Robotic Left Lower Lobe Basilar Segmentectomy

Minimally invasive anatomic pulmonary segmentectomy requires intraparenchymal dissection for the exposure of the segmental vessels and bronchi. This dissection is performed bluntly during video-assisted thoracoscopic surgery (VATS), leading to increased air leak and a longer length of stay (LOS). The robotic platform enables a meticulous dissection due to its improved visibility, enhanced dexterity, and the more-than-human-wrist range of motion of the robotic arm. This meticulous dissection in our small series of VATS versus robotic segmentectomy (22 versus 28 patients, single surgeon experience) shortened the LOS and complication rate to half (median LOS: 4 days for VATS, 2 days for robotic surgery). This video demonstrates a robotic left lower lobe basilar segmentectomy performed with the da Vinci Xi robot, using a four-arm technique and total robotic staplers.

Procedure

The patient was a 43-year-old woman with a body mass index of 49.5 who was incidentally found to have a left lower lobe, PET positive, 2 cm, suspicious lesion. Her metastatic workup did not show evidence of distal disease. Ports were placed in the eighth intercostal space with the anterior port always placed one intercostal space more superior than compared to lobectomy. After port placement, the dissection was started by taking down the pulmonary ligament. The pleura was opened over the posterior surface of the lung up to the apex, and the lymph node dissection was performed.

The inferior pulmonary vein was dissected, and the basilar and superior segment veins were exposed posteriorly. The pulmonary artery was exposed in the fissure posteriorly, and the basilar segment vein was isolated. Subsequently, the dissection was performed in the fissure to expose the basilar and superior segment branches of the pulmonary artery. The basilar segmental artery was transected using the robotic curve tip 30 mm white staple load, which was introduced through the posterior arm. Similarly, the basilar vein was transected introducing the same stapler from the posterior arm. The basilar segment bronchus was isolated in the fissure and transected using the curve tip 30 mm blue staple load, again introduced through the posterior arm. The authors also used the robotic stapler for the parenchymal resection. The 45 mm straight green staple load was introduced through the posterior arm, and the parenchyma was resected in the line of the bronchus. The specimen was placed in a bag and removed through the assistant port.

The patient was extubated, and she recovered from anesthesia without difficulty. The chest tube was removed, and the patient was discharged home without complication 20 hours later. The final tumor pathology revealed a stage IA invasive adenocarcinoma.