Robotic-Assisted Right Upper Lobe and Chest Wall Resection

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The patient was a 58-year-old female diagnosed with cT3N0M0 adenocarcinoma that appeared to be potentially invading the chest wall on preoperative imaging.  
She was a former smoker with a history of asthma  with poor pulmonary function test results, showing a forced expiratory volume in one second (FEV1) of 28 percent and a diffusion capacity for carbon monoxide (DLCO) of 36 percent. However, she was functionally excellent and underwent a cardiopulmonary exercise test (CPET), achieving a maximum oxygen uptake (VO2) of 14.2, which was 57 percent of the predicted value, and was thus offered the operation for optimal curative intent. 

A four-port approach was used, consisting of 2 x 12 mm ports and 2 x 8 mm ports, with the utility port triangulated between the two anterior ports. In the procedure, the robotic ports were inserted into the chest along with two tonsillar swabs. Adhesions were observed at the apex where the right upper lobe was adherent to the chest wall. 

Following the dissection of lymph node (LN) station 9 at the inferior aspect of the lung within the inferior pulmonary ligament, the procedure involved dividing an aberrant venous branch to the right upper lobe that crossed over the subcarinal space. The dissection then progress to LN station 11, located between the upper lobe bronchus and the bronchus intermedius.  

Moving on to stations two and four, the trachea was visible on the left side, positioned under one of the robotic arms, while the superior vena cava was on the right. The azygous vein crossed over from left to right, creating a triangle. This was followed by the dissection of LN station 10, which was inferior to the azygous vein. The dissection then proceeded down to the oblique fissure between the right upper and lower lobes. Shortly thereafter, the pulsating pulmonary artery to the right upper lobe was observed lying in the fissure.  

The stapler was then introduced to staple the oblique fissure to free up the right upper lobe from the right lower lobe. The remainder of station 11, which is an interlobar node located between the origins of the two lobar bronchi, was further dissected. Subsequently, the stapler was shown dividing the recurrent pulmonary arteries (PA) branches to the right upper lobe. The dissection continued safely around and divided the right upper lobe (RUL) bronchus. A tip-up was used to safely delineate the RUL truncus pulmonary arterial branch.  

In a similar fashion, the superior pulmonary vein draining right upper lobe was identified. A vessel loop was used for retraction and was removed prior to stapling with a 45 mm vascular Sureform stapler, which was shown dividing the superior pulmonary vein. Finally, a 45 mm green Sureform stapler was used to complete the horizontal fissure. 

Looking back up toward the apex of the lung, it was observed that the lung appeared to be adherent to the chest wall. Some of these adhesions were carefully dissected away, while keeping in mind that the right internal mammary artery was running down the anterior chest wall, just to the right of these adhesions. At this point in the operation, additional swabs were added into the chest in case of any bleeding from the internal mammary artery or indeed the subclavian artery, which was located just posterior to the chest wall adhesions.  

It was at this moment that Dr. Fitzmaurice, having completed the lobectomy, scrubbed in and attended at the patient’s bedside to introduce the Dennis thoracoscopic rib cutter into the patient’s chest, while Dr. Young continued with the chest wall dissection. At the robotic console.  

The first rib was divided at the posterior aspect initially, ensuring that only the bony structure was taken within the jaws of the thoracoscopic rib cutter. Following this, there was further safe dissection of the lung from the chest wall, and the first rib was then divided at the anterior aspect.  

Once this tissue was reflected down, the pulsating subclavian fat pad was seen, housing the subclavian artery underneath it, positioned just to the top right of the screen. 

In the remainder of the video, the swabs were removed, and surgical powder was applied for hemostasis. Local anesthetic was administered between the rib spaces. The lung and the ribs were placed into a specimen retrieval bag. A chest drain was inserted, and the lung was re-expanded under direct visualization. 

The final histopathology for this patient indicated an invasive adenocarcinoma with no nodal involvement in separately submitted LN stations 2, 4,7, 9,10, and 11, staging it as pT3N0 with a complete (R0) resection. The mass was adherent to the soft tissue of the chest wall, with PL3 involvement of the parietal pleura, but there was no invasion of the ribs. Programmed cell death ligand 1 (PD-L1) expression was found to be five percent, and she was referred for consideration for adjuvant chemotherapy. 

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