Robotic Right Middle Lobectomy and Mediastinal Lymph Node Dissection for Adenocarcinoma

Case Overview

Lung cancer remains a critical global health challenge, with non-small cell lung cancer (NSCLC) accounting for approximately 80–85% of all lung cancer diagnoses, with adenocarcinoma representing the most prevalent subtype.¹ Surgical intervention continues to be the primary curative treatment modality for early-stage and select intermediate-stage lung malignancies, with lobectomy emerging as the gold standard for lung cancer resection.^2,3

The advent of robotic-assisted thoracic surgery (RATS) has revolutionized the surgical management of pulmonary malignancies, offering several distinct advantages over traditional open and video-assisted thoracoscopic surgery approaches.^4–7

The robotic platform provides 3D high-definition visualization with 10x magnification, enhancing anatomical detail and precision. This clarity is crucial for accurate vascular navigation and complex anatomical assessment.⁸

Moreover, robotic systems eliminate physiological hand tremors, enabling more precise dissection and reduced tissue trauma.⁹ RATS has demonstrated advantages over conventional approaches, particularly in facilitating more thorough lymph node dissection, although its impact on surgical margin control remains less clearly defined.¹¹

The robotic approach minimizes surgical invasiveness, resulting in reduced postoperative pain, shorter hospital stays, faster recovery times, decreased risk of surgical complications, and improved cosmetic outcomes.^10–13
Robotic right middle lobectomy with mediastinal lymph node dissection is typically indicated for early to intermediate-stage adenocarcinoma. It is performed in patients with sufficient pulmonary reserve, targeting tumors in the right middle lobe and cases that require comprehensive mediastinal lymph node staging. This procedure demands a comprehensive approach to surgical planning and patient management, involving precise preoperative imaging and staging, meticulous assessment of patient comorbidities, evaluation of potential anatomical variations, and a multidisciplinary team approach to treatment planning.

Despite its advantages, robotic lobectomy presents unique technical challenges. These include complex port placement strategies, managing anomalous pulmonary vascular anatomy, potential conversion to open surgery, and a significant learning curve for surgical teams.

This surgical video is a step-by-step demonstration of advanced robotic-assisted thoracic surgical techniques, specifically focusing on right middle lobectomy for adenocarcinoma. It provides critical insights into the procedural steps, challenges, and strategic decision-making processes inherent in minimally invasive lung cancer surgery.

The surgical approach begins with strategic port placement to maximize surgical access. Key anatomical landmarks, including the scapula tip and costal arch, are initially identified. The primary port configuration is established with a camera port positioned in the eighth intercostal space anterior to the mid-axillary line, measuring 8 millimeters. The insertion technique involves careful pleural space entry with lung deflation. Robotic arm ports are positioned strategically, with arm one serving as the primary retracting arm placed above the superior segment of the lower lobe using an 8-millimeter port angled for optimal manipulation. Arm two, positioned in the eighth intercostal space along the posterior axillary line, provides additional surgical flexibility.

Additional ports include a 12-millimeter stapling port positioned posterior to the costal margin and an assistant port located just above the diaphragm measuring 12 millimeters. The mediastinal lymph node dissection procedure is initiated with a comprehensive initial survey to rule out potential metastatic disease and identify existing adhesions. Adhesions are managed using Maryland bipolar cautery with careful attention to tissue preservation, proceeding through multiple systematic stages targeting specific lymph node stations.

In RATS for lung resections, various port placement strategies have been developed to optimize surgical access and instrument maneuverability. While the four-arm, look-up-view approach remains the mainstream technique, alternative methods utilizing three or four ports have been explored to enhance surgical efficiency and patient outcomes. These variations aim to reduce the number of incisions, minimize invasiveness, and adapt to the surgeon’s preferences and the patient’s anatomy. For instance, some approaches employ a three-arm technique with utility incisions, while others utilize a four-arm configuration without robotic staplers.¹⁴ 
The inferior pulmonary region dissection involves elevation of the lower lung lobe, followed by careful dissection of the inferior pulmonary ligament. Lymph nodes in mediastinal stations 8R and 9R are identified and resected, with the inferior pulmonary vein serving as the critical termination point. Subsequent focus shifts to the posterior hilum, where subcarinal lymph node packet dissection is performed with precise anatomical boundaries defined by the pericardium, esophagus, and surrounding bronchial structures.

The systematic examination of mediastinal lymph node station 7 demands cautious surgical navigation through a complex anatomical landscape. The superior hilum and paratracheal node dissection emerges as the most technically challenging component of the procedure. Specifically, proper paratracheal node removal requires precise surgical techniques, with careful attention to critical anatomical landmarks including the cavoazygos junction, superior vena cava, phrenic nerve, and aortic arch, while maintaining focused exploration of lymph node station 4R.

The middle lobectomy begins with a comprehensive hilum examination, revealing complex vascular anatomy. A critical focus is the middle lobe venous branch, which demonstrates significant anatomical variability. Specifically, in 80% of cases, this vein emerges from the superior pulmonary vein, while in 20% of instances, it originates from the lower lobe vein or represents an independent atrial branch.

During surgical exploration, the major fissure between the middle and lower lobes appears relatively well-defined. However, notable adhesions are observed between the upper and middle lobes. The surgical strategy employs a methodical bottom-up approach, initially identifying pulmonary artery branches and systematically dissecting lymph nodes to clarify underlying anatomical structures. The lymph node dissection presents technical challenges, with the firm nodal tissue potentially indicating tumor involvement.

An unexpected intraoperative finding was the tumor’s proximity to the minor fissure. Its adherence to the upper lobe necessitated excising a small wedge of the upper lobe to ensure clear surgical margins. This approach highlighted the importance of visual assessment and a conservative surgical strategy, particularly when tactile feedback is limited in robotic surgical techniques.

The procedure incorporates indocyanine green dye to delineate fissural boundaries and confirm complete tissue resection. Multiple arterial branches are identified, with the surgeon noting the frequent variability of middle lobe arterial anatomy, including recurrent branches originating from the basilar pulmonary artery. Once arterial anatomy is clearly delineated, the middle lobe vein is identified—most commonly as a tributary of the superior pulmonary vein—and divided using a robotic stapler. Dissection continues with exposure of the middle lobe bronchus, which is surrounded by nodal tissue that must be cleared to ensure accurate anatomical identification. The bronchus is then safely divided.

Particular care is taken when approaching the middle lobe pulmonary artery; dissection is focused on the adventitia to allow safe and generous circumferential exposure before stapler passage. Due to the size and rigidity of robotic staplers, this step requires precise dissection to avoid vessel injury. Once all bronchovascular structures are divided, indocyanine green (ICG) dye is administered intravenously to highlight the parenchymal plane between the upper and middle lobes. The fissure is then completed using a parenchymal stapler, guided by the fluorescence-enhanced boundary. The resected lobe is placed into an endoscopic retrieval bag and set aside. The operative field is examined for hemostasis and completeness of resection.

Following resection, a posterior intercostal nerve block was administered using an anesthetic solution to aid in postoperative analgesia. The specimen was extracted, a chest drain was placed in the right pleural space for monitoring, and the surgical wounds were closed in a standard layered fashion.

The final surgical specimen confirms comprehensive resection while preserving critical anatomical structures. A fundamental principle of thoracic surgery is exemplified: systematic lymph node removal not only addresses oncological objectives but also reveals underlying anatomical complexities, facilitating precise surgical intervention.

This surgical video provides a comprehensive demonstration of advanced robotic-assisted thoracic surgical techniques, focusing specifically on right middle lobectomy for adenocarcinoma. It documents the strategic decision-making processes involved in complex thoracic interventions. It highlights how technological advancements can enhance patient outcomes. As an educational resource, the video bridges theoretical knowledge with practical application, providing surgeons and medical professionals with a nuanced understanding of advanced surgical techniques. It exemplifies how robotic assistance can enhance surgical precision, reduce invasiveness, and enable more comprehensive tissue management, ultimately representing a significant advancement in the field of oncological surgery.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.