Complex Robotic Extrapleural Completion Lobectomy for Right Upper Lobe Adenocarcinoma

A seventy-one-year-old male presented with local recurrence after a right apical posterior segmentectomy three years prior. The staging workup was consistent with localized disease, and he was deemed a good surgical candidate. After multidisciplinary evaluation, the patient was brought in for repeat resection. First, four robotic trocars were placed in the eighth intercostal space, as previously described by the authors. Dense adhesions were immediately encountered, and extensive lysis was required. Given the extent of adhesion, as well as the medial location of the nodule, the decision was made to proceed with extrapleural resection to preserve surgical margin. The right upper lobe bronchus, upper lobe tributary of the superior pulmonary vein, and anterior apical branch of pulmonary artery were all identified, circumferentially mobilized, and divided. Then the parenchyma bridge was divided for completion lobectomy. Remaining lymph nodes were harvested, which was limited given the patient’s previous oncological resection, and an apical chest tube was left in place. Finally, the patient was discharged on postoperative day one. Final pathology showed a 2 cm invasive acinar adenocarcinoma with negative resection margins and no lymph nodes involved, pT2aN0, and stage 1A. In summary, the patient presented with suspected local recurrence of lung cancer after prior anatomic resection, and robotic technology allowed to complete the case in a minimally invasive fashion despite anatomic challenges while maintaining oncological principles. References 1. Zirafa CC, Romano G, Key TH, Davini F, Melfi F. The evolution of robotic thoracic surgery. Ann Cardiothorac Surg. 2019 Mar;8(2):210-217. doi: 10.21037/acs.2019.03.03. PMID: 31032204; PMCID: PMC6462549.