Robotic Total Lung Sparing Right Main Bronchus, Secondary Carinal Bronchial Sleeve Resection, and Bronchoplastic Reconstruction

It is always preferable to save as much lung parenchyma as possible during tracheobronchial surgeries, if possible, keeping in mind the importance of complete disease clearance (R0 resection) to avoid recurrences. Previously, pneumonectomies were performed in most cases with tumors in the main bronchus. Now whenever possible, lung sparing surgeries are the norm. With more advances in technology, robotic-assisted surgeries are being performed for more complex diseases as they have similar outcomes to VATS and robotic surgeries. The added benefits include less postoperative pain, faster recovery times, and shorter hospital stays.  

This video demonstrates a case of robotic total lung sparing RMB, secondary carinal sleeve resection, and bronchoplastic reconstruction for RMB carcinoid. A thirty-two-year woman, with no comorbidities visited the hospital with chief complaints of an intermittent cough with streaky hemoptysis for a year. She was evaluated with a CT chest scan, which showed an endobronchial mass in RMB almost completely occluding the lumen with some areas of patchy atelectasis in the right lung. A Dotanoc pet scan identified a suspected bronchial carcinoid and showed a 16 by 10-millimeter avid endobronchial mass without any mediastinal lymphadenopathy. Bronchoscopic images showed the mass in RMB, and the bronchoscopy guided tumor debulking was done. Post debulking, RUL and BI were found to be patent with some residual mass on the secondary carina. After seeing the patency of RUL bronchus and BI on bronchoscopy, the decision was made to move forward with a robotic total lung sparing surgery using four ports. The lung was retracted anteriorly with ProGrasp forceps, and the mediastinal pleura opened. The RMB, RUL and BI were meticulously dissected and looped. The RUL bronchus was opened distal to the tumor leaving adequate margins. Then, the RMB was opened leaving some healthy margins and transected under vision. Finally, the BI was divided. Secondary carinal reconstruction started by suturing the walls adjacent to the RUL bronchus and the BI using a 3-0 V-loc. V-loc is a dual angle, barbed, absorbable suture made of glycolide, diaxanone and trimethylene carbonate. It has a preformed loop, which assists in avoiding knots and is especially useful in minimally invasive surgeries. After secondary carinal reconstruction, it was sutured to the RMB. Suturing started at the membranocartilaginous junction and was more toward the cartilaginous side. Three sutures were used for the reconstruction: one for reconstruction of the secondary carina and two for suturing the secondary carina to RMB, one on each side and the sutures are tied. A saline test was done to check for any air leaks, and none were found. Suture postoperative CXR showed adequate lung expansion and the six months follow-up CXR showed patent RUL bronchus and BI with a normal distal tracheobronchial tree. 

References

1. Dell’Amore, A., Chen, L., Monaci, N., Campisi, A., Wang, Z., Mammana, M., Pangoni, A., Zhao, H., Schiavon, M., Yao, F., & Rea, F. (2020a, October 20). Total Lung-sparing Surgery for Tracheobronchial Low-grade Malignancies. The Annals of Thoracic Surgery . https://www.annalsthoracicsurgery.org/article/S0003-4975(20)31719-7/fulltext

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