Multiportal Robotic Left Upper Lobar Bronchial Reimplantation Into the Mainstem Bronchus

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In this video, the patient was a 30-year-old man who reported intermittent hemoptysis. Bronchoscopy suggested a well-vascularized endobronchial lesion at the junction of the left lower lobar bronchus and the left mainstem bronchus.  

Contrast-enhanced chest computed tomography (CT) demonstrated complete atelectasis of the left lower lobe secondary to tumor occlusion. The remaining lobes were fully expanded, with no radiological lymph-node enlargement or distant metastasis. Pulmonary function tests showed normal forced expiratory volume (FEV) and diffusing capacity for carbon monoxide (DLCO).  

The multidisciplinary tumor board recommended a parenchyma-sparing bronchoplastic resection using four robotic arms plus an assistant port in a standard W shape configuration. The procedure began with the dissection of the inferior (triangular) pulmonary ligament to fully expose and mobilize the inferior pulmonary vein. 

The team continued by opening the posterior mediastinal pleura to perform a systematic lymph-node dissection of stations 7 and 10. The major fissure was developed, and a station 11 node was excised. The anterior fissure was then completed, allowing for precise dissection of the plane between the lower lobar bronchus and the arterial branches to the lower lobe. A single basal trunk was identified with an A6 and divided with a robotic stapler. 

The inferior pulmonary vein was dissected circumferentially and stapled, ensuring clear exposure of both the posterior and anterior aspects of the lower lobar bronchus. The lower lobar bronchus was opened with monopolar scissors. Additional proximal margins were taken on the left upper lobar bronchus and on the mainstem bronchus due to the tumor’s proximity. 

The junction between the left mainstem bronchus and the upper lobar bronchus was divided to secure a clear, disease-free margin on the mainstem bronchus. A small sponge was inserted into the mainstem bronchus to keep the bronchial stump correctly aligned during suturing and to tamponade any bleeding. 

The reconstruction was fashioned with two hemi-running sutures. The first hemi-running stitch is a 4-0 Quill barbed suture, chosen for its ergonomic needle and smaller puncture holes. The second hemi-running stitch was a 3-0 V-Loc barbed suture, selected after the Quill because the suture material was too fragile. A bubble test confirmed an airtight anastomosis.  

A free fat pad was then sutured over the suture line to reinforce the seal. The lung showed excellent reexpansion on insufflation. The patient was extubated in the theater and transferred to the recovery department. He was discharged on postoperative day three with no complications. Final pathology confirmed an R0 resection of a typical carcinoid. 

At the one-month follow-up, the patient was asymptomatic, with complete reexpansion of the remaining lung on chest radiography and preserved pulmonary function. 

References

1. Roviaro GC, et al. Robotic sleeve lobectomy: technical aspects and results. Ann Thorac Surg. 2023.
2. Gonzalez-Rivas D, et al. Uni-portal robotic bronchoplastic procedures. J Thorac Dis. 2022.
3. Detterbeck FC, et al. Management of bronchial carcinoid tumours. Chest. 2021.

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