This video demonstrates the case of a 51-year-old female patient with a history of smoking who presented with progressive dyspnea, hemoptysis, and status alteration. Computed tomography (CT) of the chest showed a proximal left endobronchial tumor with fissural invasion. Positron emission tomography-computed tomography (PET-CT) revealed a hypermetabolic mass with no evidence of other locations. A biopsy demonstrated carcinoma not otherwise specified (NOS).
The patient received four cycles of neoadjuvant chemoimmunotherapy. The proposed course of action was a left robot-assisted pneumonectomy, with surgical steps planned according to the “French lobectomy” technique (a new standardized five-zone lobectomy with structured assessment in robotic surgery). Although a sleeve resection had been discussed, the pneumonectomy was determined to be the preferred approach due to challenges related to the interlobar invasion.
The procedure began with the dissection of the pulmonary ligament, which corresponded to the first zone of the French lobectomy. Upward traction of the lung granted easier access to this area. Anterior traction of the lung allowed for access zone 2, as well as the dissection of the pulmonary vein and the subcarinal lymph node station number 7.
Lymph node station number 5 was excised in zone 3. The dissection of this lymph node, along with the presence of a single left pulmonary venous trunk—as seen on 3D reconstructions of the patient’s previous chest CTs—granted better access to the pulmonary artery in zone 4. The left pulmonary artery was carefully dissected, minding the recurrent laryngeal nerve, and was stapled using a vessel loop. To guarantee safe dissection and stapling of the venous trunk, the instruments were swapped, and the tip-up fenestrated grasper was used to grab the vessel loop.
The tissue around the hilum appeared very fibrotic. A posterior hilar lymphadenectomy of station 10 was performed in front of the aortic arch. The left vagus nerve was severed below the recurrent laryngeal, to access the lymph node beneath, which was categorized as belonging to the station 4L.
The main left bronchus was dissected, and with the help of a fabric vessel loop to allow for better traction, it was stapled as close as possible to the carina to decrease the risk of a bronchopleural fistula. A patch was used to reinforce and isolate the bronchial stem from the chest cavity, and a 21-French chest tube was inserted at the end of the procedure. The surgical specimen was extracted via thoracotomy using a plastic wound protector and rib retractors.
The postoperative chest X-Ray was satisfactory. The chest tube was removed on postoperative day two, and the patient was discharged on day five. The pathology report confirmed the diagnosis of carcinoma NOS. Histological analysis demonstrated a near-complete pathological response to neoadjuvant chemoimmunotherapy. No lymph node metastases were identified, and all resection margins were tumor-free.
References
- Mordojovich G, Hugen N, Bottet B, Montagne F, Bouabdallah I, Pagès PB, Sarsam M, Thomas PA, Baste JM. New standardized five-zone lobectomy with structured assessment in robotic surgery: the French lobectomy. J Thorac Dis. 2025 Apr 30;17(4):2718-2729. doi: 10.21037/jtd-24-1755. Epub 2025 Apr 23. PMID: 40400940; PMCID: PMC12090120.
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