Robotic Lobectomy for Congenital Lung Malformation in an Adult

Case Presentation 

A 31-year-old female presented with recurrent pneumonias and progressive shortness of breath attributed to suspected congenital lobar emphysema of the left upper lobe. She was initially evaluated by interventional pulmonology for possible endobronchial valve placement; however, this approach was deferred due to concerns about left upper lobe bronchial atresia. Thoracic surgery was subsequently consulted for consideration of definitive surgical management. Imaging demonstrated marked hyperinflation of the left upper lobe consistent with a congenital lung malformation. Given her symptoms and radiographic findings, a robotic-assisted left upper lobectomy was planned. 

The Surgery 

A robotic multiport approach was utilized to facilitate precise hilar dissection and optimize visualization in the setting of hyperinflation and dense adhesions. 
 
Step 1: Patient Positioning and Port Placement 

The patient was positioned in a lateral decubitus fashion. A standard robotic multiport configuration was established to allow adequate exposure of the left hilum and fissure. 
 
Step 2: Initial Exploration and Assessment 

Thoracoscopic inspection confirmed significant hyperinflation of the left upper lobe with limited initial deflation, which  impaired visualization. Adhesions were carefully lysed to improve exposure. 
 
Step 3: Hilar Dissection—Superior Pulmonary Vein 

An anterior-to-posterior approach was undertaken. The superior pulmonary vein branches to the left upper lobe were meticulously dissected and divided, taking care to preserve the inferior pulmonary vein drainage to the left lower lobe. 
 
Step 4: Bronchial Dissection 

The left upper lobe bronchus was circumferentially dissected. Particular attention was paid to preserving the left lower lobe bronchus and ensuring adequate length and integrity prior to division. 
 
Step 5: Pulmonary Artery Branch Control 

Pulmonary artery branches to the left upper lobe were individually identified, dissected, and divided. The superior segmental and basilar segmental branches supplying the left lower lobe were carefully preserved. 
 
Step 6: Fissure Completion 

The lobectomy was completed by stapling along the incomplete fissure. Progressive hilar division facilitated gradual decompression of the hyperinflated lobe, improving visualization as the operation proceeded. 
 
Step 7: Assessment of Left Lower Lobe Perfusion 

Intravenous indocyanine green was administered to confirm adequate vascular perfusion of the remaining left lower lobe following hilar division. 
 
Step 8: Staple Line Reinforcement 

A hydrogel sealant was applied along the staple line to reduce the risk of postoperative air leak. 
 
Step 9: Final Inspection and Re-expansion 

The remaining left lower lobe was inspected for expansion and hemostasis. The lung demonstrated satisfactory re-expansion prior to closure. 
 
Postoperative Course 

The patient tolerated the procedure well. At the five-month follow-up, she demonstrated excellent re-expansion of the left lower lobe and reported complete resolution of her prior shortness of breath symptoms. Final pathology revealed findings consistent with CPAM Type II, underscoring the diagnostic overlap among congenital lung malformations and the importance of surgical excision for definitive diagnosis. 
 
This case illustrated the rare presentation of congenital lung malformation in adulthood and demonstrated that a robotic-assisted lobectomy could be safely and effectively performed in the setting of hyperinflation and adhesions without conversion to thoracotomy. Further experience and long-term follow-up will be necessary to define the role of robotic resection relative to conventional thoracoscopic or open approaches. 

References

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