Robotic Left Upper Lobectomy With Chest Wall Resection

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This video represents a case of a robotic left upper lobectomy with chest wall resection and reconstruction. 
 
Patient History 

The patient was a 77-year-old male with a 30 pack-per-year smoking history who presented with left upper lobe mass with rib erosion. His past medical history was notable for asthma and a transient ischemic attack (TIA) more than 10 years ago on Plavix. The computed tomography-guided biopsy was notable for non-small cell lung carcinoma concerning for large cell carcinoma, with standard uptake value (SUV) uptake of 16.3 on positron emission tomography/computed tomography (PET/CT). There was no mediastinal or hilar lymph node uptake. He was staged as cT3N0M0 and underwent three cycles of neoadjuvant chemotherapy. A repeat PET/CT scan one month later showed an overall decreased size of the left upper lobe (LUL) mass and a hypermetabolic LUL nodule. The brain magnetic resonance imaging (MRI) was normal. Pulmonary function tests (PFTs) were reviewed, showing a forced expiratory volume in one second (FEV1) of 79 percent and a diffusion capacity of the lungs for carbon monoxide (DLCO) of 85 percent.  
 
Operative Approach 

The patient was placed in the right lateral decubitus position. An 8 mm robotic trocar and camera were placed at the eighth intercostal space in the posterior axillary line. All subsequent trocars were inserted under direct visualization: one 12 mm trocar was placed anteriorly, and two additional 8 mm trocars were placed posteriorly in the same intercostal space. 
 
The camera was targeted at the left upper lobe. The upper lobe mass was visualized, which was significantly adherent to the posterior chest wall. The dissection began by releasing the inferior pulmonary ligament, and a left level 9 lymph node was sent for analysis. The dissection continued posteriorly, releasing the pleura from the hilum and dissecting lymph nodes in the subcarinal station. 
 
Next, attention turned to the left upper lobe adhesions. The flimsy adhesions surrounding the mass and chest wall invasion were taken down with bipolar cautery. The team then switched to the monopolar hook cautery to release the lung prior to dissection of the hilum, leaving the area of tumor invasion left intact at the chest wall. 
 
The surgeons then used a bipolar instrument to dissect into the fissure, creating a tunnel. A vessel loop was used, and a tissue cutting stapler was inserted to divide the upper and lower lobes. The dissection was continued anteriorly, releasing the pleura from the hilum. An extensive lymph node dissection was performed to isolate the arteries and vessels leading to the left upper lobe. 
 
The superior and inferior pulmonary veins were identified before proceeding with the dissection of the superior pulmonary vein. The pulmonary arterial branches leading to the left upper lobe were then identified and dissected. Blue and red vessel loops were placed around the superior pulmonary veins and pulmonary arteries, respectively. The superior pulmonary artery branches were divided individually using a white load robotic vascular stapler. 
 
Next the superior pulmonary vein was then transected using a robotic white load vascular stapler to expose the anterior branches of the superior pulmonary artery. The anterior pulmonary artery branches were then divided using a robotic white load vascular stapler. Lastly, the left upper lobe bronchus and remaining fissure were transected using a robotic vascular stapler. 
 
Thoracic lymphadenectomy was performed with the removal all the tissue from the aorto-pulmonary window up to the para-aortic area while carefully identifying the vagus nerve and recurrent laryngeal nerve 
 
Attention was then turned to the area surrounding the chest wall mass, which was then dissected circumferentially using monopolar hook cautery. Next, a handheld drill was used to resect rib 4 and 5 surrounding the tumor invasion of the chest wall. The chest wall mass was removed robotically in its entirety from the inside of the chest wall with the hook cautery. 4-0 nonabsorbable sutures were placed and used to secure a 10 x 11 mm piece of mesh. The mesh was sutured circumferentially over area of the chest wall resection. Absorbable suture clips were placed after the sutures were tied down.  
 
Postoperative Course 

The patient did quite well postoperatively. His pain was controlled with intravenous narcotics and transitioned to oral medications. The chest tube was removed on postoperative day five, and he was discharged on postoperative day seven with a catheter for urinary retention. Final pathology showed a complete pathological response with no residual tumor present. A surveillance CT scan one year later showed no tumor recurrence or chest wall hernia. 

Disclosure 

Drs. Harmik Soukiaisian and Andrew Brownlee are both consultants for Intuitive. 

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