Right Robotic Sleeve Upper Lobectomy

This video presents the case of a 65-year-old woman with a T2aN0M0 centrally located right upper lobe lung cancer. She had good performance status and excellent pulmonary function. Preoperative bronchoscopy demonstrated a tumor obstructing the right upper lobe bronchus with extension into the right main bronchus. 

The video begins following the removal of the station 7 lymph node. The posterior hilum and fissure were exposed. Although the author performs this step in all right upper lobectomies, it is particularly important when undertaking a sleeve resection. In this case, the fissure was nearly complete, facilitating exposure. The posterior ascending artery (A2) was identified and divided. The limited space available for stapler placement due to the proximity of the tumor was noted. Rather than retracting the lung excessively to create space—which creates bleeding risks—the surgeons accepted minimal pulmonary artery narrowing to maintain safety. 

A small bronchial artery was divided using Hem-o-lok clips. The right upper lobe vein and the apical trunk of the pulmonary artery were then divided, ensuring that lymph nodes were excluded from the stapler line. The transverse fissure was completed above the pulmonary artery, a maneuver that is particularly helpful when managing central tumors or involved hilar lymph nodes. 

The bronchus was then skeletonized by dividing peribronchial tissue and lymph nodes. Bronchial vessels are commonly encountered in this area. These can usually be controlled with cautery, although clips may occasionally be required. Robotic scissors were used to divide the bronchus intermedius. In cases in which the tumor is close to the planned division, this step may be guided by bronchoscopy, though this was not necessary in the present case. The scissors were passed beneath the membranous portion of the bronchus to avoid injury to underlying structures, particularly the esophagus. 

The right main bronchus was then divided. Robotic scissors were intermittently used with monopolar cautery to control superficial bronchial vessels while avoiding excessive electrocautery near the future anastomotic site. The resected lobe was retrieved and sent for frozen section analysis, which confirmed negative margins. 

Before starting the anastomosis, the authors divided the inferior pulmonary ligament, removed station 4R, and released the area around the carina and azygous vein to facilitate tension-free anastomosis. More extensive release maneuvers are seldom required in standard sleeve resections.      

A single Vicryl stay suture was placed in the cartilaginous portion of the bronchus, with the knot tied extraluminally to approximate the edges and reduce tension on the anastomosis. A small remnant of station 7 lymph tissue attached to the bronchus intermedius was subsequently removed. Two V-Loc sutures were then used in a continuous fashion—one for the membranous portion and one for the cartilaginous portion of the bronchus. The sutures were not fully tightened until completion to avoid excessive tension and potential suture cut-through, particularly along the membranous bronchus. 

At this stage, a size mismatch between the bronchi was evident. A longitudinal incision was made in the bronchus intermedius using robotic scissors, and the additional length was used to correct the mismatch. Both sutures were then secured. An air leak test was negative.  

A pericardial fat pad was loosely positioned over the anastomosis. Intraoperative bronchoscopy confirmed a patent airway. The chest drain was removed, and the patient was discharged home on postoperative day three. Final histopathology demonstrated a 31 mm T2aN0R0 adenocarcinoma. 

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