Hybrid Robotic Assisted Right Upper Lobectomy With En Bloc Chest Wall Resection for Pancoast Tumor
The treatment of superior sulcus tumors (Pancoast tumors) has evolved over the past seventy years. Initial treatment was resection followed by irradiation (1). Now, the established trimodal treatment popularized by Shaw and Paulson involves neoadjuvant chemoradiation followed by thoracotomy with right upper lobectomy and resection of the involved ribs (2). The five-year survival with node-negative disease is 30–50 percent, but it is a morbid operation with 5 percent mortality and up to 40 percent major morbidity (3,4,5,6).
Resection of Pancoast tumor is a two-step operation involving dissection of the tumor from the apical structures and upper lobectomy with lymphadenectomy. The open approach is needed for apical dissection and resection of the involved ribs. The lobectomy and lymphadenectomy may be enhanced by video-assisted thoracic surgery (VATS) or a robotic approach. A hybrid approach allows both apical dissection, lobectomy, and lymphadenectomy in a less invasive fashion (7).
Recent studies have demonstrated the safety of VATS for resection of Pancoast tumors (8,9). One study demonstrated similar survival but reduced opioid and analgesics consumption with better recovery of forced vital capacity with VATS (7). In addition, initial VATS allowed exploration of the pleural cavity and avoiding thoracotomy in cases of unexpected pleural involvement. Another study found a shorter length of stay and reduced incidence of chronic pain with hybrid VATS lobectomy followed by limited open resection compared to conventional thoracotomy (10).
A robotic hybrid approach for treatment of Pancoast tumors has only been described in a few case reports (11–13). The robotic approach was first described by Mariole for an anterior Pancoast tumor in an obese patient (11). The apical structures were first dissected followed by robotic lobectomy. Kostic reported a sequential surgical approach with apical dissection followed by robotic lobectomy two days later (12). Uchidu recently described a hybrid approach with robotic inspection of the pleura followed by dissection of the apical structures and chest wall resection, then followed by robotic lobectomy (13). It has been stated that the sequence of lobectomy first has the advantage of disconnecting all pulmonary blood vessels and lymphatics before dissecting the tumor, which may prevent intravenous migration of malignant cells during chest wall resection (10).
This video demonstrates hybrid robotic assisted right upper lobectomy with en bloc chest wall resection for a Pancoast tumor. Lobectomy with mediastinal and hilar lymph node dissection was performed first, followed by posterolateral thoracotomy and dissection of the apical structures with resection of the first three ribs. The patient was discharged home on the second postoperative day. The final pathology revealed adenocarcinoma with extensive treatment effect-pT3N0M0 (Stage IIB) with zero out of eighteen lymph nodes involved. All margins were negative and there was 25 percent viable tumor.
The robotic approach offered inspection of the thoracic pleura to rule out invasion, visualization of the subclavian vessels, and allowed the appropriate number of ribs to be resected. The superior vision and stable platform associated with the robot permitted the lobectomy and lymph node dissection to be performed in a minimally invasive fashion. This resulted in reduced pain and hospital length of stay with enhanced patient recovery.
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