Robotic Right Upper Lobectomy Without Dissecting the Superior Pulmonary Vein: A Multiportal Approach

In this video, the authors present a multiportal robotic right upper lobectomy performed with a vein-sparing strategy, in which the superior pulmonary vein was not dissected. The patient was a 68-year-old man with a prior left upper lobectomy via video-assisted thoracoscopic surgery (VATS) who was found to have a 2.7-cm right upper lobe nodule without radiologic nodal disease. A computed tomography (CT)-guided biopsy confirmed TTF-1–positive adenocarcinoma.  

3D reconstruction showed the lesion spanning segments 1 and 3, with a small segment 2, making sublobar resection inappropriate. A right upper lobectomy was selected for oncologic adequacy.  
The procedure followed French lobectomy principles with a structured, zone-based exposure and systematic lymph-node dissection.  

Parenchymal division was conducted in a fissure-first/fissureless-as-needed fashion. The vein strategy relied on intraparenchymal division during the final stapler firing, thereby avoiding dissection of the superior pulmonary vein. 

Postoperative Course 

The patient was discharged on postoperative day five after the resolution of a prolonged air leak attributed to mediastinal adhesions from prior surgery. Final pathology confirmed adenocarcinoma with R0 resection and a 2.5 cm margin. At the one-month follow-up, the patient was in excellent clinical condition. 

Key Points 

Key points included systematic 3D planning to anticipate anatomic variants and guide a safe surgical plan, even for standard lobectomy. A stepwise, five-zone sequence (French lobectomy) was employed for reproducible exposure and safety. Zone 2B clearance was performed to open the posterior fissure, and systematic lymph-node dissection was conducted, including station 11 adjacent to the upper lobe bronchus to facilitate bronchovascular control. 

The vein-sparing approach favored intraparenchymal venous section, avoiding dissection of the superior pulmonary vein. Air-leak limitation was achieved with staple-line sealant and careful tube positioning. 

Conclusion 

Robotic right upper lobectomy with a vein-sparing strategy is feasible and safe when guided by 3D planning, a structured stepwise approach, and oncologic lymphadenectomy. 

References

1. Igai H, et al. A robotic fissureless right upper lobectomy using a posterior approach. Multimedia Manual of Cardiothoracic Surgery. 2024.
2. Gallina FT, et al. Robotic Lobectomy without Complete Fissure for Non-Small Cell Lung Cancer: Technical Aspects and Perioperative Outcomes of the Tunnel Technique. Current Oncology. 2023;30(6):5898-5905.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.