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31 Robotic Pulmonary Lobectomy
437
Fig. 31.4 (continued)
ensures exposure of the inferior pulmonary vein in cases of lower lobectomies and
facilitates cranial displacement of the lung to accommodate the space after upper
lobe resection. Subsequently, the lung is retracted anteriorly, and posterior hilum is
mobilized. This dissection varies depending on the laterality of the procedure.
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A. I. Gritsiuta et al.
Techniques ofIndividual Lobectomies
Despite well-established surgical protocols outlining the sequential steps of various
lobectomies, a certain degree of variability is acceptable in the conduct of each
operation. Structures may be isolated and divided in an order that is most conducive
to the patient’s individual anatomy. Below, we present our preferred approach to
these procedures, along with a description of the most common variants.
Right-Sided Resections
For the initial posterior dissection, the lung is retracted anteriorly, and the posterior
hilum is mobilized (Fig.31.4b). The subcarinal lymph node is exposed and dissected in its entirety, which may require mobilization of the esophagus from the
overlying trachea and principal bronchi. The entire posterior airway is exposed, and
the bifurcation of the right upper lobe bronchus and bronchus intermedius is dissected. A lymph node in this location is dissected and sent as station 11R, exposing
the interlobar pulmonary artery and the takeoff of the posterior ascending branch
(Fig. 31.4c). This dissection is carried all the way to the right tracheobronchial
angle. Further dissection varies based on the specic lobectomy being performed.
Right Upper Lobectomy
• After the completion of the posterior hilar dissection, the lung is retracted inferi-
orly, and the superior hilar dissection is performed (Fig. 31.4d). The plane
between the right upper lobe (RUL) bronchus and the anterior apical pulmonary
trunk of the pulmonary artery (PA) is dissected.
• Next, the lung is reected posteriorly to expose the anterior hilum. Anterior hilar
dissection begins from the inferior pulmonary vein (IPV), exposing the superior
pulmonary vein (SPV) and the bifurcation between the right upper and middle
lobar veins. The RUL vein is dissected from the underlying interlobar pulmo-
nary artery.
• The 10R lymph node, located in the space between the SPV, superior vena cava
(SVC), and azygos vein, is removed.
• The anterior apical trunk is dissected circumferentially next. The previously
developed plane between the PA and the RUL bronchus facilitates this dissec-
tion. The truncus branch of the PA is then divided with a vascular load stapler
(Fig.31.4e).
• Subsequently, the RUL pulmonary vein is divided with a vascular load stapler
distal to the conuence with the right middle lobe (RML) vein (Fig.31.4f).
• Division of the vein facilitates further posterior retraction of the RUL. This
exposes the interlobar PA and the posterior ascending PA branch. This branch is
circumferentially mobilized and divided with a vascular load stapler (Fig.31.4g).
31 Robotic Pulmonary Lobectomy
439
• Next, the RUL bronchus is approached from posterior. The lung is retracted ante-
riorly. The previous posterior dissection of the bifurcation between the RUL
bronchus and RBI facilitates this step. Prior to the division of the bronchus, the
absence of any catheters in the airway is conrmed through clear communication
with the anesthesia team. Use of robotic staplers usually prevents ring in this
situation by sensing excessive tissue thickness (Fig.31.4h).
• After the division of the hilar structures, the RUL is retracted caudally, and the
parenchymal bridge of the minor and major ssures is divided with serial rings
of a blue stapler load starting anteriorly (Fig.31.4i).
• The specimen is retrieved from the chest by placing it into a large Anchor Tissue
Retrieval System (ConMed Corporation, Utica, New York, USA), delivered
through the 15 mm assistant port. Some extension of the incision is usually
required for specimen removal (Fig.31.4j). After extraction, the assistant port is
placed back, carefully avoiding subdiaphragmatic placement due to the rise of
the diaphragm after the loss of the capnothorax, which is subsequently rein-
stated. The specimen is sent for frozen pathology for the inspection of resection
margins.
• Attention is directed to the dissection of the paratracheal lymph nodes. The
mediastinal pleura is incised vertically, posterior to the SVC, and horizontally,
over the azygos vein, with meticulous care to preserve the integrity of the phrenic
nerve. Maintaining the dissection plane along the vein wall, the dissection is
extended to the tracheal wall, allowing for the complete resection of the tissue
pocket containing lymph node stations 2R, 4R, and 3 (Fig.31.4k).
• To prevent RML torsion following the division of the incomplete minor ssure,
the tips of the right middle and lower lobes are approximated, and a small wedge
resection is performed using a vascular stapler for pexy.
• Hemostasis is meticulously ensured. A single 24 French straight chest tube is
placed through the anterior port, directed posteriorly toward the apex. The robot
is then undocked, and the lung is observed to inate under the Valsalva maneuver
without evidence of torsion (Fig.31.4l).
• Most common variation of right upper lobectomy:
– The RUL vein can be divided prior to the anterior apical trunk of the PA to
enhance arterial exposure. However, the authors prefer to divide the artery
rst to avoid parenchymal edema and difculties during specimen extraction.
– Due to the more distal takeoff of the posterior ascending branch, its dissection
and division may necessitate the initial division of the RUL bronchus. In such
cases, it is acceptable to divide the arterial branch together with the pulmonary parenchyma during ssure division.
– The RUL bronchus can be approached anteriorly, though the authors prefer a
posterior approach, as it better aligns the posterior membranous and cartilaginous portions of the airway wall.
– Depending on the thickness of the parenchymal bridge, a white stapler load
may be used for nearly complete ssures, while blue, green, and even black
loads can be employed in cases of incomplete or absent ssures.
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A. I. Gritsiuta et al.
Right Lower Lobectomy
• After completing the posterior dissection, the lung is retracted posteriorly and
superiorly. Anterior hilar dissection then begins at the IPV, exposing the SPV.
• The 10R lymph node station is dissected and removed.
• In the space between the superior and inferior pulmonary veins, dissection is
initiated under the parenchymal bridge of the main ssure. Alternating between
dissection and stapling, the division is carried posteriorly, eventually exposing
the entire interlobar PA (Fig.31.5a). In the gap between the superior segmental
and posterior ascending arteries, the dissection enters the posterior plane of dis-
section between the RUL and right bronchus intermedius.
• Next, the lymph node over the PA, exposed during the previous step, is dissected
and sent as a level 11R station specimen (Fig.31.5b).
• The interlobar PA is circumferentially dissected and divided distal to the takeoff
of the RML artery. Specic attention is paid to avoid narrowing or division of the
RML PA branch (Fig.31.5c).
• The IPV is divided ush with the pericardium to avoid a long stump, which could
later serve as a nidus for clot formation (Fig.31.5d).
• The right lower lobe (RLL) bronchus is isolated and divided with a green stapler
load, taking care to avoid narrowing the RML bronchus takeoff (Fig.31.5e). The
specimen is extracted, and the completion steps are performed as described above.
• Most common variation of the right lower lobectomy:
– If the RML vein is identied draining into the IPV during the anterior dissec-
tion, a more distal vein dissection is required for division above the RML vein
conuence.
– Depending on the anatomical relationship between the superior segmental
and RML PA branches, the interlobar PA can be divided with a single stapler
application or may necessitate separate division of the basilar trunk rst, followed by the superior segmental branch.
– Similarly, based on the relationship between the superior segmental and RML
bronchi, the RLL bronchus can be divided with a single stapler application
(green load). Alternatively, it may require separate division of the common
basilar bronchus rst (green load), followed by the superior segmental bronchus (blue load).
Right Middle Lobectomy
• Following the completion of the posterior dissection, the lung is retracted poste-
riorly and superiorly. The anterior hilar dissection begins at the IPV, exposing the
SPV and the conuence of the right upper and middle lobar veins. The course of
the RML vein is identied, as it can occasionally drain into the IPV.
• The 10R lymph node station, located in the space between the SPV, SVC, and
azygos vein, is carefully removed.
31 Robotic Pulmonary Lobectomy
441
a
c
b
d
e
Fig. 31.5 Technical steps of the RLL. (a) Alternating dissection and division of the major ssure
parenchymal bridge for exposure of the interlobar PA. (b) Dissection of the LN over the PA as
station 11R. (c) Dissection and division of the interlobar PA below the takeoff of the RML branch.
(d) Division of the inferior pulmonary vein. (e) Division of the right lower lobar bronchus
• Dissection between the superior and inferior pulmonary veins begins under the
parenchymal bridge of the main ssure. Initially, the dissection is performed on
top of the lymph node in this location. Once a tunnel is created, alternating dis-
section and serial ring of the vascular stapler are used to divide the parenchyma,
completing the ssure. The division continues to the conuence of the minor and
major ssures, or until the superior segmental and posterior ascending branches
of the PA are exposed (Fig.31.6a).
442
ab
A. I. Gritsiuta et al.
c
d
e
Fig. 31.6 Technical steps of the RML lobectomy. (a) Dissection and division of the parenchymal
bridge of the major ssure until its fusion with the minor ssure. (b) Division of the minor ssure
parenchyma until the previous plane of dissection. (c) Division of the RML PA. (d) Division of the
RML tributary of the SPV. (e) Division of the RML bronchus at its takeoff from RBI.Please note
use of blue load stapler
• Next, the lymph node over the PA, exposed during the previous step is dissected
and sent as a level 11R station specimen.
• The SPV is then dissected from the underlying interlobar pulmonary artery, and
the space between the RUL and RML venous tributaries is developed.
31 Robotic Pulmonary Lobectomy
443
• Similarly, by maintaining the dissection plane over the PA, a tunnel is created
under the minor ssure. Alternating dissection with serial ring of a vascular
stapler load, the parenchyma is divided until it meets the major ssure, entering
the previous plane of dissection, completing the minor ssure (Fig.31.6b).
• These maneuvers lead to a wide exposure of the interlobar PA and the RML
branch. The RML branch is circumferentially dissected and divided with a vas-
cular stapler load (Fig.31.6c). Utilizing the posterior axillary line for the stapler
facilitates most of the steps in a middle lobectomy.
• Next, the RML vein is encircled and divided via the same port distal to the
conuence with the RUL vein (Fig.31.6d).
• The RML bronchus is then isolated, running underneath and around the interlo-
bar PA.Careful dissection to its takeoff is required to avoid a long stump. The
bronchus is divided with a blue stapler load. As a safety measure, the absence of
a suction catheter in the airway prior to bronchus division has to be ensured
(Fig.31.6e).
• Once the specimen is resected, it is extracted from the chest as previously
described. The paratracheal lymph node pocket is dissected, the chest tube is
positioned, and the case is completed in the usual fashion.
• Most common variation of the right middle lobectomy:
– The division of the minor ssure can be postponed until after the PA branches
are divided. This approach may facilitate dissection from lateral to medial,
potentially providing better exposure.
– In cases where accessory RML PA branches are present, the division of the
most anterior branch might be limited by the pulmonary parenchyma, necessitating the division of the minor ssure.
– Prior to the division of the RML vein, its course needs to be veried, as it can
occasionally drain into the inferior pulmonary vein.
– The RML vein can be divided prior to the PA branches. This facilitates the
dissection of the tunnel under the minor ssure. Due to the smaller size of the
RML, concerns regarding edema and difculties with extraction are less
signicant.
Left-Sided Resections
After takedown of the inferior pulmonary ligament (Fig.31.7a), the lung is retracted
anteriorly, and the posterior hilar dissection exposes the interlobar pulmonary
artery. The dissection is then carried superiorly (Fig. 31.7b). The lymph nodes
overlying the pulmonary artery in this location are sent as station 11L.Deeper dissection under the interlobar artery leads to the subcarinal space, where, after dissecting the esophagus away, the subcarinal lymph node is dissected and sent as a
specimen.
444
ab
cd
ef
A. I. Gritsiuta et al.
Fig. 31.7 Technical step of the LUL. (a) Exposure and division of the left inferior pulmonary
ligament. (b) Posterior dissection of the left hilum with dissection of the interlobar PA and interlobar and subcarinal LNs. (c) Dissection and division of the ssural parenchyma for the exposure of
the PA branches. (d) Dissection and division of the lingular branch of the PA. (e) Dissection and
division of the anterior apical branch of the PA. Please note in the background prophylactic
Rommel tourniquet in place in the neoadjuvant therapy case. (f) Division of the SPV.Rommel
tourniquet and vessel loop are visible in the background. (g) Division of the LUL bronchus
31 Robotic Pulmonary Lobectomy
445
g
Fig. 31.7 (continued)
Left Upper Lobectomy
• After completion of the posterior dissection, the lung is retracted inferiorly, and
the superior dissection is completed, exposing the branches of the PA to the left
upper lobe (LUL).
• Next, the left lung is retracted posteriorly and superiorly, and the anterior hilar
dissection starts from the IPV, exposing the SPV and joining with the superior
dissection plane.
• In the space between the superior and inferior pulmonary veins, dissection is
initiated under the parenchymal bridge of the ssure, staying on top of the lymph
node in this area. Alternating dissection and division of the parenchyma with the
stapler, the division of the parenchymal bridge of the ssure is carried posteri-
orly, eventually exposing the entire interlobar PA (Fig.31.7c).
• The lymph node exposed during the previous step is dissected and removed as
station 11L.
• The branches of the PA to the LUL are circumferentially dissected and divided
with a vascular stapler load, starting with the lingular branch (Fig.31.7d), fol-
lowed by the posterior apical branch, and subsequently the anterior apical branch
(Fig.31.7e). The posterior axillary line port is most useful for stapler placement
during this step.
• Next, the SPV is circumferentially dissected and divided (Fig.31.7f). Because
the SPV can be fairly wide, consisting of lingular, intersegmental, and upper
division branches, these may need to be dissected and transected separately.
• This maneuver leads to the exposure of the LUL bronchus. The bronchus should
be encircled and divided with a green stapler load from the posterior axillary port
for better apposition of the membranous and cartilaginous portions of the airway
(Fig.31.7g).
446
A. I. Gritsiuta et al.
• The specimen is placed in a tissue retrieval system, extracted from the ches, and
sent for frozen pathological assessment for margins. Enlarging of an assistant
port site might be required.
• An assistant port is replaced for the maintanance of the capnothorax.
Lymphadenectomy is completed by dissecting the aortopulmonary window and pre-
vascular lymph nodes (stations 5 and 6). Dissection along the airway under the aortic
arch can expose the left lower paratracheal lymph node (station 4L) for resection.
• At the conclusion of the resection, the robot is undocked, and a 24 French chest
tube is advanced to the apex posteriorly through an anterior port and secured to
the skin. The lung is observed to inate without torsion with the Valsalva
maneuver.
• Common variations of the left upper lobectomy:
– Dissection of the anterior apical branch from the back can be challenging if it
is covered by the SPV, and initial division of the vein can be performed for
better exposure.
– After division of the SPV and the anterior apical branch of the PA, the LUL
bronchus can be circumferentially dissected and divided from an anterior
approach. This maneuver will expose the PA branches to the LUL and the
parenchymal bridge of the ssure from the inside. The branches of the PA can
be taken along with the parenchyma using this approach.
Left Lower Lobectomy
• After completion of the posterior dissection, the lung is retracted cranially and
posteriorly and the parenchymal bridge of the ssure is divided as described
previously.
• The lymph node, exposed during the previous step, is dissected and removed as
station 11L.
• The inferior lobar PA is circumferentially mobilized below the takeoff of the
lingular branch and is divided from the anterior port with a vascular load stapler
(Fig.31.8a).
• After division of the artery, the lung is reected cranially and posteriorly. The
IPV is dissected and divided ush with the pericardium (Fig.31.8b).
• The left lower lobe bronchus is isolated and divided from posterior axillary port
with a green load stapler (Fig.31.8c).
• Common variations of the left lower lobectomy:
– In cases of a very distal takeoff of the last lingular branch, separate division of
the basilar trunk of the left lower lobe PA and the superior segmental branch
might be required.
– In cases of early conuence of the pulmonary veins, clear identication of the
IPV branch for division is necessary to avoid accidental pneumonectomy.