Robotic Right Upper Lobectomy for Stage IIIA-pN2 Non-Small Cell Lung Cancer After Induction Chemotherapy

This video showed a robotic right upper lobectomy for stage IIIA-pN2 non-small cell lung cancer (NSCLC) following induction chemotherapy. The patient underwent three cycles of cisplatinum-based induction chemotherapy, and then she was enrolled in the authors’ ongoing prospective study to assess the safety and effectiveness of the robotic approach in patients with NSCLC, stage IIIA-pN2. Thanks to an excellent robotic view, it was possible to perform a radical and oncologically adequate hilar and mediastinal lymphadenectomy.

An adenocarcinoma was identified in the right upper lobe, with lymph node metastasis to station R4. After induction chemotherapy, the authors performed a robotic-assisted lobectomy using a four-arm, not completely portal approach, with a 3 cm utility incision and no need for CO₂ insufflation. After checking the fissure and the hilum to confirm the feasibility of the operation, the first step was the dissection of the pulmonary vein and its division using the 30 mm robotic vascular stapler through the posterior axillary port. The first pulmonary artery branch was then dissected and divided, using the same stapler cartridge through the same posterior port. The posterior segmental artery to the right upper lobe was exposed, and it was divided after dissecting the fissure to remove the N1 interlobar lymph nodes. The bronchus to the upper lobe was dissected, encircled, and divided with a 30 mm robotic stapler. The fissure was then divided using the 45 mm robotic stapler, and the specimen was removed through the utility incision using an Endobag™.

The authors then performed R2 and R4 lymphadenectomy. To better expose station R4, they divided the azygos vein, which allowed for an excellent view between the trachea and the superior vena cava where the lymph nodes were mostly attached to the underlying structures. Finally, the authors performed a subcarinal lymphadenectomy. The patient had no postoperative complications, and the chest tube was removed on postoperative day three.