Robot-Assisted Left Upper Lobectomy After Immunotherapy

This video demonstrates a robot-assisted upper left lobectomy as surgical treatment for a patient with a lung adenocarcinoma that had been previously submitted to immunotherapy. It was performed with the da Vinci Si platform with a 3-arm technique plus a 10 mm assistant port. In the right arm, the authors used the Marlyland bipolar forceps and on the left arm the thoracic grasper forceps. The assistant helped on the lung exposition with a regular laparoscopic grasper and performed all vessel, bronchial, and parenchyma stapling through the 10 mm port. The authors want to highlight the technical difficulties encountered due to the tumor volume plus the previous immunotherapy.

Procedure

The patient was a 64-year-old woman with lung adenocarcinoma who had received three months of immunotherapy with pembrolizumab due to large tumor volume plus a recent myocardial infarction that had been treated with two pharmacological stents, which led to three months of triple antiaggregating therapy. Ports for the camera and for the right arm were placed in the seventh intercostal space with the anterior port for the left arm placed in the sixth intercostal space.

After port placement, the authors started to divide the pleural adhesions, and it took almost 20 minutes to fully free the lung. Then, they started the division of the inferior pulmonary ligament and the harvest of the lymph node station 9. After anterior retraction of the lung, they dissected the hilum posteriorly and harvested stations 8 and 7, but the dissection of the superior part of the artery was extremely difficulty due to tumor volume plus tissue inflammation and enlarged lymph nodes. They tried to reach the artery by the fissure, but this strategy also failed due to tissue inflammation. So they decided to proceed similar to a “fissureless VATS lobectomy” from the front to the back.

They managed to reach, dissect, and divide the first arterial branch from the front, then they divided the upper pulmonary vein. The dissection of the bronchus was difficult but manageable with the Maryland bipolar robotic forceps, and after the bronchus division they could expose the remaining arterial branches. Finally, they divided the fissure with four endoscopic loads. Once the upper left lobe was loose, they used a bag to remove the specimen through the assistant port.

The patient was extubated in the immediate postoperative period, and she recovered from anesthesia without difficulty. The chest tube was removed on the third postoperative day and the patient was discharged uneventfully on postoperative day five. The pathological examination showed a lung adenocarcinoma with a partial response to immunotherapy, and the final staging was T2aN1.

Disclosure

Dr Ricardo M. Terra is on the Johnson & Johnson advisory board, is a Medtronic speaker and preceptor, and is a speaker and preceptor for H. Strattner/Intuitive.