Right robotic-assisted thoracic surgery retrograde fissureless en bloc S2/6 bisegmentectomy

Patient presentation

A 76-year-old male with a background of hypertension, gout and arthritis was referred because of an incidental, 18-mm, partially ground-glass/partially solid opacity of the right lung following a chest infection. Clinical assessment was unremarkable. The patient was an active smoker with a performance score of 0.

His lung function test results showed a forced expiratory volume in 1 second of 103% and a transfer factor for carbon monoxide of 84%.

Investigations revealed a 18- x 12-mm right lung lesion, positioned in a totally incomplete oblique fissure, within its posterior aspect and most of its length lying between segments 2 and 6. The lesion was increasing in size on the follow-up computed tomography (CT) scan; a subsequent positron emission tomography scan showed the lesion to be mildly avid (standard uptake value 1.9) while it excluded any other disease.

A CT-guided biopsy was not feasible because of the fear of complications and of the significant possibility of missing the diagnosis.

The lung multidisciplinary team members decided to go with resection of the lesion.

An en block bisegmentectomy of the adjacent segments 6 and 2 was recommended to ensure resection of the lesion and provide an acceptable oncological outcome.

The procedure was performed using the da Vinci X system (Intuitive Surgical, Sunnyvale, CA, USA) (utilizing 4 ports: 2 x 12 mm and 2 x 8 mm). The surgeon prefers to avoid inserting ports behind the scapular line in order to minimize pain and to set the ports in a straight line.

Inferior pulmonary ligament and lymph node dissection

After docking and inserting the instruments, the inferior pulmonary ligament was divided. The posterior hilum was dissected, retracting the lung anteriorly. Station 7 was dissected and sent for histological analysis. Next, station 4 was opened, and lymph node dissection of stations 4R and 2R was completed.

The inferior pulmonary vein was dissected posteriorly. The V6, together with the rest of the basal vein tributaries, was recognized and dissected. The V6 was disconnected with a vascular robotic SureForm stapler (Intuitive).

Because it was anticipated that the oblique fissure was not developed posteriorly (where the lesion was positioned), we attempted to create the fissure anteriorly in an effort to dissect the pulmonary artery (PA). This endeavour was tedious, and the PA sheath was entered. The anatomy of the PA was clarified, and all branches were recognized. At this stage, an anatomical variation was observed with the A6 originating with a common trunk with the A2b (posterior recurrent branch). Based on these findings and the position of the lesion, it was decided that the S6 should be detached first to avoid traumatizing the common arterial trunk and also to avoid missing the lesion.

Starting posteriorly and on top of the basal part of the inferior pulmonary vein, slow and careful dissection continued towards the middle of the fissure and under the B6 (exit point between the A6 and rest of artery for the basal segments of the lower lobe). A urine catheter was pulled through to designate the pathway of the segmental plane. Because the A6 was not divided, we could not use indocyanine green to demarcate the exact S6 segmental plane. The S6 was disconnected from the rest of the lower lobe with serial black robotic Sureform staplers (Intuitive).

Once the S6 was detached from the lower lobe, the next structure divided was the B6, which was done similarly with the green stapler.

Next, the A6 and A2b were divided with similar vascular staplers. This step was done separately because, given that the S6 and upper lobe were pushed apically, the A6 was seen first with the A2b being positioned posteriorly to it.

After all arterial branches were divided, indocyanine green was administered to demarcate the S2 segmental plane. The marking was done using cautery.

The posterior hilum was opened even further and more peripherally to identify the right upper lobe bronchus branching posteriorly. Dissection continued superiorly and anteriorly to the bronchus to ensure that a separate B3 was present. Once all the anatomical relationships were clarified, the B2 was divided with a green Sureform stapler.

The S2 was disconnected from the rest of the upper lobe using similar serial black staplers. The stapling line followed the previous markings created after administering indocyanine green, as previously described.

The specimen was removed in an Endo bag (not shown in the video), and the surfaces were covered with a haemostatic agent. A 20 Fr chest drain was inserted postero-apically. After thorough endobronchial suctioning (performed by the anaesthetist), the lung was inflated.

The patient was extubated and after recovery was taken to the ward. His post-operative chest X-ray was acceptable.

His recovery was uneventful, and he was found to be medically fit to be discharged the next day.

The histological report verified that the resected lesion was an adenocarcinoma non-small cell lung cancer (pT1bN0M0V1PL0) with negative margins (R0).

The patient is without issues 1 year postoperatively without cancer recurrence.