Robotic Right Upper Sleeve Lobectomy With Rotational Azygous Vein Flap

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In this video, the authors demonstrate a robotic right upper sleeve lobectomy with a rotational azygos vein flap. The patient was a 68-year-old female presenting with a right supra-hilar non-small cell lung cancer, which caused obstructive atelectasis of the right upper lobe (RUL). A computed tomography (CT) scan showed the RUL mass involving the RUL bronchus, adjacent to the bronchus intermedius, near the bifurcation of the right main stem bronchus. 
 
For the surgery, the patient was placed in a left lateral decubitus position, and the ports—four robotic ports and one assist port—were inserted in standard fashion for an RUL lobectomy. The initial dissection involved lysis of adhesions due to the presence of fibrous bands near the upper lobe, which restricted its mobility. Next, the inferior pulmonary ligament was released. Any station 9 nodes that were encountered were also removed and sent to pathology. 
 
The dissection proceeded superiorly, and any station 7 or 8 lymph nodes were dissected. The next step involved the dissection and mobilization of the azygos vein as it arched anteriorly over the right main bronchus and joined the posterior aspect of the superior vena cava, from which it was separated using a vascular stapler. Subsequently, its first, second, and third branches were also dissected and separated to aid in the mobility of the azygos vein segment. 
 
The surgeons then proceeded to dissect near the bronchus intermedius, starting at the space between the intermedius and the RUL to remove station 11 lymph nodes. The dissection was further continued around and behind the RUL bronchus to create a window. The bronchus was sharply cut, first distal to the RUL, separating it from the bronchus intermedius. Then, the bronchus was proximally cut, separating the sleeve from the right main stem bronchus. 
 
Next, the upper lobe vein was dissected, encircled, and divided. Fissural division and division of the pulmonary arterial branch were then performed to complete the lobectomy. The bronchial anastomosis was performed by joining the bronchus intermedius to the right main stem bronchus, using two 3-0 sutures. After completion, the lumen of the azygos vein segment was opened to provide maximal coverage of the bronchial anastomosis. Vicryl sutures were then placed to join the anastomosis to the azygos vein patch. After completion, the chest was irrigated, and two 24F chest tubes were placed prior to closure. 
 
In this case, the lesion involved the RUL bronchus, requiring a sleeve resection. A tension-free anastomosis is essential after this resection. If this cannot be attained, the alternative is pneumonectomy, which carries far greater morbidity. Using a segment of the azygos vein as an autologous patch reconstructs the airway defect, restores full circumference, and allows for tension-free anastomosis, thereby avoiding pneumonectomy. The patient recovered successfully after surgery and was discharged on postoperative day four. She is now four months out from surgery and continues to remain cancer-free based on standard of care and molecular testing. A postoperative CT scan, obtained six weeks after surgery, showed good reexpansion and aeration of the right lung. 

References

1. Cerfolio, Robert J. (2016). Robotic sleeve lobectomy: technical details and early results. Journal of Thoracic Disease, 8(Suppl 4), S223–S226. DOI: 10.21037/jtd.2016.03.88.

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