Right transthoracic approach for robotic left main stem bronchus sleeve resection

Abstract

Central MessageThere are conflicting descriptions in the literature for the approach to a lung-sparing left main stem bronchus resection. We provide a detailed description of a robotic technique from the right side.See Commentaries on pages 575 and 577. There are conflicting descriptions in the literature for the approach to a lung-sparing left main stem bronchus resection. We provide a detailed description of a robotic technique from the right side. See Commentaries on pages 575 and 577. A 43-year-old female patient had a proximal left main stem bronchus (LMSB) lesion identified 2 years previously on a computed tomography scan of the chest (Figure 1) during workup for severe asthma. The lesion was debrided via rigid bronchoscopy by a pulmonologist before surgical referral. Pathology revealed a well-differentiated neuroendocrine tumor. A gallium dotatate scan reported uptake in a subcarinal lymph node with a standardized uptake value of 13.8. Flexible bronchoscopy with endobronchial ultrasound was performed 3 weeks before surgical resection, and the base of the tumor was tattooed at the time with vital blue dye to facilitate its identification at the time of resection and allow visible margin assessment. Endobronchial ultrasound–guided biopsy confirmed isolated subcarinal lymph node involvement. We planned a right robotic thoracoscopic approach. Intraoperative ventilation to the left lung was accomplished with 6-mm single lumen wire-reinforced tube (Fuji Systems Corporation. Tokyo, Japan). A similar tube was available at the bedside for cross-field ventilation through a separate thoracoscopic port but was not needed. Two venous central catheters were placed in the right internal jugular vein and the right femoral vein in case extra corporeal membrane oxygenation (ECMO) was required. The patient was placed in the left lateral decubitus position. Four 8-mm intercostal robotic ports were placed in the seventh to eighth intercostal space and one 12-mm assistant port at the tenth intercostal space mid-axillary line. Robotic instruments included bipolar Maryland (right arm), bipolar grasper (left arm), and tip-up grasper (retracting arm) for the dissection. The bronchus was divided with robotic scissors, and robotic needle driver was used for the anastomosis. The surgical field was controlled with a remotely operated surgical irrigator system. The procedure was completed by the da Vinci Xi robot (Intuitive Surgical, Sunnyvale, Calif). A capnothorax of 10 mm Hg was achieved. After division of the mediastinal pleural reflection along the posterior hilum, the esophagus was mobilized posteriorly, exposing the distal trachea and mainstem bronchi. Subcarinal lymph node package was completely resected. Both the carina and the proximal 3 cm of the LMSB were circumferentially dissected. It is important to protect the cuff of the endobronchial tube by pushing it as far as possible distally before dividing the bronchus. Based on the endobronchial appearance, we divided the proximal LMSB flush with the carina. We then resected the carinal end as a 5-mm ring for proximal margin. Two stay sutures were placed in the distal LMSB bilaterally to prevent left intrathoracic retraction of the bronchus. After identifying the tattooed base of the tumor, we proceeded to resect a similar 5-mm ring for distal margin, about 3 cm from the carina and 1 cm proximal to the secondary carina. After removing the margins for frozen section, we completed the dissection and removal of the main bronchial segment. After confirming negative margins, a primary bronchial carinal end-to-end anastomosis was performed with 2 running absorbable 3-0 barbed sutures. The sutures were placed at the left membranous–cartilaginous junction, and the anastomosis was performed in a running fashion first anteriorly then posteriorly. After we tested for an air leak, a pedicled pericardial thymic flap was developed and used to encircle the anastomosis (Video 1). Final pathology revealed a 6