Case report
Uniportal robotic right lower sleeve lobectomy
Bronchial sleeve lobectomies are technically challenging procedures. The robotic technique provides some advantages, especially for the anastomosis.
In this case report, we present a uniportal robotic sleeve lower lobectomy with a middle lobe anastomosis for an endobronchial tumour of the lower lobe, extending to the distal end of the intermediate bronchus.
A 4-cm skin incision is made at the sixth intercostal space in the middle axillary line. A 30-degree 10-mm camera is placed on the posterior edge of the incision and the other two arms are crossed inside the chest. We performed a right lower sleeve lobectomy with an end-to-end anastomosis between the proximal intermediate bronchial stump and the middle lobe bronchial stump. A postoperative endobronchial examination shows a well-done anastomosis. The patient was discharged on postoperative day 5.
A histologic examination confirmed the diagnosis of a 2-cm atypical carcinoid without lymph node involvement.
Sleeve lobectomy was initially proposed for patients who were ineligible for pneumonectomy. In contrast, it is now indicated for any anatomically suitable tumours. It reduces the loss of lung function and deaths compared with pneumonectomy [1, 2].
Bronchial sleeve lobectomies are still performed via thoracotomy, but robotic-assisted thoracic surgery (RATS) has recently become the preferred technique in many centres; it is routinely performed using three or four ports with at least one service incision, contrasting with the real concept of invasiveness, especially when compared to uniportal video-assisted thoracic surgery. We present a uniportal robotic sleeve lower lobectomy with a middle lobe anastomosis.
A 58-year-old woman was referred to our attention with cough and recurrent pneumonia of the right lower lobe. A total body computed tomography (CT) scan showed a 2-cm endobronchial tumour at the origin of the lower bronchus. No extra thoracic extension of the disease was evident on a positron emission tomography-CT scan. Fibreoptic bronchoscopy confirmed the infiltration of the distal end of the intermediate bronchus by the tumour, whereas the middle lobe bronchus was tumour-free. The results of pulmonary function tests were normal. Thus, a uniportal robotic sleeve lower lobectomy with reimplantation of the middle lobe was scheduled.
1 - Case presentation (0:13)
We present the case of a 58-year-old female referred to our attention with cough and recurrent pneumonia of the right lower lobe. A total body CT scan showed a 2-cm tumour at the origin of the lower lobe bronchus with clear endoluminal extension. The positron emission tomography-CT scan did not show any extra thoracic extension of the disease, and the functional respiratory evaluation results were normal. Fibreoptic bronchoscopy revealed the infiltration of the distal end of the intermediate bronchus by the tumour. The middle lobe bronchus was tumour-free. Thus, a uniportal robotic sleeve lower lobectomy with reimplantation of the middle lobe was scheduled.
2 - Patient position, port placement, inferior pulmonary vein suture (0:57)
The patient is placed in the left lateral decubitus position, and the docking of the da Vinci Xi robot (Intuitive Surgical, Sunnyvale, CA, USA) with 3 arms is settled from the back side of the patient. The camera is in the posterior edge of the uniportal 4-cm right access. The operative robotic arms work by crossing each other inside the chest [3]. The procedure begins from the pulmonary ligament and the harvesting of lymph node station 9. The inferior pulmonary vein is isolated, encircled with a vessel loop and sutured with a robotic vascular stapler. We completed the horizontal fissure using a robotic stapler with multiple blue reloads. The pulmonary artery is exposed proximal to the middle lobe artery and encircled with a vessel loop.
3 - Oblique fissure, inferior pulmonary artery suture (2:11)
Opening the anterior oblique fissure exposes the interlobar lymph nodes, which are removed; the anterior oblique fissure is completed with the robotic stapler. Lymphadenectomy of the interlobar fissure lymph nodes allows the exposure of the inferior pulmonary artery, which is isolated and sutured with the robotic vascular stapler.
4 - Bronchial sleeve resection (2:49)
The operation proceeds with the dissection of the intermediate bronchus that is encircled and tractioned anteriorly. We started the bronchial resection cutting the middle lobe bronchus with scissors at the level of healthy bronchial tissue. In the same way we cut the intermediate bronchus above the tumour. The specimen is then removed from the chest en bloc with the lower lobe, the middle lobe bronchial stump and the intermediate bronchial stump. The bronchial margins were disease-free as seen on intraoperative frozen sections. The vessel loop anterior traction of the middle lobe artery and posterior ascending artery (A2) of the upper lobe exposes the bronchial plane. This traction is temporarily fixed to the anterior parietal pleura with silk stitches.
5 - End-to-end anastomosis (4:39)
We performed an end-to-end anastomosis between the proximal intermediate bronchial stump and the middle lobe bronchial stump with 2 halves of continuous 3/0 barbed sutures starting from the deep bronchial side. The first half of the running suture starts from the posterior wall of the middle lobe bronchial stump and the second half starts from the cartilaginous part of the intermediate bronchial stump. The sutures are knotted, and the anastomosis is tested with the underwater test.
6 - Mediastinal lymphadenectomy and pleural flap (6:32)
A standard mediastinal lymphadenectomy of the stations 2R, 4R and 7 is performed. A parietal pleural flap is then prepared to cover and protect the anastomosis.
7 - Fibreoptic bronchoscopy and postoperative course (7:03)
The postoperative endobronchial examination showed a well-done anastomosis. The patient was discharged on postoperative day 5.
The console time was 300 minutes, with minimal blood loss. The postoperative course was uneventful. The chest tube was removed on postoperative day 5, and the patient was discharged the same day. The final pathology report confirmed the diagnosis of an atypical, 2-cm carcinoid without lymph node involvement. The Tumour, Node, Metastasis stage is pT1cN0M0. A follow-up examination at six months showed no recurrence of the disease.
Discussion
Bronchopulmonary carcinoids are malignant tumours with an indolent behaviour. Surgery is the treatment of choice with the goal of removing the tumour and preserving as much lung parenchyma as possible. The surgical approach depends on the size and the location of the tumour. Whenever possible, bronchial sleeve resection or sleeve lobectomy should be performed instead of pneumonectomy [4, 5].
Compared with video-assisted thoracic surgery, several aspects of the robotic approach facilitate the bronchial anastomosis in sleeve resections, such as the 3-dimensional surgical view, tremor-free motion and seven degrees of freedom of the wristed robotic instruments [6, 7].
Several cases of multiportal robotic sleeve lobectomies are reported in the literature, whereas only a few cases of uniportal RATS sleeve lobectomies are described [8].
This case describes the technique of uniportal RATS sleeve lower lobectomy with reimplantation of the middle lobe and shows that, thanks to our daily experience with the uniportal robotic approach for standard lobectomies, uniportal RATS is feasible also for more complex operations such as sleeve lobectomies.
1. Ma Z, Dong A, Fan J, Cheng H. Does sleeve lobectomy concomitant with or without pulmonary artery reconstruction (double sleeve) have favorable results for non-small cell lung cancer compared with pneumonectomy? A meta-analysis. Eur J Cardiothorac Surg 2007;32:20–8.
PubMed Abstract | Publisher Full Text
2. Stallard J, Loberg A, Dunning J, Dark J. Is a sleeve lobectomy significantly better than a pneumonectomy? Interact Cardiovasc Thorac Surg 2010;11:660–6.
PubMed Abstract | Publisher Full Text
3. Mercadante E, Martucci N, De Luca G, La Rocca A, La Manna C. Early experience with uniportal robotic thoracic surgery lobectomy. Front Surg 2022; 9:1005860.
PubMed Abstract | Publisher Full Text
4. Detterbeck FC. Management of carcinoid tumors. Ann Thorac Surg 2010;89:998–1005.
PubMed Abstract | Publisher Full Text
5. Caplin ME, Baudin E, Ferolla P, Filosso P, Garcia-Yuste M, Lim E et al. Pulmonary neuroendocrine (carcinoid) tumors: European Neuroendocrine Tumor Society expert consensus and recommendations for best practice for typical and atypical pulmonary carcinoids. Ann Oncol 2015;26:1604–20.
PubMed Abstract | Publisher Full Text
6. Cerfolio RJ. Robotic sleeve lobectomy: technical details and early results. J Thorac Dis 2016;8(Suppl 2):S223–6.
7. Hashimoto K, Ichinose J, Matsuura Y, Nakao M, Okumura S, Mun M. How to Perform and Prepare for Robotic Sleeve Lobectomy. Ann Thorac Surg Short Rep 2023;1:530–2.
PubMed Abstract | Publisher Full Text
8. Gonzalez-Rivas D, Bosinceanu M, Manolache V, Gallego-Poveda J, Paradela M, Li S et al. Uniportal fully robotic-assisted sleeve resections: surgical technique and initial experience of 30 cases. Ann Cardiothorac Surg 2023;12:9–22.
Authors
Edoardo Mercadante, Giorgia Opromolla, Mary Bove, Antonello La Rocca, Giuseppe De Luca, Carmine La Manna & Nicola Martucci
Affiliation
Thoracic Surgery Unit - Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale", Naples, Italy
Corresponding Author
Giorgia Opromolla
Thoracic Surgery Unit
Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale”
Naples
Italy
Keywords
© The Author 2025. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
