Robotic Assisted Lung Sparing Resection of the Left Mainstem Bronchus

Lung sparing bronchial sleeve resection was first described by Paulson and Shaw in 1955 (1). Resection of the left mainstem bronchus (LMSB) is challenging due to its location adjacent to the aortic arch and left main pulmonary artery. The surgical approach can be anterior or lateral (1-5). The anterior approach can be transsternal or hemi-clamshell (2,3). The lateral approach can be left thoracotomy or, most recently, robotic through a right-sided approach (1,4-6). A left thoracotomy has been the traditional approach and more recently thoracoscopically (1,4,5,7). Resection of the LMSB is preferred over pneumonectomy for parenchyma preservation (5, 8, 9).

Traditional approaches to resection of the LMSB have resulted in high morbidity (1-5). A minimally invasive approach offers reduced morbidity with improved exposure. A uniportal VATS approach was recently demonstrated and resulted in low morbidity (7). In addition, a right transthoracic approach for robotic left main stem bronchus sleeve resection was recently demonstrated and offered improved vision to facilitate the resection and anastomosis (6).

This video demonstrates robotic assisted lung sparing resection of the left mainstem bronchus through a right-sided approach. The patient is a seventy-two-year-old asymptomatic active smoker. CT lung screen demonstrated a 6 mm soft tissue density in the left mainstem bronchus. Bronchoscopy demonstrated a small endobronchial lesion in the left mainstem bronchus and pathology returned adenoid cystic carcinoma-cT2N0M0. A PET scan demonstrated the density in left mainstem bronchus with an SUV of 2.4 but no other FDG uptake to suggest metastatic disease. PFTs demonstrated an FEV1 of 1.5 to (46 percent of predicted) and DLCO of 20.4 (76 percent of predicted). A Lexiscan myocardial perfusion scan showed no ischemia, normal wall motion, and an EF of 73 percent. Bronchoscopy and airway biopsy of the carina and proximal and distal left mainstem bronchus were negative. 

The patient underwent resection of his left mainstem bronchus and endobronchial tumor through a right-sided robotic approach utilizing ECMO. Pathology demonstrated adenoid cystic carcinoma-T2aN0M0 (stage IB) with 0/6 lymph nodes (stations 7, 8, 9) and negative margins. The patient was extubated in the operating room and was discharged home on the second postoperative day. The patient was doing well at his one month follow-up with no chest pain or shortness of breath.

Lung sparing resection of the left mainstem bronchus can be performed robotically with minimal morbidity, resulting in reduced pain, reduced length of hospital stay, and enhanced recovery. The robotic approach offers stability with superior vision. The right-sided approach offers easier dissection and exposure of the left mainstem bronchus. ECMO can facilitate the anastomosis of the left mainstem bronchus with minimal additional morbidity.

References

1. Paulson DL, Shaw RR. Preservation of lung tissue by means of broncho-plastic procedures. Am J Surg 1955; 89:238-59.
2. Spaggiari L, Mariolo AV, Petrella F, Romano R, Torre M. Transsternal Transpericardial Approach for Left Main Bronchus Sleeve Resection Due to Pulmonary Glomus Tumor. September 2018. doi:10.25373/ctsnet.7017683.
3. Mantovani S, Gust L, D’Journo XB, et al. Left main bronchial sleeve resection with total lung parenchymal preservation: A tailored surgical approach. Eur J Cardio-thoracic Surg 2020; 57:596-597.doi:101093/ejcts/ezz300
4. Ragusa M, Vannucci J, Cagini L, et al. Left main bronchus resection and reconstruction. A single institution experience. Journal of Cardiovascular Surgery 2012; 7:29. doi:10.1186/1749-8090-7-29
5. Tang J, Cao M, Qian L, et al. The pure distal left main bronchial sleeve resection with total lung parenchymal preservation: Report of two cases and literature review. J Thorac Dis 2014; 6 (12): E294-E298. doi: 10.3978/j.issn.2072-1439.2014.12.14
6. Iriarte F, Abbas A, Petrov R, et al. Right transthoracic approach for robotic left mainstem bronchus sleeve resection. JTCVS Techniques 2021; 10:572-4. doi.org/10.1016/j.xjte.2021.07.005
7. Mercadante E, Alessandrini G, Forcella D, et al. Uniportal thoracoscopic left main bronchus resection with new lobar carina reconstruction. MMCTS 2020. doi:10.1510/mmcts.2020.039
8. Newton JR, Grillo HC, Mathisen DJ. Main bronchial sleeve resection with pulmonary conservation. Ann Thorac Surg 1991; 52:1272-80.
9. Cerfolio RJ, Deschamps C, Allen MS, et al. Mainstem bronchial sleeve resection with pulmonary preservation. Ann Thorac Surge 1996;61:1458-63

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