Robotic Surgery For a Large Pulmonary Metastasis with Bronchial Involvement

Minimally invasive surgery is now a reality in most surgical specialties. With new technological improvements, new instruments, better video support, anesthesia refinement, and robotic platforms allowing 3D view and extension of the surgeon’s hands, increasingly challenging cases are suitable to this approach. The case featured in this article and the accompanying video demonstrates the safety and efficiency of the robotic platform in the treatment of large pulmonary masses.

This video presents a case of a thirty-four-year-old woman, diagnosed with right ovarian malignant germ cell tumor with an isolated lung metastasis, both histologically confirmed by core biopsies. The patient underwent an oncological gynecologic surgery with adjuvant chemotherapy with no response on the pulmonary lesion. She had no additional medical records and no tobacco exposure.

The patient had a large pulmonary mass on the right superior lobe measuring 9 cm on the long axis. The lesion protruded to the secondary carina between the right main bronchus and bronchus intermedius, without signs of invasion. A chest contrast-enhanced computed tomography showed no vascular relationship.

After a multidisciplinary board discussion, the patient was submitted to undergo a robotic assisted resection. 

The Surgery

A robotic-assisted thoracoscopic surgery (RATS) was performed using a Da Vinci Xi® surgical platform with four 8 mm ports for the robotic arms and one 15 mm port for the assistant on a right-side approach. 

The surgery began by dissecting the pulmonary ligament, with lymphadenectomy, and opening the posterior mediastinal pleura until the azygous vein. The sump node dissection was hampered by the superior mass, so the tunnel was started by the fissure. To perform a safe dissection of the superior vein, the camera was switched from the second posterior port to the second anterior port, greatly increasing the visibility. After dissecting and stapling the A2 and the superior vein, an on-set bronchoscopy was made with the robotic Firefly™ to better relate the surgical margin, and it was decided to open the bronchus with the scissors, directly guaranteeing the surgical margin and achieving the repair with interrupted suture with PDS® 4.0. The specimen was removed with an extension of the auxiliary port on the tenth intercostal space with the brief use of a rib retractor. 

The procedure was uneventful, with good pain control supported by the use of erector spinae plane block, and the patient was discharged on the fourth postoperative day. The final anatomopathological result confirmed the ovarian metastasis with all surgical margins free and all lymph nodes negative. 

Firstly, the records were to prove a non-inferiority of the RATS surgery with the VATS, restricting the indications for small lesions (1). After, with the exponential boost of RATS and tendency to lower overall complication and mortality, it started a trend to perform more and more testing cases (2). 

Regardless, the indifference in overall major complications, mortality, and the achievement of an R0 surgery, one thing appears to be evident: the conversion to thoracotomy is much lower during RATS (2-6%) compared to VATS (11-25.1%), and also the reason why it was created (3,4). On the robotic arm, major bleeding is the leading obstacle, perhaps due to the increase in courage. In VATS, the main obstacle is technical difficulty of dissection. Some even suggest that large tumors (> 5 cm), neoadjuvant chemoradiotherapy, and body mass index ≥ 25, a robotic approach is the preferable choice to perform minimally invasive surgery (5,6).

References

1. Flores RM, Alam N. Video-Assisted Thoracic Surgery Lobectomy (VATS), Open Thoracotomy, and the Robot for Lung Cancer. Ann Thorac Surg. 2008 Feb;85(2):S710–5.
2. Kent M, Wang T, Whyte R, Curran T, Flores R, Gangadharan S. Open, Video-Assisted Thoracic Surgery, and Robotic Lobectomy: Review of a National Database. Ann Thorac Surg. 2014 Jan;97(1):236–44.
3. Chen D, Kang P, Tao S, Wu L, Li Q, Tan Q. Risk factors of conversion in robotic- and video-assisted pulmonary surgery for non-small cell lung cancer. Updat Surg. 2021 Aug;73(4):1549–58.
4. Servais EL, Miller DL, Thibault D, Hartwig MG, Kosinski AS, Stock CT, et al. Conversion to Thoracotomy During Thoracoscopic vs Robotic Lobectomy: Predictors and Outcomes. Ann Thorac Surg. 2022 Aug;114(2):409–17.
5. Scheinerman JA, Jiang J, Chang SH, Geraci TC, Cerfolio RJ. Extended Robotic Pulmonary Resections. Front Surg. 2021 Feb 22;8:597416.
6. Baig MZ, Razi SS, Agyabeng-Dadzie K, Stroever S, Muslim Z, Weber J, et al. Robotic-assisted thoracoscopic surgery demonstrates a lower rate of conversion to thoracotomy than video-assisted thoracoscopic surgery for complex lobectomies. Eur J Cardiothorac Surg. 2022 Aug 3;62(3):ezac281.

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