Robotic-Assisted Right Middle and Lower Lobe Bilobectomy for a Right Lower Lobe Carcinoid Tumor Invading the Bronchus Intermedius

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The patient was a 67-year-old male with no significant past medical history who presented to the emergency department with acute on chronic hemoptysis. The patient reportedly had episodes of hemoptysis that lasted several days and occurred intermittently during the past 5 to 6 years. These episodes had typically been mild and self-resolved without workup or intervention. This was the worst episode he had experienced. He denied any other symptoms associated with hemoptysis, such as shortness of breath, fevers and chills, weight loss, and exposures. He has never smoked and did not use drugs. He had no known risk factors for tuberculosis or pulmonary infection. A CT chest scan was performed, which found a 2.3 x 2.2 cm nodule in the right lower lobe (RLL). A biopsy demonstrated a carcinoid tumor. Given the location in the bronchus intermedius (BI), a bilobectomy needed to be performed for complete resection. All risks, benefits, and alternatives were discussed. 
 
The patient was brought into the operating room and placed in the supine position. A double-lumen endotracheal tube was placed. A flexible bronchoscope was passed down the tube and revealed no abnormalities down to the subsegmental levels on the left. On the right, the tumor was identified approximately 1 cm down the BI and below the take-off of the right upper lobe. The patient was then turned to the lateral decubitus position, and the right chest was prepped and draped in the usual sterile fashion. An 8 mm incision was made in the eighth intercostal space, and the chest was entered. 

There was no adhesion, and the lung was well isolated. Two posterior and one anterior port were placed. The robot was docked to the patient. The inferior pulmonary ligament was taken down, and the level 9 lymph nodes were dissected and sent to pathology. The anterior and posterior pleura were opened, and the station 7 lymph node was dissected at this time. 

The lower lobe and middle lobe pulmonary veins were isolated and divided after dissection using a white load of the SureForm robotic stapler. The fissure was opened, and the station 11 lymph node was dissected. Next, the middle lobe, basilar lower lobe, and superior segment pulmonary arteries were isolated and divided with the white load of the SureForm stapler. 

Dissection continued down to the BI, and a bronchus was passed to confirm an adequate margin. The bronchus was clamped, and the remaining lung was ventilated to ensure proper placement of the stapler, which was then divided. The lobe was placed in an endocatch bag, and the bag was brought out through the anterior port site. The specimen was sent to pathology for a frozen section. 

A multilevel intercostal cryonerve ablation of levels 4-8 was completed. A chest tube was placed in the apex of the chest, and the right upper lobe was reexpanded. The incisions were closed in multiple layers. The patient was awakened from anesthesia, extubated in the operating room, and taken to recovery in good condition. 

References

1. Rea G, Rudrappa M. Lobectomy. [Updated 2023 Feb 13]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK553123/

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