 4: CTA of the upper abdomen: the left artery of the gastric omentum arced upward into the thoracic cavity. 1.2.2 The projection of the lesion was marked on the body surface preoperatively according to the imaging data. Figure 5: Diaphragm and mass projection marked on the body surface. 1.2.3 Determine the light source and arm position of the da Vinci robot according to the lesion site. Figure 6: The three operation holes shown in the picture, from left to right, are the robotic arm operation 1 hole (fifth intercostal space 2 cm medial to the anterior axillary line), the light source hole (fourth intercostal space in the mid-axillary line), and the robotic arm operation 2 hole (seventh intercostal space at the anterior border of the latissimus dorsi muscle). 1.2.4 Placement of the appropriate patient position to facilitate fixation of the flat carriage portion of the da Vinci Surgical System patient. According to the working principle of the da Vinci Surgical System and the lesion site, the patient was placed in the right lateral recumbent position, and the da Vinci robot system was introduced from the direction of the patient’s head, with its main axis at an angle of about 20 degrees to the long axis of the patient’s body. The da Vinci Surgical System was able to complete the diaphragm repair operation successfully. In 1 hour and 20 minutes, part of the greater omentum and fundus herniated into the thoracic cavity were completely returned into the abdominal cavity, and the defective diaphragm was sutured with a No. 7 silk thread through the da Vinci robot arm. No collateral injuries such as injury to the lung, heart and thoracic aorta occurred during the operation, and one closed chest drain was left in the seventh intercostal space in the mid-axillary line. The patient was discharged on the 7th postoperative day without complications such as fever, abscess chest, pneumothorax and hemothorax, and was followed up for 1 month without complications. The da Vinci Surgical Systems revolutionized surgery and opened a new chapter in minimally invasive surgery by combining high-definition 3D endoscopic technology, a flexible articulated instrument arm, and state-of-the-art robotics to substantially extend the surgeon’s eye and hand functions and provide unparalleled dexterity, accuracy, and maneuverability. accuracy and maneuverability. The system consists of three components: the surgeon’s console, the patient trolley and the camera system trolley. It has been progressively used in urology, obstetrics and gynecology, hepatobiliary surgery, and cardiac surgery [1]. The development of da Vinci surgical system in the field of thoracic surgery is emerging, and lobectomy, mediastinal mass resection and esophageal cancer resection have been reported abroad through the da Vinci system [2]. In China, due to the late introduction, few cases have been performed and clinical experience is lacking, and most of the applied cases are benign lesions. Adequate preoperative preparation and precise localization of the lesion site are prerequisites to be able to successfully complete da Vinci Surgical System-assisted surgery [2]. Most patients with diaphragmatic hernia are operated using the transabdominal route [3-4], whereas in this patient, a transthoracic route was chosen for the repair of the diaphragmatic hernia because of the previous transabdominal repair, considering the possibility of abdominal adhesions and operational difficulties. The chest X-ray, chest CT plain, and abdominal angiography completed before the operation provided a strong guarantee for precise localization with multiple means and directions to understand the site and size of the diaphragmatic defect and its relationship with the surrounding tissues and organs. Although the da Vinci Surgical System appears to be the same as the thoracoscopic system in that it operates through the chest wall by poking holes and inserting instruments, once the chest wall poke holes are identified and the robotic arm is inserted, it will be a tedious process to change the location of the poke holes again during the operation. In addition, although the operating end of the in vivo part of the da Vinci Surgical System is designed to imitate the human wrist joint and has flexible movements, the large robotic arm, to a certain extent, restricts the movement of its extracorporeal part. If the distance of the chest poke hole is designed too short or improperly operated intraoperatively, the extracorporeal part of the robotic arm may collide with each other, affecting the surgical process or making the operating end unable to reach the surgical target area. Through the application of this patient, combined with the design principles of the da Vinci Surgical System, we summarize the following five points of experience needed in the operation process: 1, the light source hole, the surgical target area and the main axis of the patient’s flat car part should be in a straight line to fundamentally ensure the best comfort of the robot’s operating posture. 2, the light source hole should be at least 20 cm from the surgical target area, not too long or too short, too long may lead to instruments 3.The layout of the light source hole and other operation holes should preferably be in a “C”-shaped arc distributed on the chest wall, or at least at an obtuse angle if space does not allow, so as to reduce the chance of mutual collision between the outer parts of the robot arm. 4.The straight-line distance between each The straight line distance between each poke hole should be at least 8cm, which is also aimed at reducing the occurrence of mutual collision of the extracorporeal part of the robotic arm.5. If it is difficult to operate the robot alone, the auxiliary hole can be made at the distal end of the light source hole or between each two poke holes as appropriate, and the auxiliary hole can be placed into the thoracoscopic instruments for auxiliary operation, especially when the suction operation is needed, the opening of the auxiliary hole is especially important. Of course, accurate positioning of the surgical target area is a prerequisite for the successful implementation of the above 5 points. In this case, due to the large amount of abdominal contents and the high pressure compared to the thoracic cavity, it was difficult to return the hernia contents into the abdominal cavity with the limited operating arm. Instead, we gave due consideration preoperatively by placing the patient in a head-high, foot-low position and giving an artificial pneumothorax with appropriate pressure. Once the hernia sac was completely free from the diaphragm, its contents were successfully returned. The da Vinci Surgical System has little experience in performing extra-thoracic surgery in China, and from this case, a comprehensive preoperative examination and a reasonable design of the chest wall poke are important prerequisites for successful transthoracic diaphragmatic hernia repair.