Robotic-Assisted Right Upper Sleeve Lobectomy

A seventy-five-year-old man, also a heavy smoker, was admitted with an incidental finding of a lesion in the right upper lobe (RUL) near the right main bronchus. A PET scan revealed a slight hypermetabolic lesion (SUV max of 5) close to the origin of the right upper bronchus. No previous medical history was referred; physical examination, pulmonary function, and laboratory data were normal.

A bronchoscopy showed an enlarged bronchial carina between the anterior segmental bronchus and the posterior segmental bronchus, with a hyperemia and irregularity of the mucosa. A squamous cell carcinoma of the lung was confirmed by endoscopic biopsy and surgical treatment was planned.

In this video, a step-by-step explanation of a robotic assisted sleeve lobectomy for the treatment of a non-small cell lung cancer (NSCLC) in the right upper lobe is described.

Surgical Technique
The operation was performed under general anesthesia with single lung ventilation. The patient was placed in left lateral decubitus position with arms flexed toward the head and the surgical table was flexed in wedge-shaped position to obtain maximum separation of the intercostal spaces. A four-port approach with a utility incision was used for this procedure: an 8 mm camera port was placed in the eighth intercostal space (ICS) at the posterior axillary line, the next two 8 mm ports were placed in the seventh ICS posteriorly and in the auscultatory triangle, and a final 3 cm utility incision was realized at the fifth ICS anterior axillary line with a soft tissue retractor.

After inspection of the pleural surface to confirm the absence of metastasis, the lung was retracted posteriorly and mediastinal pleura was opened widely along the anterior hilum, superior pulmonary vein, and continued upward around the pulmonary artery, extending the dissection posteriorly. The superior pulmonary vein, excluding the middle lobe vein, was encircled with a vessel loop and divided with a 35 mm vascular stapler. The next step was the identification and division of the truncus anterior and ascending branch.

The removal of interlobar lymphatic tissue helped in the identification of the saddle between the upper lobe and intermedius bronchus. The interlobar artery was reached via the fissure using a combination of bipolar energy and blunt dissection.

Completion of the anterior and posterior part of the fissure was performed using a 60 mm endostapler.

The division of the pulmonary ligament, as well as the subcarinal lymph node dissection before the bronchial sleeve procedure, helped to facilitate the lung mobility and to avoid traction on, or manipulation of, the anastomosis.

The lobe was then pulled anteriorly and upward, thus exposing the upper lobe bronchus that arose vertically. Next, the bronchus was cut using monopolar robotic scissors, starting from the anterior wall of the right main bronchus. The section of the airway was then extended to the intermediate bronchus. Finally, the specimen was removed through the utility incision into an endobag.

After the bronchial stump was evaluated by frozen section to be pathologically free of neoplasm, an end-to-end anastomosis could be carried out.

Bronchial anastomosis was performed using two running sutures with PDS Stratafix 3-0 Spiral Knotless starting from the caudal corner of the pars membranacea and progressing on the cartilaginous portion. Both sutures were then tied through a double knot.
The postoperative course was uneventful and the patient was discharged on the sixth postoperative day.

The histological confirmed squamous cell carcinoma of the lung, and the final stage was pT2aN0 (PL0) (sec. AJCC 8th).

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.