Robotic Anatomic Segmentectomy

Robotic anatomic lung segmentectomy is a feasible and safe procedure. In patients with metastatic cancer to the lung who are eligible for surgery, anatomic segmentectomy may be beneficial as a way of optimizing future resection. In such cases, hilar node dissection often uncovers occult nodal involvement when the metastases are centrally located. In this video, the authors present a surgical technique for a robot-assisted left lower lobe superior segmentectomy performed with the DaVinci Xi.

Case Summary

A 70-year-old man was admitted with a diagnosis of a single lung metastasis, with a previous history of colon carcinoma, located in the left lower lobe superior segment. The patient was scheduled for anatomic segmentectomy (segment 6).

Patient Positioning

The patient was placed in the right lateral decubitus position. Single-lung ventilation was achieved by the use of a double-lumen endotracheal tube. The robot is usually placed at the head of the patient.

Port Placement

The operation begins by making a 3.5 – 4 cm utility incision anteriorly in the fourth or fifth intercostal space. The camera (30° stereoscopic instrument) is inserted to explore the thoracic cavity and to provide visual guidance to perform three more 8 mm incisions. The first (camera) port is made in the 7th intercostal space in the mid-axillary line (for left procedure the camera port is placed in a more lateral position, compared to the right approach, to keep the heart out of the way). The next 8 mm incision is made in the 8th intercostal space in the posterior axillary line. The fourth incision is performed posteriorly in the auscultatory triangle, allowing lung retraction and better exposure.

Surgical Procedure

The pulmonary ligament is divided up to the pulmonary vein. Distal dissection of the vein posteriorly exposes the superior segmental vein, which is ligated with the endovascular stapler. The lower lobe superior segmental artery is then identified in the fissure and stapled or clipped. The bronchus is finally isolated with the lung retracted anteriorly. The last step is transection of the parenchyma, with the stapler introduced through the utility incision or the port placed anteriorly. The authors routinely perform a hilar lymph node dissection (stations L12, L11, L10). The patient recovered well and was discharged in third post-operative day. The final pathological histology confirmed metastatic lesion from the previous colon cancer.

The Xi architecture allows placement of the telescope in any of the four robotic arms. Switching the camera to a different port can improve the view of the lung hilum. For lower lobe superior segmentectomy, the camera is moved from the anterior to the posterior port to facilitate dissection of the vein and bronchus.