Robotic Left Upper Lobectomy with Aberrant Lingular Bronchus and Mediastinal Lingular Artery

This article details the step-by-step procedure for a robot-assisted left upper lobectomy and mediastinal lymphadenectomy in a sixty-two-year-old male.

Background 

The patient had a past medical history of significant tobacco use of ten to fifteen packs a year, and coronary artery disease complicated by STEMI, status post drug-eluting stent x3 with preserved ejection fraction, and Factor V Leiden with acute onset left-sided chest pain. Workup included a chest CTA, which noted an incidentally discovered 1.6cm left upper lobe solid pulmonary nodule in the posterior apical segment. An outpatient follow-up with pulmonary medicine was arranged, and a PET scan showed a 2.5cm nodule in the left upper lobe with increased FDG avidity and a standardized uptake value of 3.76. There was no evidence of hilar/mediastinal FDG avidity and no metastatic disease. The CT-guided biopsy was found to be positive for adenocarcinoma. An endobronchial ultrasound was performed to complete mediastinal staging and was negative for malignancy.  

Procedure Setup 

The patient was positioned in a right lateral decubitus position. An 8mm incision was made for the camera port in the seventh intercostal space and a 30-degree camera was used. Another 8mm incision was then made posteriorly two intercostal spaces below the major fissure. A 12mm port was placed between the camera and posterior ports. A 12mm port was then placed anteriorly in the eighth intercostal space, in line with the major fissure, similar to the anterior port placement for VATS procedures. It is important that the ports are inserted in the middle of the intercostal space to minimize bleeding of the intercostal artery and avoid excessive traction on the rib. This is achieved using a finder needle. An assistant port was then placed inferiorly and posteriorly in the tenth intercostal space just above the diaphragm. The skin incision for this port was made lower than the intercostal space so that the port would be inserted at a flat angle. This facilitates easy and safe insertion of instruments. Next, a complete intercostal nerve block was performed with Experel. The robot-assisted portion of the operation was now ready to begin. 

Robot-Assisted Procedure 

Step 1: Dissection of the inferior pulmonary ligament 

The operation begins with division of the inferior pulmonary ligament. Then, retraction of the left lower lobe is performed with a tip-up fenestrated grasper in the posterior port, which grasps a cigar and retracts superiorly. The left hand (arm 1) is a cadiere forceps, and the right hand is a long bipolar grasper. Then, a level 9 lymph node is dissected and removed. 

Step 2: Anteromedial dissection 

The dissection of the inferior pulmonary ligament is continued in an anterior and medial direction. This facilitates later identification of the space between the lingular vein and the inferior pulmonary vein. This sets up the ultimate fissural division later in the case. The dissection here proceeds close to the lung. 

Step 3: Posterior dissection 

The lung is then retracted anteriorly, and the remainder of the inferior pulmonary ligament is divided. Dissection down to the pericardium here facilitates identification of the most proximal aspect of the vein and leads to level 7 lymph nodes. The esophagus and aorta are located screen right. Using the bipolar directly on the lymph nodes allows for the removal of lymph nodes with minimal bleeding. Clips are sometimes needed for sizeable bronchial arteries. 

Step 4: Suprahilar dissection 

The left upper lobe is then retracted inferiorly to dissect the superior hilum. The vagus and phrenic nerves are identified, and the left recurrent laryngeal nerve is noted. Dissection is then carried out around the left main pulmonary artery, while being careful to avoid the surrounding phrenic, vagus, and recurrent laryngeal nerves. A plane directly on the pulmonary artery helps identify lymph nodes and later facilitates safe identification of pulmonary artery branches. 

Step 5: Medial dissection 

The left upper lobe is retracted posteriorly, and the phrenic nerve is identified. Then, dissection proceeds down to the superior pulmonary vein, and a plane directly on the vein is identified. Next, hemostasis is achieved with the bipolar, and the inferior aspect of the vein is dissected now for later division. 

Step 6: Fissural dissection 

In this patient, the interlobar artery is clearly seen within the fissure. Dissection proceeds to the plane of Leriche on the pulmonary artery. After this, a tunnel is made that exits posteriorly and a 12 FR red rubber catheter is used as an endoleader for safe division of the major fissure with a 45mm blue load stapler. The stapler is brought through arm 1 through a 12mm port, which is placed at the beginning of the case in line with the fissure. This allows for minimal articulation of the stapler while using it. 

Step 7: Posterior apical artery 

The dissection in the fissure continues along the pulmonary artery and extends superiorly. Here, a sizeable pulmonary artery branch is identified and dissected. The long bipolar is excellent at fine dissection and hemostasis. The cadiere forceps, as well as the tip-up fenestrated instruments in some circumstances, are blunt and offer a safe option for dissecting around pulmonary artery branches. This is the posterior apical artery. An endoleader is passed, and the branch is divided with a vascular load stapler. Care is taken to minimize any tension on the artery before closing the stapler and prior to firing. Further division of the major fissure is performed with two blue load staplers. Retraction here demonstrates the space between the lingular vein and the inferior pulmonary vein. 

Step 8: Aberrant Lingular Structure 

The left upper lobe is the retracted posteriorly, and the left upper division vein and lingular vein are identified. Posterior to the lingular vein is the lingular bronchus, which is aberrantly coming off the lower lobe bronchus (1). The fissure is reevaluated to try to make sense of the anatomy. Exposure of the lingular bronchus clearly confirms it goes to the upper lobe. Therefore, it is isolated, dissected, and divided with a 45mm green load stapler via the posterior 12mm port. Posterior to the bronchus was a mediastinal lingular artery, which was isolated and divided with a vascular load stapler via the 12mm posterior port with the aid of an endoleader (2). Next, the lingular vein was isolated and divided in a similar fashion. At this time, the major fissure was completed with a final fire of the blue load stapler. 

Step 9: Remaining LUL Structures 

The left upper lobe is retracted superiorly, and a level 10 lymph node is removed. Hilar lymph node dissection is necessary for adequate lung cancer staging. It also aids in the identification of major structures. The posterior apical bronchus is divided with a green load stapler. Then, the upper division vein is dissected and divided with a white load stapler. Next, the tip-up fenestrated is used to safely get around the vessel. The left upper lobe is then retracted inferiorly, and an apical segmental branch is isolated and divided. Further retraction is performed that exposes an anterior segmental branch, which is divided. Finally, the remaining structure is an anterior apical bronchus, which is divided. The specimen is removed with a 15mm Endo Catch bag, which is inserted through the assistant port. Hemostasis is achieved, and a chest tube is placed. 

Conclusion 

Postoperatively, the patient was able to achieve adequate pain control with oral medications and tolerate a regular diet. On postoperative day 1 (POD1), supplemental oxygen was weaned off, IV fluids were discontinued, and patient instructions and educational materials were reviewed. Also, on POD1, both the chest tube and Foley catheter were removed and the patient was discharged home. 

The final intraoperative pathology was consistent with stage IA2 lung adenocarcinoma, T1b, N0, Mx. Resection margins were negative for adenocarcinoma and 0/9 lymph nodes harvested were involved. The patient was readmitted on POD7 for acute left lower extremity deep vein thrombosis consistent with phlegmasia cerulea dolens, which required admission, operative embolectomy, thrombolysis, balloon angioplasty, and therapeutic anticoagulation. The patient was discharged home on POD9 with a treatment plan involving Xarelto (rivaroxaban). Finally, there was a telehealth follow-up visit on POD17 with plans for a surveillance chest CT in six months. 

References

1. Gossot D, Seguin-Givelet A. Anatomical variations and pitfalls to know during thoracoscopic segmentectomies. J Thorac Dis. 2018;10(Suppl 10):S1134-S1144. doi:10.21037/jtd.2017.11.87
2. Subotich D, Mandarich D, Milisavljevich M, Filipovich B, Nikolich V. Variations of pulmonary vessels: some practical implications for lung resections. Clin Anat. 2009;22(6):698-705. doi:10.1002/ca.20834

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