Total Robotic Right Pneumonectomy

Pneumonectomy is occasionally required for pulmonary resection but is associated with increased incidence of morbidity and mortality (1). Recent reviews have compared minimally invasive surgery (VATS) to thoracotomy (2,3). A report from National Cancer Database 2010–2014 had 4,938 patients who underwent pneumonectomy and 15.3 percent were VATS (2). The VATS approach did not compromise perioperative mortality or long-term outcomes; however, VATS had a 36.7 percent conversion rate to thoracotomy. Another multicenter study demonstrated that VATS pneumonectomy resulted in a significantly greater number of lymph nodes, had similar complications and five-year survival compared with open thoracotomy, and had a conversion rate of 19 percent (3). The VATS approach for pneumonectomy can therefore be performed safely with equivalent oncological outcomes compared to thoracotomy. Data on robotic pneumonectomy had been limited to a few case reports (4,5) until a recent series demonstrated that it is a safe procedure and a reasonable alternative to thoracotomy (6), but 38 percent of the robotic pneumonectomies were converted to thoracotomy and most of those were early in the series of thirteen, with only 20 percent in the last year. Conversion to thoracotomy was not related to size of the tumor. Robotic pneumonectomy has recently been described in detail (7), but there are few videos on the technique of robotic right pneumonectomy (8). This video demonstrates the technique of total robotic right pneumonectomy. The robotic approach offers improved vision and a stable platform allowing right pneumonectomy and lymphadenectomy, which resulted in reduced pain and length of hospital stay with enhanced patient recovery. Case Summary The patient is a sixty-five-year-old with a history of cough. A chest computed tomography angiography (CTA) demonstrated right lower lobe mass with consolidation of right middle and lower lobes. A PET scan demonstrated a 3.4 x 2.9 cm central right lower lobe mass with SUV of 6.6 and paratracheal/hilar uptake. A bronchoscopy with brushing and fine-needle aspiration (FNA) of the right hilum demonstrated squamous cell carcinoma-cT2aN1M0 (Stage IIB). A CTA of the chest demonstrated the 3.7 cm mass occluding the right lower lobe bronchus and abutting the interlobar artery, narrowing and occluding the lower lobe and middle lobe vessels. An MRI of the brain was negative for metastatic disease. A quantitative ventilation perfusion scan demonstrated predicted postoperative with right middle and lower lobectomy and pneumonectomy. FEV1 was 56 percent and 50 percent, and DLCO was 67 percent and 59 percent, respectively. The staging mediastinoscopy had stations 2R and 4R lymph nodes without metastatic disease. Intraoperatively it was felt that a middle/lower lobectomy could not be performed because of the central location of the mass abutting the vessels; therefore, a total robotic right pneumonectomy was performed. Postoperatively, the patient did well and was discharged home on the second postoperative day. Final pathology revealed squamous cell carcinoma-T2bN1M0 (Stage IIB) with six of twenty-three total lymph nodes with cancer, but six of thirteen lymph nodes were involved by direct extension of the tumor within the specimen. Reference(s) 1. Shapiro M, Swanson SJ, Wright CD, Chin C, Sheng S, Wisinivesky J, Weiser, TS. Predictors of major morbidity and mortality after pneumonectomy utilizing the Society for Thoracic Surgeons General Thoracic Surgery Database. Ann Thorac Surg 2010; 90:927-34. 2. Hennon MW, Kumar A, Devisetty H, et al. Minimally invasive approaches do not compromise outcomes for pneumonectomy: A comparison using the National Cancer Database. J Thorac Oncology. 2019: 14; 107-114. 3. Yang CF, Yendamuri S, Mayne N, et al. The role of thoracoscopic pneumonectomy in the management of non-small cell lung cancer: A multicenter study. J Thorac Cardiovasc Surg. 2019; 158: 252-264. 4. Rodriguez J.R. Total portal robotic pneumonectomy. Gen Thorac Cardiovascsurg 2013; 61:538-541. 5. Giulianotti PC, Buchs NC, Caravaglios G, et al. Robotic-assisted lung resection: Outcomes and technical details. Interact Cardiovasc ThoraC Surg. 2010; 11:38 a.m. 8-392. 6. Patton BD, Zarif D, Bahroloomi DM, et al. Robotic pneumonectomy for lung cancer: Perioperative outcomes and factors leading to conversion to thoracotomy. Innovations. 2021; 16:136-141. 7. Amirkhosravi F, Kim M. Complex robotic lung resection. Thorac Surg Clin. 2023; 33: 51-60. 8. Vidanapathirana CP, Papoulidis P, Nardini M, et al. Subxiphoid robotic-assisted right pneumonectomy. J Thorac Dis. 2019; 11: 1629-1631.