Robotic-Assisted Left Pneumonectomy

Introduction

Robotic anatomic pulmonary resection with the da Vinci robotic system (Intuitive Surgical, Mountain View, CA) for early-stage lung cancer is a safe and well-established procedure. The authors decided to explore the technical feasibility of a robotic major lung resection (pneumonectomy) for cancer. In this video, the authors report their first robotic assisted left pneumonectomy for non-small cell lung cancer. 

Case Video Summary 

A 53-year-old man was referred to the authors’ division for investigation of a left upper lobe lesion, discovered on chest roentgenogram. Chest computed tomography scan confirmed the presence of a 5 cm mass located in the hilar region of the left upper lobe, infiltrating the left pulmonary artery. Positron emission tomography scan was positive only in the pulmonary lesion, with no evidence of metastatic disease. Biopsies performed by flexible bronchoscopy showed large cell carcinoma. Patient was scheduled for robotic assisted left pneumonectomy.

Surgical Technique

The patient was intubated with a double-lumen endotracheal tube, placed in the right lateral decubitus position, and draped with the left arm down. The da Vinci system (4-arm robot) was draped and docked from the side of the patient’s head, with the center of the column at an approximately 45-degree angle with respect to the longitudinal axis of the patient. Three 1-cm port incisions were made: in the seventh intercostal space (for the camera, a 30-degree three-dimensional scope), in the eighth intercostal, and in the sixth intercostal space. A 4-cm minithoracotomy, without rib spreading, was performed in the fourth intercostal space, anteriorly.  Cadiere forceps, used to retract the lung and expose structures, were introduced by trocars positioned in the sixth intercostal space and in the minithoracotomy. A hook was introduced through the port positioned in the eighth intercostal space, and was used to isolate vascular structures and the bronchus. The pneumonectomy was started by isolating and resecting first the inferior pulmonary vein, followed by the superior vein, to facilitate the exposure and transection of the left pulmonary artery. All vessels were sectioned with Endo-GIA 30 Roticulating Staplers (Autosuture, Covidien, Dublin, Ireland). The main left bronchus was stapled with an Endo-GIA 45 Roticulating Stapler (Autosuture, Covidien). The vascular and bronchial transections were accomplished through the minithoracotomy, or through the port positioned in the eighth intercostal space. A standard mediastinal lymph-node dissection was performed. The left lung was extracted through the utility thoracotomy using an EndoCatch (Autosuture, Covidien).  The operative time was 192 minutes. Pathologic examination revealed a pT2N1 neoplasm. The patient’s postoperative course was uneventful, and he was discharged on postoperative day seven. He was well at the 48-month follow-up, with an excellent functional and aesthetic result. 

Initial Results

From June 2009 to September 2011 four patients underwent robotic-assisted pneumonectomy for non-small cell lung cancer. The authors performed three right pneumonectomies and one left pneumonectomy. One patient was initially treated with induction chemotherapy. The mean operative time was 235 minutes (range: 192 to 311 minutes). All patients were discharged after seven days with no post-operative complications. After a mean follow up of 48 months all patients are living (one patient alive with the disease). 

Comment

Robotic pneumonectomy is a feasible and safe procedure, and probably easier than robotic lobectomy due to the lack of fissures and small vessels. From an oncologic point of view, the completeness of resection is equivalent to that of an open procedure, with an associated radical lymph node dissection of stations 5, 6, 7, 8, and 9. Robotic pneumonectomy for localized lung cancer could be considered as an effective alternative to standard open procedures.

References

1. Spaggiari L, Galetta D. Pneumonectomy for lung cancer: a further step in minimally invasive surgery. Ann Thorac Surg. 2011;91(3):e45-7.
2. Spaggiari L, et al. Robotically assisted pneumonectomy for lung cancer. R.G.Inderbitzi et al. (eds), Minimally Invasive Thoracic and Cardiac Surgery Textbook and Atlas. Springer-Verlag, 2012: 161-174