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The patient was a 77-year-old male with a history of asthma, type 2 diabetes, and end-stage interstitial lung disease secondary to common variable immune deficiency. Despite escalating immunotherapies and steroids, his lung function continued to deteriorate, leading to his listing for bilateral lung transplantation. Preoperative imaging revealed extensive bilateral pulmonary fibrosis, ground-glass opacities, and bronchiectasis. Given the authors’ significant experience with this approach since pioneering it in October 2021, they intended to perform the operation robotically.  
 
A 6 cm right minithoracotomy was created in the third intercostal space, supplemented by three robotic ports in the second, fourth, and fifth spaces. Femoral veno-arterial extracorporeal membrane oxygenation was initiated in the usual manner, and the robot was docked. The right superior pulmonary vein, the right pulmonary artery branches, and the right inferior pulmonary vein were isolated and divided using a robotic vascular stapler. After removing the native right lung, the donor lung was introduced via a Keller funnel to minimize trauma. 
 
The bronchial anastomosis was constructed with a continuous 4-0 PDS suture. Next, the left atrium was clamped, and a cuff was fashioned for a continuous 4-0 GORE-TEX anastomosis in a vertical everting pattern. A vascular clamp was placed on the proximal pulmonary artery, and the pulmonary artery anastomosis was completed with a 5-0 Prolene suture in a continuous fashion. The donor lung was deaired and gradually reperfused, allowing a 15-minute interval of ventilation and bilateral perfusion at low pulmonary artery pressures. 
 
An 8 cm left thoracotomy was then performed, revealing extensive adhesions that necessitated continuing the transplantation under a direct minimally invasive approach. Postoperatively, the patient recovered well, no longer required supplemental oxygen or narcotic pain medication, and was discharged on postoperative day 11. 

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