RATS Extended Left Upper Lobectomy With Intrapericardial Vascular Control and Bronchoplasty

In this video, the authors present the case of a 65-year-old female diagnosed with a central squamous cell carcinoma of the left upper lobe with nodal involvement in stations 5 and 6, initially detected during the evaluation of a persistent cough.

Computed tomography revealed a 57 mm centrally located mass in the left upper lobe with involvement of the segmental arteries. Following induction chemoimmunotherapy, significant tumor regression was observed, and the patient was deemed a suitable candidate for surgical resection.  

Pulmonary function testing indicated that pneumonectomy would have been feasible; however, the primary intention was to perform a robotic-assisted left upper lobectomy. The case was discussed in a multidisciplinary tumor board. 

The surgical approach consisted of four robotic 8 mm ports placed in the sixth, eighth, and 10th intercostal spaces, along with a 12 mm subcostal assistant port aligned with the eighth intercostal space. 

Robotic-assisted resections have been shown to be safe, with lower conversion rates to thoracotomy and higher lymph node yields compared to video-assisted thoracoscopic surgery (VATS) in the setting of anatomical resections following neoadjuvant treatment. In addition, perioperative outcomes such as blood loss, operative time, duration of air leak, and chest tube duration tend to favor the robotic approach. 

This video demonstrates how a complex resection can be successfully accomplished using a minimally invasive approach while adhering to the fundamental surgical principles of open surgery. It further highlights the importance of systematic and thorough lymphadenectomy, not only for oncological radicality but also for the identification of key anatomical landmarks. Subcostal access provided excellent exposure and enabled the safe retrieval of a large specimen while minimizing trauma to the intercostal spaces. At the time of publication, histopathological results were still pending, and the patient was recovering uneventfully. 

This video is the winner of the 2026 CTSNet Instructional Video Competition. Stay tuned to CTSNet.org and the CTSNet YouTube channel in the coming weeks to watch all entries from the competition, including the second and third place winners. Additionally, watch the interview featuring Dr. Luis Filipe Azenha with CTSNet Editor-in-Chief Joel Dunning. 

References

1. Zeng J, Yi B, Chang R, Chen Y, Yu Z, Gao Y. Safety and feasibility of robotic-assisted thoracic surgery after neoadjuvant chemoimmunotherapy in non-small cell lung cancer. Front Oncol. 2023;13:1134713. Published 2023 Feb 23. doi:10.3389/fonc.2023.1134713
2. Li X, Li Q, Zhao E, et al. Perioperative Outcomes of Robotic- vs Video-Assisted Thoracoscopic Surgery in Non-Small Cell Lung Cancer After Neoadjuvant Therapy. Ann Thorac Surg. Published online December 26, 2025. doi:10.1016/j.athoracsur.2025.12.003
3. Li HJ, Ding JY, Nie Q, et al. Advantages of robotic-assisted thoracic surgery after neoadjuvant therapy in NSCLC: A propensity score-matched analysis. Eur J Surg Oncol. 2025;51(8):110022. doi:10.1016/j.ejso.2025.110022

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