Robotic Left S10 Anatomic Resection with 3D Perioperative Planning

A sixty-year-old woman underwent a chest computerized tomography (CT) scan during the timeframe of a flu frame and a suspected COVID-19 infection. From the CT scan, a pulmonary nodule in the left lower lobe was identified. Following resolution of the infection, the patient repeated a new CT within a three-month time interval. The patient displayed a 1.5 cm solid pulmonary nodule with spiculated margins in a peripheral position of the left lower lobe posterior segment. Other small pure ground-glass pulmonary subcentimetric nodules (pGGN) were observed in the contralateral lung.

Investigation continued with a transthoracic biopsy, and the results led to the diagnosis of lung adenocarcinoma. Next, staging was complemented with positron emission tomography (PET-CT). The imaging displayed exclusive uptake in the pulmonary nodule, with an SUV of 2.8. With no history of smoking and the sole comorbidity of controlled hypertension, the patient’s surgical risk was low. Furthermore, readings for the patient’s respiratory function were adequate for lung resection: FEV1 2.7 L (98%), FVC 3.3 L (94%), and DLCO (96%).

In view of the characteristics of the nodule and the possibility of multicentric disease associated with a mutational state, a sublobar anatomical resection of the posterior segment of the left lower lobe (S10) was proposed. The 3D surgical planning was routinely performed through the reconstruction of tomographic images with 3D Slicer software (1). Robotic access with the da Vinci Xi platform was used with the four-arm technique. Specifically, portals were performed in the eighth intercostal space for arm two (Cadiere forceps), arm three (0° optics) and arm four (bipolar Maryland forceps). Arm one (tip-up forceps) was located in a medial position one space above (seventh intercostal space). This was done to provide more working space for the assistant operating the instruments through an access in the tenth intercostal space with a 1.5 cm trocar.

The procedure was uneventful. There was no quantifiable bleeding, and the total console time allotted to 126 minutes. The patient was extubated in the operating room and sent to the ward with a 24 French chest tube. Afterward, the tube was removed on the first postoperative day. The patient was then discharged on the second postoperative day, having undergone a good recuperation.

Closing Remarks

Anatomical resection of S10 is considered a complex resection. The use of the robotic platform allows for a more precise dissection in smaller and more delicate sublobar hilar structures. Surgical planning and the use of in-room 3D reconstruction allows for accurate identification of target structures. The sum of these technologies is critical for obtaining consistent results within the context of complex sublobar resections.

References

1. Fedorov A., Beichel R., Kalpathy-Cramer J., Finet J., Fillion-Robin J-C., Pujol S., Bauer C., Jennings D., Fennessy F., Sonka M., Buatti J., Aylward S.R., Miller J.V., Pieper S., Kikinis R. 3D Slicer as an Image Computing Platform for the Quantitative Imaging Network. Magnetic Resonance Imaging. 2012 Nov;30(9):1323-41. PMID: 22770690.
2. Terra RM, Lauricella LL, Haddad R, de-Campos JRM, Nabuco-de-Araujo PHX, Lima CET, Santos FCBD, Pego-Fernandes PM. Robotic anatomic pulmonary segmentectomy: technical approach and outcomes. Rev Col Bras Cir. 2019 Sep 30;46(4):e20192210. Portuguese, English. doi: 10.1590/0100-6991e-20192210. PMID: 31576987.

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