Robotic Left Upper Lobectomy with Aberrant Lingular Bronchus and Mediastinal Lingular Artery

The patient is a 62 year old male with past medical history significant for remote 10-15 pack year history of tobacco use, coronary artery disease complicated by STEMI, status post drug eluting stent x3 with preserved ejection fraction, and Factor V Leiden who presented to the UMass Memorial Medical Center with acute onset left sided chest pain. Work-up included a CTA Chest which noted an incidentally discovered 1.6cm left upper lobe solid pulmonary nodule in the posterior apical segment. Outpatient follow-up with Pulmonary Medicine was arranged. PET scan showed a 2.5 cm nodule in the left upper lobe with increased FDG avidity and SUV 3.76, no evidence of hilar/mediastinal FDG avidity and no metastatic disease. CT guided biopsy was found to be positive for adenocarcinoma. EBUS was performed to complete mediastinal staging and was negative for malignancy. The patient was taken to the OR for robot assisted left upper lobectomy and mediastinal lymphadenectomy.

The patient was positioned in a right lateral decubitus position. An 8 mm incision was made for the camera port in the seventh intercostal space. A 30 degree camera was used. Another 8 mm incision was then made posteriorly, 2 intercostal spaces below the major fissure. A 12 mm port was placed between the camera and posterior ports. A 12 mm port was then placed anteriorly, in the 8th intercostal space, in line with the major fissure, similar to the anterior port placement for VATS procedures. It is important that the ports are inserted in the middle of the intercostal space in order to minimize bleeding of the intercostal artery and to avoid excessive traction on the rib. This is achieved using a finder needle. An assistant port was then placed inferiorly and posteriorly in the 10th intercostal space just above the diaphragm. The skin incision for this port is made lower than the intercostal space, so the port is inserted at a flat angle, which facilitates easy and safe insertion of instruments. A complete intercostal nerve block was performed with Experel.

Step 1: Dissection of the inferior pulmonary ligament

The operation begins with division of the inferior pulmonary ligament. Retraction of the left lower lobe is performed with a tip up fenestrated grasper in the posterior port, which grasps a cigar and retracts superiorly. The left hand, arm 1, is a cadiere forceps, and the right hand is a long bipolar grasper. A level 9 lymph node is dissected and removed.

Step 2: Anteromedial dissection

The dissection of the inferior pulmonary ligament is continued in an anterior and medial direction, which facilitates later identification of the space between the lingular vein and inferior pulmonary vein. This sets up the ultimate fissural division later in the case. The dissection here proceeds close to the lung.

Step 3: Posterior dissection

The lung is then retracted anteriorly and remainder of the inferior pulmonary ligament is divided. Dissection down to the pericardium here facilitates identification of the most proximal aspect of the vein and leads to level 7 lymph nodes. The esophagus and aorta are located screen right. Using the bipolar directly on the lymph nodes allows for removal of lymph nodes with minimal bleeding. Clips are sometimes needed for sizeable bronchial arteries.

Step 4: Supra-hilar dissection

The left upper lobe is then retracted inferiorly to dissect the superior hilum. The vagus and phrenic nerves are identified and the left recurrent laryngeal nerve is noted. Dissection is then carried out around the left main pulmonary artery being careful to avoid the surrounding phrenic, vagus, and recurrent laryngeal nerves. A plane directly on the pulmonary artery helps identify lymph nodes and later facilitates safe identification of pulmonary artery branches.

Step 5: Medial dissection

The left upper lobe is retracted posteriorly. The phrenic nerve is identified. Dissection proceeds down to the superior pulmonary vein and a plane directly on the vein is identified. Hemostasis is achieved with the bipolar. The inferior aspect of the vein is dissected now for later division.

Step 6: Fissural dissection

In this patient, the interlobar artery is clearly seen within the fissure. Dissection proceeds to the plane of Leriche on the pulmonary artery. A tunnel is made which exits posteriorly and a 12Fr red rubber catheter is used as an endoleader for safe division of the major fissure with a 45mmblue load stapler. The stapler is brought through arm 1, a 12mm port, which is placed at the beginning of the case in line with the fissure. This allows for minimal articulation of the stapler while using it.

Step 7: Posterior apical artery

The dissection in the fissure continues along the pulmonary artery and extends superiorly. Here, a sizeable pulmonary artery branch is identified and dissected. The long bipolar is excellent at fine dissection and hemostasis. The ca diere forceps and rarely the tip up fenestrated instruments are blunt and offer a safe option for dissecting around pulmonary artery branches. This is the posterior apical artery. An endoleader is passed and the branch is divided with a vascular load stapler. Care is taken to minimize any tension on the artery before closing the stapler and prior to firing. Further division of the major fissure is performed with two blue load staplers. Retraction here demonstrates the space between the lingular vein and the inferior pulmonary vein.

Step 8: Aberrant lingular structure

The left upper lobe is the retracted posteriorly, and the left upper division vein and lingular vein are identified. Posterior to the lingular vein is the lingular bronchus, which is aberrantly coming off the lower lobe bronchus (1). The fissure is re-evaluated to try to make sense of the anatomy. Exposure of the lingular bronchus clearly confirms it goes to the upper lobe. Therefore it is isolated, dissected, and divided with a 45mm green load stapler via the posterior 12mm port. Posterior to the bronchus was a mediastinal lingular artery, which was isolated and divided with a vascular load stapler via the 12mm posterior port, with aid of an endoleader (2). Next, the lingular vein was isolated and divided in a similar fashion. At this time, the major fissure was completed with a final fire of the blue load stapler.

Step 9: Remaining LUL structures

The left upper lobe is retracted superiorly. A level 10 lymph node is removed. Hilar lymph node dissection is necessary for adequate lung cancer staging. It also aids in identification of major structures. The posterior apical bronchus is divided with a green load stapler. The upper division vein is dissected and divided with a white load stapler. The tip up fenestrated is used to safely get around the vessel. The left upper lobe is then retracted inferiorly and an apical segmental branch is isolated and divided. Further retraction is performed that exposes an anterior segmental branch, which is divided. Finally, the remaining structure is an anterior apical bronchus, which is divided. The specimen is removed with a 15 mm EndoCatch bag which is inserted through the assistant port. Hemostasis is achieved, and a chest tube is placed.

Postoperatively, patient was able to achieve adequate pain control with oral medications and tolerate a regular diet. On POD1, supplemental oxygen was weaned off, IV fluids were discontinued, and patient instructions/education materials were reviewed. Both the chest tube and Foley catheter were removed POD1. The patient was discharged to home POD1.

The Final intraoperative pathology was consistent with stage IA2 lung adenocarcinoma, T1b, N0, Mx. Resection margins were negative for adenocarcinoma and 0/9 Lymph nodes harvested were involved. The patient was readmitted POD7 for acute LLE DVT consistent with phlegmasia cerulea dolens requiring admission, operative embolectomy, thrombolysis, balloon angioplasty, and therapeutic anticoagulation. The patient was discharged POD9 home on Xarelto (rivaroxaban). Telehealth follow-up visit POD17 with plans for surveillance CT Chest in 6 months.

Reference(s)

1. Gossot D, Seguin-Givelet A. Anatomical variations and pitfalls to know during thoracoscopic segmentectomies. J Thorac Dis. 2018;10(Suppl 10):S1134-S1144. doi:10.21037/jtd.2017.11.87

2. Subotich D, Mandarich D, Milisavljevich M, Filipovich B, Nikolich V. Variations of pulmonary vessels: some practical implications for lung resections. Clin Anat. 2009;22(6):698-705. doi:10.1002/ca.20834