Robotic-Assisted Left Lower Lobectomy With Intrapericardial Pulmonary Vein Dissection and Division

Introduction

The standard of care for patients with advanced non-small cell lung cancer without mediastinal lymph node invasion is up-front surgical resection, if feasible (1). This can sometimes be difficult to achieve using a minimally invasive method due to tumor size, expected margins, invaded structures, and potential intraoperative injuries. Several authors have shown safety and feasibility of resection of locally advanced lung cancer using a robotic-assisted approach (2, 3). In this video, the authors present a case of a robotic-assisted left lower lobectomy with intrapericardial pulmonary vein dissection and division.

Case Description

The patient is a fifty-nine-year-old woman with a 17-pack-per-year smoking history who was found to have a 6 cm left lower lobe mass upon workup of left sided chest pain. She underwent an endobronchial ultrasound and biopsy, which was significant for a poorly differentiated non-small cell lung cancer favoring adenocarcinoma. Her lymph node levels 4L, 4R, and 7 did not have evidence of malignancy on cytology.

A CT scan of the chest showed a left lower lobe mass with adjacent atelectasis,  complete occlusion of the left lower lobe bronchus, and encasement of the inferior pulmonary vein. In addition, a single pulmonary vein trunk variant was identified. Similarly, a PET-CT scan showed a 9.3 x 5.5 cm mass with an SUV of 12.5 and no signs of distant metastasis. An MRI of the head was negative for metastatic disease as well. 

Set Up and Positioning

For this case, surgeons used the standard instruments used for robotic-assisted lobectomies at their institution: a zero-degree camera, tip up grasper, long bipolar, and force bipolar forceps. For the pericardial division and dissection, a vessel sealer was used.

The patient was positioned in right lateral decubitus and the camera port was placed at the level of the xyphoid process in the anterior axillary line. The surgeons then positioned a 12 mm trocar 8 cm anteriorly at the level of the lower edge of the major fissure, followed by a 12 mm port 8 cm posteriorly at the lower edge of the left lower lobe. Finally, a posterior 8 mm port was placed two rib spaces under the level of the major fissure, and an air seal port between ports one and two at the diaphragmatic insertion. The team generally starts the case with three cigars and an endoleader.

The initial set up includes a force bipolar on arm one, a long bipolar in arm three, and a tip-up grasper in arm four.

Procedure

After division of the inferior pulmonary ligament and harvest of level 9 lymph nodes, surgeons confirmed that the mass was encasing the left inferior pulmonary vein. At this point, the pericardium was opened, initially with the long bipolar grasper and then by the vessel sealer anterior to the phrenic neurovascular bundle.

The dissection was then continued posteriorly to identify the pulmonary vein using a mix of blunt and bipolar dissection. During this step, the bedside assistant kept the field clear of pericardial fluid with the robotic suction irrigator. The single pulmonary vein variant was visualized and the inferior branch was dissected first from the caudal edge using the long bipolar forceps. Next, the confluence of the superior and the inferior veins was dissected anteriorly to gain control of the inferior vein.

For the posterior intrapericardial dissection, surgeons switched to the suction irrigator in arm one and a tip up grasper in arm three. This allowed it to bluntly encircle the vein until the grasper was able to pass through without resistance. This also confirmed by passing an endoleader.

After the vein was fully dissected, the major fissure was opened using bipolar energy and the superior segment pulmonary artery was dissected, encircled with a vessel loop, and divided using a vascular staple load. Dissection was carried anteriorly to the basilar trunk and divided in a similar fashion. Next, the previously dissected left inferior pulmonary vein was divided with a vascular staple load.

Finally, the left lower lobe bronchus was dissected and divided using a green staple load. Some of the challenges in retracting the lower lobe, given the size of the mass, can be seen in the video, which is why the authors performed an anterior approach. After this step, the surgeons completed a mediastinal and hilar lymph node harvest, extracted the specimen and completed the procedure.

Outcomes

The patient was discharged on postoperative day four without complications. Final pathology showed a 5.5 cm poorly differentiated invasive adenocarcinoma with negative margins (T4N1b, stage IIIA). The patient underwent adjuvant chemotherapy with cisplatin, pemetrexed, and pembrolizumab. She had no evidence of local or distant recurrence six months after resection.

References

1. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Non-Small Cell Lung Cancer. Version 4.2024. https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf.
2. Zirafa CC, Romano G, Sicolo E, et al. Robotic versus Open Surgery in Locally Advanced Non-Small Cell Lung Cancer: Evaluation of Surgical and Oncological Outcomes. Curr Oncol. Oct 12 2023;30(10):9104-9115. doi:10.3390/curroncol30100658
3. Veronesi G, Park B, Cerfolio R, et al. Robotic resection of Stage III lung cancer: an international retrospective study. Eur J Cardiothorac Surg. Nov 01 2018;54(5):912-919. doi:10.1093/ejcts/ezy166

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