Robotic Sleeve Resection of a Bronchus Intermedius Tumor

In this video, the authors present a parenchymal sparing robotic sleeve resection of a bronchial carcinoid tumor. Carcinoid tumors are low grade neuroendocrine neoplasms that comprise 0.5-5% of resected lung tumors and 20-30% of all carcinoid tumors. They often involve the main or lobar bronchi and frequently occur in young, otherwise healthy patients. As established by Hermes Grillo and colleagues, bronchial carcinoid can often extend full thickness through the bronchial wall, and thus the only way to ensure a complete R0 resection in patients with these tumors is to perform a full thickness bronchial resection. It is for this reason that this technique of completely parenchymal sparing bronchial sleeve resection is so important, because it can facilitate an R0 resection without any compromise in postoperative lung function. This patient was a 29-year-old woman with progressive shortness of breath, dyspnea on exertion, and trace hemoptysis. She had no significant medical or surgical history. She never smoked and denied unusual environments exposures. She underwent a CT scan of the chest, which showed an endobronchial mass causing near complete obstruction of the proximal bronchus intermedius with associated postobstructive atelectasis.

The patient was taken for bronchoscopy to obtain biopsies, allow tumor debulking for symptomatic relief, and to define the required extent of resection. The tumor was pedunculated with the stalk attached to the lateral wall of the bronchus intermedius just distal to the right secondary carina. The tumor was resected with an endobronchial snare cautery. Final pathology showed a well differentiated typical carcinoid tumor with a maximum diameter of 1.1 cm. Approximately four weeks later, she was brought to the OR for a parenchymal sparing robotic sleeve resection of the bronchus intermedius. The authors describe the key portions of the procedure in a stepwise fashion. Important to note is the degree of mobilization of the bronchus intermedius that was achieved, which was key in facilitating a tension-free bronchial anastomosis. The anastomosis was performed with two 4-0 barbed unidirectional absorbable sutures, running in opposite directions from deep to superficial and subsequently overlapping to ensure a secure closure. A chest tube was then placed, and the right lung was then gently re-inflated. All lobes completely re-expanded prior to removal of the robotic camera. Recovery room chest X-ray confirmed complete re-expansion of the right lung and no air leak. Her postoperative course was uncomplicated. Her chest tube was removed on postoperative day two, and she was discharged home the following day. Outpatient flexible bronchoscopy one week later demonstrated the anastomosis was widely patent with minimal inflammation or granulation tissue formation. Final pathologic stage was pT2a N0 M0, stage 1b.

References

1. Aigner C, Jaksch P, Seebacher G, Neuhauser P, Marta G, Wisser W, et al. Single running suture – the new standard technique for bronchial anastomoses in lung transplantation. Eur J Cardiothorac Surg. 2003 Apr;23(4):488-493.
2. Maurizi G, Ibrahim M, Andretti C, D’Anrilli A, Ciccone AM, Pomes LM, et al. Long-term results after resection of bronchial carcinoid tumor: evaluation of survival and prognostic factors. Interact Cardiovasc Thorac Surg. 2014 Aug;19(2):239-244.
3. Frist W, Mathisen D, Hilgenberg A, Grillo H, Bronchial sleeve resection with and without pulmonary resection. J Thorac Cardiovasc Surg. 1987 Mar;93(3):350-357.
4. Bueno R, Wain J, Wright C, Moncure AC, Grillo HC, Mathisen DJl. Bronchoplasty in the management of low-grade airway neoplasms and benign bronchial stenoses. Ann Thorac Surg. 1996 Sep;62(3):824-828.

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