Robotic-Assisted Middle Lobe Sleeve Lobectomy for Carcinoid Tumor

The Patient

A forty-year-old woman was referred to the institution after incidental finding of a carcinoid tumor of the middle lobe bronchus. The patient was formerly planned for elective breast surgery for cancer.

The diagnosis was obtained during the standard preoperative workup. A CT scan showed a solid, round-shaped 3 cm lesion of the medium lobe hilum associated with distal parenchymal dystelectasis. A PET scan revealed an increased FDG uptake of the lesion.

Preoperative bronchoscopy confirmed the involvement of the insertion of middle lobe bronchus. Furthermore, a transbronchial needle aspiration biopsy documented a highly differenced neuroendocrine tumor. Pulmonary functionality was normal and no anesthesia contraindication emerged. Consequently, lobar resection with bronchoplasty was planned.

The Surgery

First, the patient was placed under general anesthesia with single lung ventilation. The patient was then placed in left lateral decubitus with her arms flexed towards her head and the surgical table placed in a wedge-shaped position to obtain maximum separation of the intercostal spaces.

Surgeons used a four-port approach with a utility incision. An 8 mm camera port was placed in the eighth intercostal space (ICS) at the posterior axillary line, and the next two 8 mm ports were placed in the seventh ICS posteriorly and in the auscultatory triangle. A final 3 cm utility incision was then realized at the fifth ICS anterior axillary line with a soft tissue retractor.

The team then inspected and confirmed the absence of pleural metastasis. The lung was retracted posteriorly, and the mediastinal pleura was opened widely along the anterior hilum and superior pulmonary vein and continued upward around the pulmonary artery, extending the dissection posteriorly. Two veins of the middle lobe were encircled with a vessel loop and divided with a 35 mm vascular stapler. The anterior fissure was then divided with a 60 mm parenchyma Endostapler. Two arteries for the middle lobe were encircled with a vessel loop and divided with a 35 mm vascular Endostapler. Division with the upper lobe was obtained by stapling the fissure with a 60mm parenchyma Endostapler. 

After wrapping the artery with a laminar drainage, the insertion of middle lobe bronchus was exposed and cut both proximally and distally using monopolar robotic scissors. The specimen was then removed through the utility incision into an Endobag. The bronchial stump was evaluated by frozen section to be pathologically free of neoplasm. Bronchial end-to-end anastomosis was performed using two running PDS Stratafix 3-0 Spiral Knotless sutures, starting from the caudal corner of the pars membranacea and progressing on the cartilaginous portion. Both sutures were then tied with a double knot.

The postoperative course was substantially uneventful. Bronchoscopy confirmed regular healing of the bronchial suture on the sixth postoperative day, and the patient was discharged the same day.

The final pathologic report confirmed atypical carcinoid pT1bN2MO, PLO with 3 mytosis/2 mm2, no evidence of necrosis, and Ki67 20 percent. At station 10 there were two positive lymph nodes out of eight, station 7 had two positive lymph nodes out of five, and stations 12, 11, 4R, and 2R were negative.

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