12-Step Robotic Right Upper Lobectomy

This video shows a robotic right upper lobectomy in twelve steps with a focus on technique, technical pearls, and anatomy.

The patient is a sixty-four-year-old woman with a 10.5 pack-per-year smoking history. In 2017, she was found to have a 1.6 cm cystic lung nodule in the periphery of the right upper lobe (RUL). In 2021, on repeat CT, the lung nodule had enlarged to 2.3 cm with an increase in the solid component. She underwent a PET-CT scan, which demonstrated fluorodeoxyglucose (FDG) avidity of the nodule (SUV 5) and no evidence of metastatic disease.

Preoperative pulmonary function testing was significant for FEV1 of 93 percent and DLCO 96 percent. She was taken to the operating room for wedge resection, and if malignancy found, completion right upper lobectomy. Sublobar resection was not performed due to the nodule being greater than 2 cm and its proximity to visceral pleura with concern for invasion.

Ports and Instruments

The patient was positioned in a left lateral decubitus position. A camera port was placed at the midpoint of the chest in the eighth intercostal space. Next, the anterior port was placed in the seventh intercostal space, adjacent to, but not involving the diaphragm. The robot ports were placed in the middle of the intercostal space, airing inferiorly, with a balance between pressure on the inferior rib and potential injury to the intercostal artery of the superior rib. The most posterior port was an 8 mm port in the seventh intercostal space and was placed directly over the inferior rib because the rib spaces were narrow in this area, leading to increased risk of bleeding from an intercostal artery. The final port was placed between the posterior port and the camera port.

An assistant port was placed inferiorly and anteriorly, just above the diaphragm. The skin incision for this port was made lower than the intercostal space, so the port was inserted at a flat angle, facilitating easy and safe insertion of instruments by the assistant. A complete intercostal nerve block was performed with Experel. The procedure began with a tip up fenestrated grasper in arm one, Cadiere forceps in arm two, long bipolar forceps in arm four, and the camera in arm three.

Procedure

Step 1: Wedge Resection

Preoperative localization using a chest CT on the sagittal view, flipped horizontally to the right side with a lung window, allows for precise localization of the concerning nodule. The operation began with a wedge resection. Lung parenchyma became distorted when the staple line began, so the boundaries were marked prior to stapling, improving accuracy once stapling began. The wedge resection was then performed using a series of blue load staplers.

Step 2: Dissection of Inferior Pulmonary Ligament

Next, the specimen was delivered to pathology by the surgeon to ensure proper handling of the margin. The frozen section analysis returned consistent lung adenocarcinoma and the surgeons proceeded with a right upper lobectomy. This began with dissection of the inferior pulmonary ligament, which was facilitated by upward retraction on the lung. Full division of inferior pulmonary ligament allowed for complete upward expansion of the lung after lobectomy into the apical space. Level nine lymph nodes were dissected while taking the inferior pulmonary ligament. By dissecting directly on the lymph node, bronchial arteries were avoided rather than divided. The bipolar was set to eight, the highest setting, with auto-stop turned off. (Note: the surgeon has used these settings in over 160 lung resections, and there have been no instances of thermal injury to airway or surrounding structures.)

Step 3: Posterior Dissection

Dissection of the inferior pulmonary ligament continued until inferior pulmonary vein was visualized. Next, using two cigars, the right lower lobe was retracted anteriorly. The more posterior the location of the cigar, the better the retraction. The pleura was then divided along the lung. The dissection proceeded to visualize both cartilaginous tips of bronchus intermedius. Getting down to pericardium is ideal, as it is a bloodless plane and allows for complete lymphadenectomy. In this area, there was liberal usage of clips to prevent bronchial bleeding.

Step 4: Sump Node Dissection

Next, level seven lymph nodes were dissected. There are numerous branches off the aorta and esophagus that can be sources of bleeding during level seven lymph node dissection, and a clip applier allows for numerous clips to be applied at once. The right upper and lower lobes were retracted anteriorly to dissect out the sump node (11R), which is between the RUL bronchus and the bronchus intermedius. Removal of this node begins a plane on the RUL bronchus, often leads to visualization of the posterior ascending artery, and facilitates division of the major fissure later in the case.

Step 5: Suprahilar Dissection and 4R Dissection

The lung was then retracted inferiorly and attention was turned to the suprahilar area. The azygos vein was identified and dissected free, facilitating level 4R dissection. The mediastinal pleura was divided parallel to the superior vena cava (SVC) and parallel to the azygous vein, and the vagus nerve was preserved. Dissection inferior to the azygos vein allows for dissection right on to the truncus and facilitates 4R lymph node dissection. Again, clips were used liberally in this area to achieve adequate hemostasis. Thorough dissection at this point helps with the truncus dissection and division later in the operation.

Step 6: Anterior Dissection

The team then proceeded with the anterior dissection, taking care to avoid thermal injury to phrenic nerve, which can be seen quite clearly coursing over the pericardium to the right of the superior pulmonary vein. To get around major vessels, the lymph tissue was grasped in one hand and delivered up and away from the vessel while the opposite hand pushed the vessel down and in the opposite direction. Dissection then proceeded between the superior pulmonary vein and middle lobe vein. Dissecting right on to the vessel helps to avoid aberrant branches. Posterior to the superior pulmonary vein lies the first branch of the pulmonary artery.

Step 7: Fissure Dissection and Division

With the lymphadenectomy complete, the fissure dissection began. The RUL was retracted superiorly, and the interlobar pulmonary artery was identified. If it is not clearly seen, then an anterior to posterior approach is performed. In this patient, the interlobar artery was dissected. Before dividing either the horizontal or major fissure, pulmonary artery branches were identified, including the right middle lobe artery, basilar artery, super segmental artery, and the posterior ascending artery. To divide the horizontal fissure in the fissural view, the dissection must proceed superior to the right middle lobe artery. From an anterior view, the tunnel was made between the superior pulmonary vein and the middle pulmonary vein. With a tunnel created and both the right middle lobe artery and the right middle lobe vein inferior, the horizontal fissure could be divided safely. A 12 French red rubber catheter was cut to 6 cm to act as an endoleader that facilitated passage of a stapler through the tunnel. The accuracy of the tunnel was confirmed with the preservation of the right middle lobe (RML) vein visualized. The horizontal fissure was then stapled with a series of blue load staplers.

Next, another tunnel was completed in the major fissure, overlying the interlobar pulmonary artery and ending at the sump node. This tunnel is below the posterior ascending artery and above the superior segmental artery. Again, an endoleader was used to ensure safe handling of the stapler around vascular structures. The endoleader is cut to 8 cm if there is a large amount of lung to divide. A series of blue load staples were then used to divide the posterior aspect of the major fissure.

Step 8: Division of Superior Pulmonary Vein

Prior to clamping the stapler, the retraction of the lobe was removed to minimize any tension on the vein before stapling. The superior pulmonary vein was then divided with a white load stapler. During stapling, the instrument in the anterior port held a cigar, and was ready to hold pressure in case of bleeding. The superior pulmonary vein was divided through the posterior port.

Step 9: Truncus Division

The truncus was divided with a white load stapler through the anterior port.

Step 10: Division of Posterior Ascending Artery

The posterior ascending artery was then dissected free. Three clips were placed adjacent to the takeoff from the pulmonary artery, and one clip was placed on the specimen side. The artery was then divided using a vessel sealer. If the artery is slightly larger, a white load stapler can be used.

Step 11: Division of RUL Bronchus

Attention was then turned to the RUL bronchus. By taking the RUL bronchus in this orientation, the posterior tracheal membrane could be stapled to the cartilaginous rings. The RUL bronchus was then divided with a green load stapler. Green load cartridges are used for division of lobar bronchi, while this procedure required use of blue load cartridges for division of segmental bronchi. The RUL was removed with a large Endocatch bag through the anterior port, which was increased to 3 cm. Progel was administered, as is done with all lung resections to decrease the risk of postoperative air leak, and a 24 French chest tube was placed.

Step 12: Lung Pexy

If the remainder of the major fissure is complete, a pexy is required to prevent torsion. To do this, the right lung was inflated and the position was identified where the right middle lobe and right lower lobe were opposed. The pexy was performed using two blue load staplers and the operation concluded.

Patient Postoperative Course

Postoperatively, the patient recovered well. Her chest tube was removed on the first postoperative day (POD), per institutional ERAS protocol. She was discharged home on POD 2. Final pathology demonstrated poorly differentiated lung adenocarcinoma. Seventeen lymph nodes were sampled from six different stations, and all seventeen were negative for malignancy. Final pathologic stage was pT2a, N0, M0 due to visceral pleural invasion, consistent with stage IB lung adenocarcinoma. Adjuvant chemotherapy was discussed with the patient by an oncologist, and the patient ultimately did not receive adjuvant chemotherapy. She continues to follow up with thoracic surgery for surveillance CT scans.

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