Robotic Right Upper Lobe Sleeve Lobectomy

Clinical Summary

A 52-year-old male light smoker was under regular annual checks following a previous ocular melanoma, which was treated in 2013 with brachytherapy. During one of the follow-up visits, a lesion was found in the upper right lobe (RUL), close to the right main bronchus without hilar or mediastinal adenopathy. Flexible bronchoscopy showed, in the right-side airways, a tumor occluding almost the entire right upper bronchus and involving the proximal main bronchus. A biopsy confirmed a typical carcinoid tumor, and the patient was scheduled to undergo a robotic upper lobe sleeve-lobectomy (daVinci Surgical System, Intuitive Surgical, Mountain View, CA, USA). 

Surgical Technique

Under general anesthesia, the patient was positioned into a left lateral decubitus position. The port-mapping implied 4 ports: an 8 mm camera port in the sixth intercostal space below the scapula tip; two ports at the sixth intercostal space posteriorly, following the same space with a distance between them of about 5 cm; and a final port placed anteriorly at the 6th intercostal space, just above the diaphragm. The camera was maintained in the same position for the entire procedure. The first step was to open the mediastinal pleura below the azygos vein to identify the tumor arising from the right upper bronchus. This was followed by the exposure of the Boyden branch and the upper vein. All lobar vessels were individually dissected and encircled with a vessel loop. To complete the posterior fissure and all the vessel transections, a 45 mm robotic stapler (Intuitive Surgical, Mountain View, CA, USA) was used. At this point, a 45 mm endostapler (Covidien Endo GIA™) was used to complete the fissures.

The right main bronchus and the upper lobe bronchus were dissected and cleared using the robotic scissors. The bronchial resection started from the anterior wall of the right main bronchus. Once the tumor was visualized, the resection was extended to the intermediate bronchus under bronchoscopic control. The specimen was removed and the inferior pulmonary ligament was released to allow a decrease in tension on the anastomosis. The anastomosis was performed through two running V-lock™ (Covidien) sutures using a 3-0 nonabsorbable autolocking suture. The suture was started from the caudal corner of the pars cartilaginea to the pars membranacea, toward the anterior bronchial wall. The tension of the suture was assessed at each step. The continuity of the suture was guaranteed by tying the two sutures through a double knot. The pars membranacea was left as a final step. Once concluded, the integrity of the anastomosis was checked endoscopically and through irrigation. A single 24 Fr chest tube was placed through the camera port. The patient had an uneventful clinical course and was discharged on the fifth postoperative day. Pathological analysis confirmed typical carcinoid with bronchial involvement, with no bronchial margins and no lymph node malignancy. The follow-up through bronchoscopy showed a good caliber anastomosis [1-2].

References

1) Schmid T, Augustin F, Kainz G, Pratschke J, Bodner J. Hybrid video-assisted thoracic surgery-robotic minimally invasive right upper lobe sleeve lobectomy. Ann Thorac Surg. 2011;91(6): 1961-1965.
2) Cerfolio RJ. Robotic sleeve lobectomy: technical details and early results. J Thorac Dis. 2016;8(suppl 2): S223-S226.