Totally Endoscopic Robotic Left Pneumonectomy

This video presents the case of a fifty-nine-year-old man who is a former smoker with no significant comorbidities. He came to the team’s attention in January 2023 with fever and hemoptysis. First, he was treated with an antibiotic therapy and then underwent a CT scan.

In the CT scan it was possible to observe a neoplastic lesion with irregular margins of 3 cm in the left upper perihilar location, which was associated with ipsilateral perihilar hypodense adenopathic tissue. In the PET scan, surgeons could see an intense uptake in the left upper lobe and ipsilateral hilum.

In the first preoperative bronchoscopy, the team observed an obstruction in the left upper bronchus by a vegetative lesion. When the intraoperative bronchoscopy was performed, they saw an infiltrating lesion in the main bronchus. Therefore, a left pneumonectomy surgery with a totally endoscopic robotic approach was planned.

First, dissection of the anterior and posterior mediastinum was performed. After that, surgeons began the isolation of the inferior pulmonary vein, which was then encircled by placing an endoloop. Subsequently, the lung hilum was accessed in its upper portion to identify the main pulmonary artery.

Next, the superior pulmonary vein was isolated and an endoloop was placed around the vein to encircle it. To complete the inferior pulmonary vein resection, the stapler was introduced by the surgeon at the operating table through the same port used for the robotic instrument. A utility incision was not considered in this approach.

The posterior passage to access the superior pulmonary vein was better identified and, after removing the lower posterior robotic arm, the stapler was again introduced through the working port to complete the vein section. This allowed access to the main bronchus, which was an important step to identify the cleavage plane between the bronchus and the artery.

The suture on the main branch of the pulmonary artery was completed by making an upward angular movement of the stapler. For the bronchus resection, the assistance of an endoscopist in the room was requested. The introduction of a bronchoscope allowed for the identification of a macroscopic margin to safely perform the resection of the main bronchus.

Using firefly technology, the most proximal point possible for the bronchial section was identified on endoscopic guide and the bronchus division was performed by using the stapler. Once the bronchus was resected, the pneumonectomy was completed.

The histological analysis on the surgical specimen revealed two different squamous cell carcinomas, one in the left main bronchus and one in the left upper lobe. There was no evidence of malignancy in the lymph nodes and the surgical margin was negative.

The patient underwent four cycles of adjuvant chemotherapy every 21 days, and after seven months no signs of disease recurrence were observed at the total body CT scan.

References

1. Louie BE. Robotic pneumonectomy. Thorac Surg Clin. 2014 May;24(2):169-75, vi. doi: 10.1016/j.thorsurg.2014.02.007. PMID: 24780421.

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