Robotic Left Upper Lobectomy With Arterioplasty of the Pulmonary Artery Trunk and Intrapericardial Vein Dissection

Introduction 

Due to certain limitations of video thoracoscopy compared to robotics, such as the mobilization of forceps and 3D vision, the robotic technique has been gaining ground and showing promising results. 

Several authors have demonstrated the safety and feasibility of resection in locally advanced lung cancer using a robotic-assisted approach (2, 3). In this video, the authors present a case of robotic-assisted left upper lobectomy, which involved the dissection and division of the intrapericardial pulmonary vein and arterioplasty of the pulmonary artery trunk to effectively preserve the lower lobe. 

Case description 

A sixty-three-year-old female patient presented with a 4 cm atypical carcinoid tumor in the left upper lobe, with left vocal cord paralysis as the first symptom.

The chest tomography showed a 4.5-centimeter mass invading the pulmonary artery trunk and insinuating itself into the superior venous tract, associated with an increase in the lymph nodes in the aortopulmonary window. Her VEF1 was 1.73 liters, and PET DOTA showed a maximum SUV of 2. 
 
Set Up and Positioning 

For this case, the authors used the da Vinci SI system with standard instruments for robotic-assisted lobectomies at their institution—a 30-degree camera, two Cardiere forceps, and a bipolar Maryland forceps. 

The patient was positioned in the right lateral decubitus position, and three incisions were made in the eighth intercostal space, with one more anteriorly in the seventh space. The order for placing the instruments was from posterior to anterior: Cardiere, bipolar forceps, camera, and Cardiere.  
The surgeons then positioned a 15 mm trocarter in the 10th intercostal space for the assistant. 

After dividing the inferior pulmonary ligament, the dissection was then continued to identify the low pulmonary vein, bronchus and artery, associated with lymphadenectomy of this region using a mixture of blunt and bipolar dissection. This was followed by a counterclockwise release, freeing the aortopulmonary window from the lymph nodes until it reached the anterior face of the vein. The surgeons confirmed that the mass involved the left superior pulmonary vein. At this point, the pericardium was opened with bipolar forceps, and a vein was prepared for suturing in the next step. The fissure was then accessed, free branches of the pulmonary artery were dissected and ligated with advanced energy. The following steps included closing the vein into the pericardium and then the upper lobar bronchus. After the proximal and distal release of the arterial trunk, and before placing the vascular clamps, a Foley catheter was passed proximally to gain space, which greatly facilitated the passage of the vascular clamp. Next, the arterial trunk was resected and sutured. 

Outcomes 

The patient was discharged on the fourth postoperative day without any complications. Final pathology showed a 4.5 cm atypical carcinoid tumor with negative margins (T2bN2 with negative 7, stage IIIA). The patient underwent targeted chemotherapy and, at the one-year assessment, was free of recurrences. 

References

1. National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Non-Small Cell Lung Cancer. Version 4.2024. https://www.nccn.org/professionals/physician_gls/pdf/nscl.pdf
2. Zirafa CC, Romano G, Sicolo E, et al. Robotic versus Open Surgery in Locally Advanced Non-Small Cell Lung Cancer: Evaluation of Surgical and Oncological Outcomes. Curr Oncol. Oct 12 2023;30(10):9104-9115. doi:10.3390/curroncol30100658
3. Veronesi G, Park B, Cerfolio R, et al. Robotic resection of Stage III lung cancer: an international retrospective study. Eur J Cardiothorac Surg. Nov 01 2018;54(5):912-919. doi:10.1093/ejcts/ezy16
4. Caplin ME, Baudin E, Ferolla P, Filosso P, Garcia-Yuste M, Lim E, Oberg K, Pelosi G, Perren A, Rossi RE, Travis WD., ENETS consensus conference participants. Pulmonary neuroendocrine (carcinoid) tumors: European Neuroendocrine Tumor Society expert consensus and recommendations for best practice for typical and atypical pulmonary carcinoids. Ann Oncol. 2015 Aug;26(8):1604-20. [PubMed]
5. Gosain R, Mukherjee S, Yendamuri SS, Iyer R. Management of Typical and Atypical Pulmonary Carcinoids Based on Different Established Guidelines. Cancers (Basel). 2018 Dec 12;10(12) [PMC free article] [PubMed]
6. Lababede O, Meziane MA. The Eighth Edition of TNM Staging of Lung Cancer: Reference Chart and Diagrams. Oncologist. 2018 Jul;23(7):844-848. [PMC free article] [PubMed]

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