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Similar to traditional video-assisted thoracic surgery (VATS) segmentectomy, robotic segmentectomy is commonly used as an approach for patients presenting with early-stage lung cancers, low-grade infectious processes, or borderline pulmonary function tests. For patients presenting with lesions suspicious for or proven to be non–small cell lung cancer, the preoperative work-up includes high-resolution computed tomography of the chest, positron emission tomography–computed tomography, and pulmonary function testing. Axial imaging allows for a careful assessment of disease burden but also provides an important roadmap for understanding segmental anatomy, lymph node location, and fissure status. At our institution, preoperative invasive mediastinal staging for early-stage non–small cell lung cancer is not typical for patients undergoing segmentectomy but may be used if clinically indicated. Absolute and relative contraindications are not well defined for robotic segmentectomy; however, robotic pulmonary resection in general has been used in scenarios involving previous thoracic surgery, neoadjuvant chemoradiation, chest wall invasion, and hilar lymphadenopathy.
Compared with traditional open and thoracoscopic methods, our opinion is that RATS provides a combination of outstanding exposure, enhanced optics, and unparalleled dexterity. These advances make RATS an ideal tool that can facilitate the precision necessary for isolation and division of segmental anatomy. Although there is a learning curve, we believe that with mastery of basic robotic techniques and a thorough understanding of 3-dimensional thoracic anatomy, robotic segmentectomy is feasible for most, if not all, thoracic surgeons. With these considerations in mind, the goal of this Video Atlas is to provide a comprehensive, step-by-step description of our approach to robotic lingulectomy that can serve as a useful reference for both novice and experienced thoracic surgeons using RATS.
This approach to robotic lingulectomy is described in 8 distinct steps. The described approach uses the da Vinci Xi System (Intuitive Surgical). Instrumentation descriptions are provided within the text. We acknowledge that there are other reproducible approaches to robotic lingulectomy.
Step 1: Patient Positioning, Port Placement
After placement of a double-lumen endotracheal tube, the patient should be positioned in the right lateral decubitus position. After generous flexing of the bed, the hips should fall below the level of costal margin and left arm should be extended with minimal abduction of the shoulder; these considerations allow for maximum mobility of robot arms after docking.
We place 5 ports in a fairly standardized manner and in a method similar to Cerfolio and colleagues.
To summarize, we use 4 robotic arms which are placed in the 8th or 9th intercostal space and an assistant port which is placed 1 to 2 spaces below (Figure 1). The robotic ports are as follows: port 1 is a 12-mm port and is placed anteriorly so that port enters the chest at the cardiophrenic recess, port 2 is an 8-mm port that is placed 1 to 2 interspaces below and just anterior to the scapular tip and will serve as the camera port, port 3 is a 12-mm port that is positioned midway between scapular tip and the spine, and port 4 is an 8-mm port that is placed fairly posteriorly and approximately 3 to 4 cm anterior to the spine. The assistant port is a 15-mm port and is triangulated with ports 1 and 2. We use a 15-mm port to accommodate a large specimen collection bag and for the Endo GIA stapler (Medtronic), which may be used for challenging stapler angles. It is helpful that ports be spaced at least 8 to 10 cm apart to maximize workspace and minimize collision of robotic arms. In smaller patients, ports can be positioned a bit closer, with as little as 6 to 7 cm of distance between them. After the ports have been placed, the robot is docked at the patient's bedside with arm 1 initially using the Cadiere forceps (Intuitive Surgical; will later serve as a stapler port), arm 2 using the 30° camera, arm 3 using a Maryland Bipolar grasper (will also serve as a stapler port), and arm 4 using a Tip-Up Fenestrated Grasper (Intuitive Surgical). We use CO2 insufflation set to 5 to 8 mm Hg to improve exposure as it pushes the diaphragm inferiorly and displaces the mediastinum toward the contralateral hemithorax.
Step 2: Division of Inferior Pulmonary Ligament and Dissection of Stations 8 and 9
We begin with an inspection of the hemithorax to rule out advanced disease (Video 1, Figure 2). After metastatic disease has been ruled out, the Tip-Up Fenestrated Grasper is used to gently retract the lung in a medial/cephalad direction and place traction on the inferior pulmonary ligament. The inferior pulmonary ligament is released using a bipolar cautery. Any level 9 lymph nodes encountered are dissected and sent for a permanent pathology. At this time, we also take level 8 lymph nodes, which are within view. The lung is then repositioned and retracted anteriorly; this redistributes tension, thus allowing for continued cephalad dissection along the posterior hilum. To maintain hemostasis and minimize distortion of tissue planes, the pleura should be incised immediately posterior to the lung parenchyma.
This dissection is continued until station 7 is encountered between the inferior vein, left mainstem bronchus, and the esophagus. We routinely perform a complete level 7 nodal dissection. We begin by carefully clearing the most superficial tissue off the node. Once approximately 50% of the node is clear, we grasp the node with the Cadiere forceps and gently retract the node. This retraction nicely exposes bronchial vessels and lymphatics which can be ligated with the Maryland bipolar. Residual oozing is typically controlled with Surgicel (Ethicon).
Step 3: Identification of the Pulmonary Artery in the Posterior Hilum, Dissection of Stations 5 and 6
Releasing the posterior hilum continues in a cephalad direction, heading toward the left pulmonary artery and then the aorticopulmonary window (Video 2, Figure 3). We point out that one can almost always identify the interlobar pulmonary artery posteriorly, even in circumstances of an incomplete fissure. Identifying the pulmonary artery in this location provides a useful landmark to begin the fissure dissection. After identification of the pulmonary artery and before beginning our fissure work, we complete the posterior hilum and take station 10 lymph nodes. We then continue to mobilize in a cephalad direction and free superior hilum by retracting the upper lobe inferiorly and taking nodal stations 5 and 6. We are careful to avoid injury to the recurrent nerve with traction and dissection in the aorticopulmonary window.
Step 4: Unroofing the Pulmonary Artery and Identification of Lingular Branches
With the posterior hilum released, we move our dissection to the fissure where we unroof the interlobar pulmonary artery (Video 3, Figure 4). Beginning posteriorly at the already identified pulmonary artery, we arrive at the subadventitial plane and proceed with unroofing the pulmonary artery in anterior direction with use of the bipolar cautery or stapler (blue loads of the SureForm stapler; Intuitive Surgical). To maximize exposure in the fissure, the Tip-Up Fenestrated Grasper (arm 4) is used to retract the upper lobe superiorly while the assistant provides gentle traction inferiorly using a rolled sponge. It is common to identify level 11 lymph nodes along the interlobar pulmonary artery and 12 lymph nodes at branch points. When encountered, these are carefully dissected for 2 primary reasons: (1) removal enhances exposure of the pulmonary artery and branches and (2) involved lymphadenopathy on frozen section analysis suggests the need for lobectomy. The lingular artery branches are typically isolated and divided using a white load of the SureForm stapler (brought in through arm 1). Although there is typically a singular lingular artery, some patients may have multiple branches, some of which may arise from the locations other than interlobar pulmonary artery. In the circumstances of an incomplete fissure, it is common to identify small crossing veins, which can be controlled with a bipolar cautery. Infrequently, we turn our attention to the anterior hilum when dissection in the fissure becomes cumbersome, as noted in this example.
Step 5: Division of the Lingular Vein
We typically move to the anterior hilum and focus on the lingular vein after completing the fissure dissection and dividing the lingular arteries (Video 4, Figure 5). As previously noted, we will occasionally need to turn our attention to the anterior hilum before completing our fissure dissection in cases an incomplete fissure (as demonstrated in this video). After confirming the origin of the lingular vein from the superior pulmonary vein, the lingular vein is dissected circumferentially and taken with White load of the SureForm stapler (brought in with arm 3). Any level 10 nodes encountered in the hilum are again taken and sent for frozen section analysis as nodal disease may suggest the need for lobectomy.
Step 6: Completion of the Anterior Fissure
In cases of an incomplete fissure, we return focus to the fissure after freeing the anterior hilum and dividing the lingular vein, which is typically the most inferior branch of the superior pulmonary vein (Video 5, Figure 6). Common variations include circumstances of more than lingular vein or an origin off the inferior pulmonary vein. Identification of the characteristic level 11 lymph node packet at the secondary carina is important as dissection of this nodal tissue provides a safe window to divide the anterior fissure. Once this window is cleared, a vessel loop can be passed that allows for gentle retraction and positioning of a blue load of the SureForm stapler (brought in brought in with arm 1). Dividing the anterior fissure improves the mobility of the upper and lower lobes, and therefore allows for improved exposure of the interlobar pulmonary artery and lingular branches. Lingular artery branches can be readily skeletonized and freed circumferentially using the bipolar cautery and then isolated with vessel loops. In general, there is a single lingular artery; however, approximately 25% of patients will have multiple branches.
After carefully isolating the arterial blood supply to the lingula, vessels may be taken with a White load of the Surefire stapler (brought in through arm 1).
Step 7: Division of the Lingular Bronchus
With the vascular supply divided and fissure released, attention is turned to the lingular airway which typically lies below the venous staple line and anterior to the lingular artery staple line(s) (Video 6, Figure 7). One should expect to encounter a station 12 lymph nodal packet at the tertiary carina between the airways to the superior division and lingula. If frozen section demonstrates station 12 nodal involvement, we advocate for formal lobectomy if the patient can tolerate. Removal of these tissues greatly enhances the view of the lingular airway. After the nodal dissection has been completed, remaining peribronchial tissue is carefully dissected distally (so that it is included within the specimen). Once adequate dissection of the airway is achieved, the airway is transected with a blue load of the SureForm stapler (brought in through Arm 3).
Step 8: Parenchymal Division Along the Intersegmental Plane
With the lingula artery, vein, and airway dissected, the final step remaining involves division of parenchyma at the intersegmental plane (Video 7, Figure 8). To identify this line, we use intravenous indocyanine green (ICG) and near-infrared imaging using the Firefly system in the Xi Robot as previously described.
To summarize, 5 mg of ICG is delivered as an intravenous push by the anesthesia team. Within 1 to 2 minutes, the camera is switched to the Firefly mode, which allows the surgeon to identify the well-perfused superior division (displays green near-infrared signal from circulating ICG) and the ischemic lingular specimen (does not illuminate). The plane between these areas is scored using a bipolar cautery, and then divided from posterior to anterior using the several blue loads of the SureForm stapler (brought in through arm 3). With the lingula now fully freed, the specimen is placed in a specimen bag and removed through the assistant port.
Although RATS segmentectomy is viewed as technically challenging, after overcoming learning curves excellent results are achievable. Data suggest that outcomes are comparable with traditional VATS segmentectomy, with complication rates less than 10% and a negligible risk for perioperative mortality. In general, we find that most patients are discharged on postoperative day 1 or 2 in good condition and with minimal narcotic needs. Chest tubes are removed when the air leak has resolved. A full review of postoperative outcomes is beyond the scope of this technical piece, and has been comprehensively reviewed elsewhere.
As compared with traditional thoracoscopic segmentectomy, RATS offers subjective advantages including improved visualization, dexterity, and exposure We acknowledge that despite previously noted advantages, there remains no clear outcome data suggesting superiority of RATS over VATS segmentectomy.
Lingulectomy is a common application for RATS. Safety, feasibility, and outcomes are comparable with more traditional open and VATS approaches. Subjective advantages include improved optics, enhanced dexterity, and better ergonomics for the surgeon. We believe that with proper training and experience, robotic segmentectomy can become a useful tool for the current generation of thoracic surgeons.
Disclosures: L.S. is a speaker and proctor for Intuitive Surgical. In addition, L.S. has a research and education grant from Intuitive Surgical . J.D.P. has ongoing research collaborations with Olympus, Tokyo, and is a consultant for OnTarget Laboratories. All other authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.