RATS Bilateral Lobectomy and Tangential Resection of Left Main Pulmonary Artery

Recently, a subxiphoid approach has become popular in thoracic surgery because it provides more freedom of movement, as there is no limitation by the ribs, and it avoids trauma to the intercostal nerves, thereby creating less postoperative pain.

Although subxiphoid video-assisted bilateral anatomic resections have been successfully performed, to the authors’ knowledge, robotic-assisted thoracoscopic bilateral anatomic resections have not been reported (1, 2). This video presents a case of bilateral synchronous non-small cell lung cancer successfully treated via subxiphoid incision for assistance, stapling, to retrieve the specimen, and for chest tube insertion.

The patient is a forty-seven-year-old male. He was diagnosed with two FDG avid nodules in the left upper and right middle lobe after undergoing a PET/CT scan. The left upper lobe nodule was diagnosed as adenocarcinoma with fiberoptic bronchoscopy, and the right middle lobe nodule was diagnosed as squamous cell lung cancer using a transthoracic fine needle aspiration biopsy. The cranial MRI was free of metastatic lesions. 

First, the surgical team performed a mediastinoscopy for staging and frozen section. No metastasis was found at the mediastinal lymph nodes. The patient was then positioned in the left lateral decubitus position and three ports were placed in the right hemithorax, with a subxiphoid port for assistance. 

After the right middle lobectomy, surgeons opened three ports in the left hemithorax for the arms of the robot. Then the left upper lobectomy with mediastinal lymph node dissection was performed. Because of a lymph node stuck to the first branch of left main pulmonary artery, a tangential resection was done. The chest tubes were then taken out from the subxiphoid area. 
After an uneventful postoperative period, the patient was discharged on postoperative day four.
 

References

1. Uniportal subxiphoid video-assisted thoracoscopic bilateral segmentectomy for synchronous bilateral lung adenocarcinomas. G. Aresu, J Vis Surg 2016 Nov 30;2 170
2. Subxiphoid uniportal video-assisted thoracoscopic surgery for synchronous bilateral lung resection. Yang X., Wang L. Postgraduate Medicine. 2018. 130(1), pp. 142-145

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