Robotic Lobectomy

Fig. 27.1

Angle of approach of robot docking for lobectomy (da Vinci Si system) (a) right lobectomy, (b) left lobectomy

Fig. 27.2

Angle of approach of robot docking for lobectomy (da Vinci Xi system) and possible room layout

Patient Positioning/Port Placement

The patient is positioned in lateral decubitus position and the operating table flexed to open up the intercostal spaces. The patient should be moved posteriorly as much as possible so that the patient’s arms can fit on the bed in front of the patient’s head. Axillary rolls and arm boards are unnecessary (Fig. 27.3). The robotic ports are inserted in the seventh intercostal space for upper/middle lobectomy and in the eighth intercostal space for lower lobectomy. Typical port placement is shown in Fig. 27.4 for a right robotic lobectomy. The ports are marked as follows: robotic arm 3 (5 or 8 mm port) is located 1–2 cm lateral from the spinous process of the vertebral body, robotic arm 2 (8 mm) is 10 cm medial to robotic arm 3, the camera port (we prefer the 12 mm camera) is 9 cm medial to robotic arm 2, and robotic arm 1 (12 mm) is placed right above the diaphragm anteriorly. The assistant port is triangulated behind the camera port and the most anterior robotic port, and as inferior as possible without disrupting the diaphragm. We use a zero-degree camera for this operation. Insufflation of the camera or assistant port with carbon dioxide is used to depress the diaphragm, decrease bleeding, and compress the lung .

Fig. 27.3

Patient position for robotic lobectomy, viewed from anterior

Fig. 27.4

Port placement for right robotic lobectomy. C camera port, 1 robotic arm 1, 2 robotic arm 2, 3 robotic arm 3, A assistant port, MAL mid-axillary line

Mediastinal Lymph Node Dissection

After examining the pleura to confirm the absence of metastases, the next step during our performance of robotic lobectomy is removal of the mediastinal lymph nodes , for staging, and also to help expose the structures of the hilum.

Right side—The inferior pulmonary ligament is divided. Lymph nodes at stations 8 and 9 are removed. Robotic arm 3 is used to retract the lower lobe medially and anteriorly in order to remove lymph nodes from station 7. Robotic arm 3 is used to retract the upper lobe inferiorly during dissection of stations 2R and 4R, clearing the space between the SVC anteriorly, the esophagus posteriorly, and the azygos vein inferiorly. Avoiding dissection too far superiorly can prevent injury to the right recurrent laryngeal nerve that wraps around the subclavian artery.
Left side—The inferior pulmonary ligament is divided to facilitate the removal of lymph node station 9. The nodes in station 8 are then removed. Station 7 is accessed in the space between the inferior pulmonary vein and lower lobe bronchus, lateral to the esophagus. The lower lobe is retracted medially/anteriorly with robotic arm 3 during this process. Absence of the lower lobe facilitates dissection of level 7 from the left. Finally, robotic arm three is used to wrap around the left upper lobe and pressed it inferior to allow dissection of stations 5 and 6. Care should be taken while working in the aorto-pulmonary window to avoid injury to the left recurrent laryngeal nerve. Station 2 L. cannot typically be accessed during left-sided mediastinal lymph node dissection due to the presence of the aortic arch, but the 4 L. node is commonly removed.

Wedge Resection

Wedge resection of a nodule may be necessary to confirm the presence of cancer prior to proceeding with lobectomy. Because the current iteration of the robot does not offer tactile feedback, special techniques may be necessary to identify a nodule that is not obvious on visual inspection. An empty ring forceps may be used via the assistant port to palpate the nodule. Alternatively, preoperative marking of the nodule with a dye marker injected via navigational bronchoscopy can help facilitate location of the nodule. Preoperative confirmation of a cancer diagnosis with tissue biopsy is helpful to avoid being unable to locate the nodule intraoperatively. In the future, the use of injected indocyanine green (ICG) may also allow surgeons to visualize nodules intraoperatively [4].

The Five Lobectomies

A certain degree of adaptability is necessary for performance of robotic lobectomy. Structures may be isolated and divided in the order that the patient’s individual anatomy permits. What follows is a description of an outline of the typical conduct of each lobectomy.

Right Upper Lobectomy

The right upper lobe is then reflected anteriorly to expose the bifurcation of the right main stem bronchus. There is usually a lymph node here that should be dissected out to expose the bifurcation. The right upper lobe bronchus is then encircled and divided. Care must be taken to apply only minimal retraction on the specimen in order to avoid tearing the remaining pulmonary artery branches.
Retraction of the right upper lobe laterally and posteriorly with robot arm 3 helps expose the hilum.
The bifurcation between the right upper and middle lobar veins is developed by dissecting it off the underlying pulmonary artery.
The 10R lymph node between the truncus branch and the superior pulmonary vein should be removed or swept up towards the lung, which exposes the truncus branch.
The superior pulmonary vein is encircled with the vessel loop and then divided. The truncus branch is then divided.
Finally, the posterior segmental artery to the right upper lobe is exposed, the surrounding N1 nodes removed, and the artery encircled and divided.
The upper lobe is reflected again posteriorly, and the anterior aspect of the pulmonary artery is inspected to make sure that there are no arterial branches remaining. If not, then the fissure between the upper and middle lobes, and the upper and lower lobes, is then divided. This is typically done from anterior to posterior, but may be done in the reverse direction if the space between the pulmonary artery and right middle lobe is already developed. During completion of the fissure, the right upper lobe should be lifted up to ensure that the specimen bronchus is included in the specimen.

Right Middle Lobectomy

Retraction of the right middle lobe laterally and posteriorly with robot arm l helps expose the hilum.
The bifurcation between the right upper and middle lobar veins is developed by dissecting it off the underlying pulmonary artery. The right middle lobe vein is encircled and divided.
The fissure between the right middle and lower lobes, if not complete, is divided from anterior to posterior. Care should be taken to avoid transecting segmental arteries to the right lower lobe.
The right middle lobe bronchus is then isolated. It will be running from left to right in the fissure. Level 11 lymph nodes are dissected from around it. It is encircled and divided, taking care to avoid injuring the right middle lobar artery that is located directly behind it.
Dissection of the fissure should continue posteriorly until the branches to the superior segment are identified. Then the one or two right middle lobar segmental arteries are isolated and divided.
Stapling of middle lobar structures may be facilitated by passing the stapler from posterior to anterior, to have a greater working distance.
The fissure between right middle and upper lobes is then divided.

Right Lower Lobectomy

The inferior pulmonary ligament should be divided to the level of the inferior pulmonary vein.
The bifurcation of the right superior and inferior pulmonary veins should be dissected out. The location of the right middle lobar vein should be positively identified to avoid inadvertent transection.
A subadventitial plane on the ongoing pulmonary artery should be established. If the major fissure is not complete, then it should be divided. The superior segmental artery and the right middle lobe arterial branches are identified. The superior segmental artery is isolated and divided. The common trunk to right lower lobe basilar segments may be taken as long as this does not compromise the middle lobar segmental artery/arteries; otherwise, dissection may have to extend further distally to ensure safe division.
The inferior pulmonary vein is divided.
The right lower lobe bronchus is isolated, taking care to visualize the right middle lobar bronchus crossing from left to right. The surrounding lymph nodes, as usual, are dissected and the bronchus divided. If there is any question of compromising the right middle lobe bronchus, the surgeon can ask the anesthesiologist to hand-ventilate the right lung to confirm that the middle lobe expands.