Robotic Right Middle Lobectomy and Mediastinal Lymph Node Dissection for Adenocarcinoma

CHAPTER 1

I am Hugh Auchincloss. I'm a thoracic surgeon at the Massachusetts General Hospital. Today we'll be presenting a right middle lobectomy, which we're performing in this case for a woman with a biopsy proven adenocarcinoma involving her right middle lobe. She also has a good deal of FDG-avid mediastinal lymph nodes, which were previously sampled by me with a mediastinoscopy in which are all consistent with granulomatous disease. And so she's being brought to the operating room today for a curative intent, middle lobectomy. The key steps to the operation - so we'll bring her to the operating room and after induction of anesthesia and placement of a double lumen endotracheal tube for lung isolation, I'll perform a quick bronchoscopy just on the right side to confirm that there's no significant secretions and that the right sided tracheal bronchial anatomy is normal. We'll then position her with her right side up in the lateral decubitus position, we'll flex the table slightly to extend her rib spaces and then prep and drape her right chest in the standard fashion. I do a robotic approach and so we'll place four robotic ports. Typically we'll use three or sometimes two eight-millimeter ports and one or two 12-millimeter ports which would be used for stapling. The camera port is gonna be placed in the eighth inner space in the midaxillary line. The remaining ports kind of orient around that one, but basically the retractor arm is gonna be the robot's arm number one and that's gonna go just off the tip of the superior segment of the right lower lobe. The arm two is gonna be predominantly a retracting arm and that's gonna go in on the posterior axillary line in the eighth inner space. And then a stapling port's gonna go anteriorly just posterior to the costal margin. And then we'll place an assistant port just above the diaphragm through which we'll insufflate the chest to a pressure of eight millimeters of mercury and then dock the robot. There's no standard way to proceed with the lobectomy. A lot of it is just adapting to the anatomy that you encounter. There are some steps that we do routinely follow. So at the beginning of the operation, we'll inspect and make sure there's no metastatic disease that would prevent us from going forward with a curative intent operation. Then we will elevate the lower lobe and incise the inferior pulmonary ligament up to the level of the inferior pulmonary vein. And if there's lymph node material in the inferior pulmonary hilum, we'll resect that. I then typically go to the posterior hilum and dissect out the subcarinal lymph node packet, then go to the superior hilum and dissect out the paratracheal lymph node packet. So we'll complete our mediastinal lymph node dissection before setting about doing lung resection. I'll then often go to the anterior hilum for a middle lobectomy, make sure that the venous anatomy is normal. One of the key steps in this case is identifying anomalous pulmonary arterial and venous anatomy, which is very common. So we'll isolate the middle lobe vein, make sure that it's arising from the structure that we think it is. And then we have a decision to make about what the best way to approach it is. You can go sort of anterior to posterior where you begin by mobilize the anterior hilum and dissecting and dividing the vein and then bronchus and then artery. Or you can go from the bottom up as I usually do with the robot where we'll elevate the middle lobe, develop the fissure between the middle lobe and the lower lobe, and then see which structure is most amenable to division first. Alternatively, you could try to separate the upper lobe from the middle lobe and isolate the artery first, but that's typically more difficult because the fissure between the upper lobe and the middle lobe is seldom complete. So we'll see. We'll see which this case sets up best for. Assuming we go with a bottom up approach, so what I would do first is sort of elevate the middle lobe, create the fissure between the middle lobe and the lower lobe by following a basilar branch of the pulmonary artery back to its confluence with the middle lobe artery. And typically there's gonna be lymph node material around here. And by removing that lymph node material, the critical anatomic structures are evident. Usually there's also some lymph nodes around the middle lobe artery and the middle lobe bronchus, which should be right in that confluent area. And by resecting those lymph nodes, we'll see the bronchus as well. And the middle lobe vein usually arises as a branch of the upper lobe vein, but occasionally you can see it come off the lower lobe vein. But I think we'll probably divide that first and then get around the bronchus, divide that and then contend with the middle lobe pulmonary artery. We wanna be very careful when dissecting out the middle lobe pulmonary artery. Really what you want to do is work on the adventitia of the pulmonary artery and define a lot of it before you try to circumferentially dissect an artery. The staplers are quite large and passing them around an artery is a lot more challenging than it is just to to pass a vessel loop or a small instrument. So we really want to create a lot of room around the arteries as we're moving. Once all those structures are divided and we'll typically give some ICG dye, which will demarcate the fissure between the upper lobe and the middle lobe, which again is usually incomplete, although you can you get a sense for where it is. But the ICG dye will really make it stand out. And then using a parenchymal stapler we will complete that fissure, place the specimen into an Endo Catch bag and then I will set it aside, look for hemostasis, do some posterior rib blocks for pain control, make sure all of our sponges and other instruments are removed, and then undock the robot before withdrawing the specimen and closing our ports.

CHAPTER 2

All right. So yeah, we'll just start with a quick bronch. Mostly to assess for normal anatomy and the absence of significant tracheal bronchial secretions. We're just gonna look down the operative side here. That's the carina, the right upper lobe. That's bronchus intermedius. And then in the usual orientation you see the middle lobe bronchus to the screen left and the lower lobe, basilar bronchus and superior segment bronchus to screen right. That all looks like normal anatomy, no secretions. So we'll go ahead and get her positioned for a lung surgery.

CHAPTER 3

So with regard to positioning, she's lateral decubitus, the operative side is up. She's evenly balanced, neither prone nor supine, just full lateral. The bed is slightly flexed with the flexion point being about her xiphoid, but somewhere between the xiphoid and the anterior superior iliac spine. Her lower leg is straight, her upper leg is bent, supported on pillows and her arm is supported on an arm board. So we'll have her prepped and draped as if a thoracotomy was gonna be needed.

CHAPTER 4

So we'll start by marking out some thoracic landmarks, beginning with the tip of the scapula and then the costal arch here. That's pretty much all I do. If we are gonna do a posterolateral thoracotomy, it would come over the tip of the scapula beginning midway between the posterior scapula and the the spine, curving, crossing the tip of the scapula and then curving down like this. We hope to not do that today. Our camera port's gonna be in about the eighth inner space, just anterior to the midaxillary line, and it's gonna be an eight-millimeter port. So we'll take a knife please. So yeah, just stab down on that and I'll take a snap. And the lung is isolated? The lung is isolated. Yes. Good. You pop into the pleural space and just spread just enough to let the lung deflate. All right, so we'll confirm that we're in the pleural space before we insufflate, can we have the gas on pressure of eight please? So once we know we're safely in the pleural space, we're gonna insufflate here and create some working space. Take the local next. 40 flow eight pressure on. All right, just look up to the tip of that superior segment. And I'm gonna administer externally some posterior rib blocks. Okay, the rest we can use at the end. Look back up to the tip of the superior segment again. Let me see that needle again, please. Yeah, so we want arm one, which is gonna be our primary retracting arm to be above the superior segment of the lower lobe. This will be a sharp eight-millimeter port, which is aimed up a little bit. And I'll take a knife please. Arm two, which is our left hand, can kind of be in the same - no. Also in the eighth interspace posterior axillary line. And I'll take the camera. We're gonna put a working port, stapling port just posterior to the costal margin. It's gonna be a 12-millimeter port. And let's go here for that. The challenge in middle lobectomies is that the anatomy's often quite close to the stapling port, especially for a small person. So we're trying to put this port as low as possible. And lastly, we'll place an assistant port just above the diaphragm right about here. This is a 12 also. All right, we're ready for the robot to come in. Okay.

CHAPTER 5

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CHAPTER 6

Okay, looks like we're operational here. I'll take some sponges please. Another one. All right. The first step is just to take a look around, make sure there's no metastatic disease, nothing obvious on a first survey of the pleural space. You can see a small apical adhesion up here. Might as well take care of that now. In arm four we have a Maryland bipolar with cautery set to eight units. All right, so our first step is gonna be to elevate the lower lobe of the lung. No, we're good. Elevate the lower lobe of the lung and take down the inferior pulmonary ligament. And if we see any lymph node material down here, we're gonna take it. This I would consider to be mediastinal lymph nodes station 8R. We will go back and take down more of the ligament here. Can I get you to kind of lean on the middle lobe? Thank you. This is a lymph node that's associated with the inferior pulmonary ligament. So we're gonna call this a nine mediastinal lymph node, station 9R. And our stopping point for the inferior pulmonary ligament is when we see the bottom of the inferior pulmonary vein. Which is right here. That's the inferior pulmonary vein. And after that we're gonna turn and go to the posterior hilum. Lemme go underneath you. What's up Jess? All right, so now we go to the posterior hilum and we're gonna dissect out the subcarinal lymph node packet. And if we do a good dissection here, we should be looking at the posterior aspect of the pericardium when we're done on the underside of the bronchus intermedius. Here's our pericardium down here. It's probably a little vagus nerve branch, maybe a little bronchial, but we can try to save it. And we'll just work our way back to the carina here. Pretty robust lymph node here. So we'll probably just amputate it here before we can actually see the left main stem bronchus. This is mediastinal lymph node station seven. Need to lean down here again. This lymph node is far enough out on the end of the hilum that I'm gonna call it a 10R lower lobe lymph node. Okay and this is just a good visual reminder that the borders of a good mediastinal subcarinal lymph node dissection are the pericardium anteriorly, the esophagus posteriorly, the left main stem bronchus laterally and the right main stem bronchus on the other side. And then up here we should see the carina where you've got a little bit of bleeding from the truncated node. So I think we'll just leave that be. Sometimes I'll leave a little sponge back there and grab another one, please. And next we'll go to the superior hilum where we have some flimsy adhesions and we'll do a right paratracheal node dissection. Some inflammatory adhesions here between the upper lobe and the cava. And there's the cava azygos junction. And this is the phrenic nerve overlying the cava. And just do this just to release this hilum. So this lymph node is below the azygos vein and so we're not gonna call that a right parietal. This belongs to the upper lobe and we'll call it a 10R upper lobe lymph node. And I don't feel as the need to be quite as thorough removing it 'cause this is a middle lobe tumor. And the truncus branch of the PA is right below it. So that's just a sample of that node, we'll call that 10R lymph node upper lobe. We do want to do a pretty thorough paratracheal node dissection. I did a mediastinoscopy on her before, so this plane's gonna be a little bit scarred in. But I've began right at the caval atrial junction, sorry, the azygocaval junction. And then we go right behind the cava here. Everything above the azygos, behind the cava belongs to this right paratracheal node packet. You can see a good deal of node material here. And this is our airway behind us. So posteriorly is the airway, anteriorly is the SVC. Inferiorly is the azygos and then the deep border of this should really be the aortic arch on the left side of the patient. So this is mediastinal lymph node station 4R. 4R? Mm-hmm. So this is aortic arch and that's good enough for our purposes today. Why don't we swap this one out please.

CHAPTER 7

So the next thing we're gonna do is just see what's happening in the anterior hilum here as we start thinking about where to start for our middle lobectomy. So we see the full course of the phrenic nerve. This is all superior pulmonary vein beneath me here. And I'm just gonna take the hilum, the mediastinal pleura overlying it. Okay, so that's superior pulmonary vein. The middle lobe branch of the superior pulmonary vein is buried in this stuff. And about 80% of people, the middle lobe vein is a branch or a tributary or whatever of the superior pulmonary vein. And 20% it comes off of the lower lobe vein or is an independent branch off the atrium. So you just need to be mindful of that anatomic variant. But here we see pretty clearly that's middle lobe vein in there. And it looks like it's got two branches. All right, now that we got a sense of sort of what, what the anterior hilum is gonna look like, my next step would be to look into the major fissure between the middle lobe and the lower lobe. Get a sense of how complete that is. And it looks like we've got some, you know, adhesions between the upper lobe and the middle lobe. But it looks like the middle lobe, the major fissure is pretty complete, which is nice. That's a nice little gift. That you have to worry a little bit about your margin if this is gonna be tumor. My inclination there is to favor taking a wedge of the upper lobe when we create our minor fissure. So I'll just leave that alone for now and we'll come from the bottom up. Jess, you wanna just lean on the lower lobe. So our next step is really to find the PA and the fissure. And then we just start removing lymph nodes until we have a better sense of the anatomy. You can see a flash of pulmonary artery right there. You're not quite sure which branch it is yet, but you know, if you take out this lymph node, you're gonna have a very good sense. This looks like a little intralobar crossing vein, which could be taken if we needed to, but also we'd rather sort of avoid it. So now we're gonna start just working right on this pulmonary artery, getting this lymph node right off it. And it's quite a firm lymph node and that makes you suspicious it's gonna be stuck to the structures beyond it. Yeah, difficult to grab and one starts to wonder that it's involved with the tumor. And the best solution for lymph node bleeding is almost always to complete taking out the lymph node and it'll stop bleeding. Can I borrow your sponge for a sec? A little bronchiole back there. Suck right there. All right, back up your section please. Here's the lymph node. It is gonna be 10R middle lobe lymph node. Oop. So at the end of that exercise, what we can see here is this is gonna be middle bronchus here. We don't yet see middle lobe pulmonary artery, which is probably behind the bronchus and behind this lymph node here. But we're, we've at least got a sense of where that middle lobe bronchus is. So we've got the middle lobe pretty well separated from the lower lobe there, that's part of the lower lobe vein. Following this perhaps is gonna bring us up underneath the underside of the middle lobe vein. And usually then the next thing to do is to start taking out more lymph nodes. Call this middle lobe, sorry, 10R middle lobe lymph node number two. All right. Can you clean the camera please? All right, so what we should be looking at here is a much better view of the middle lobe bronchus and the underside of the middle lobe vein. And we're not gonna be able to really see the artery unless we either go into the minor fissure, which we don't want to do or divide these structures. So that's what I would do next. So this lymph node here is certainly the posterior aspect of one we saw from the anterior hilum. That lymph node just keeps going. That's probably a superior pulmonary vein branch that we're picking it off of up there. It's a little hard to imagine getting this thing out intact. Without it kind of shredding. I think instead, we'll just amputate it here and get the rest with the specimen. This is middle lobe 10R, middle lobe lymph node number three. So we're all the way around the middle lobe vein here. So we're just gonna go ahead and divide that. Can I have a white load please? And from this view, you really do kind of believe that this middle lobe is more a branch off the lower lobe veins than it is off the upper lobe veins. So this probably isn't gonna be an ideal stapling angle. It looks much more like it would come in from the posterior port, but right now I only have a stapling port anteriorly. So we'll see how bad it is before we upsize. Take a little tension off the lobe while we're firing the stapler. And then we really wanna make sure the staple angle is straight so the assistant can pull it out without too much resistance. All right, so our vein's divided, which means we're kind of on the clock when it comes to venous engorgement of the lobe. It's a middle lobe so it shouldn't matter all that much. There's our middle little bronchus, there's our superior pulmonary vein branches. Now that we can see it a little better, we can get the rest of that node out. Just know that it's a classic old granulomatous disease, very chalky, very firm, difficult to manipulate and really want to fall apart. Again, just kind of amputated that one here. You can add that to the last one. So what we'd really like to do now is get around that bronchus, which I think we can see a lot more clearly. But there's gonna be a PA branch right behind it and with nodes that are sticky as hers, we can't just kind of go behind it and hope. So getting that node out would be the key. But that node is also underneath the PA. Just trying to get a sense for how stuck things are back there. Do you have a vessel loop please? Okay, camera please. We'll want to upsize that posterior port. Gimme just a second to play around, but I'm looking at the staple angle of that middle lobe bronchus and thinking probably it's gonna come from the back. So I try to avoid using the vessel loops whenever I can because it's just one more, you know, thing to put around, another step. And sometimes what it's really good for is now you can kind of pull this forward into your field and dissect a little bit more behind what you couldn't see. Because it was a pretty tight fit just getting that... I'll do a green. Yeah, you wanna upsize please? Ready for the stapler or? Ready for the stapler. So we know this is gonna be a tight fit. When we're going for something that's a tight fit. The key here is we're just gonna be really patient, engage the tip. And then not forcing it behind, just almost letting the beating of the heart advance it for us in mediastinal motion. I'm just slightly angling it up to get over the pericardium, get rid of the vessel loop. If we were worried that this might not be the middle lobe bronchus, we could do a test inflation and confirm, but I'm quite confident that it is, so we'll fire. And again, take a little tension off the bronchus. The last thing we want to do is have that be the last thing that's holding the lobe except for the artery behind it. And as we take the bronchus away, it avulses the artery. We straighten our stapler out, stapler's out. So with that out of the way, we can now get a good look at that lymph node, and we can lift up that bronchus a little bit. This will be number four. I think what you'll see is this is actually the middle lobe PA right here. It was sort of inseparable from the vein before. Now that we've got those structures outta the way, it's a little bit more obvious it's its own structure. When you're working on the PA, it's always a good idea to give yourself as much space as possible. So dissect all this stuff out. It's gonna help our stapler pass around this thing eventually. And if anything, I'm not quite close enough to it. You should be right on the adventitia of the PA. It's the safest spot to be. I feel okay grabbing this upper lobe vein branch. Would never do a similar thing to the PA. It's not a forgiving structure. So you can put a little traction on the vein. Not a great angle to do that at. So you lose the tactile feedback with the robot. So you really gotta pay attention to visual clues that you're, have too much tension or that your plane's obstructed. So you just look to make sure that PA doesn't move at all when you go behind it. Looks like we got lots of space. So I'll take a white load. This one's coming on the, Cadiere, please. You guys have some ICG in the room please. Okay. So we'll follow the same angle we did for the bronchus. Really try to get your hands set up so that they're gonna be optimally positioned for where the stapler ends up. I don't like that. I'm not sure the vessel loop was really helping there. Okay, I'm just letting the heart beat this on. Not really advancing it. Very patient. And then as soon as it's beyond the cut zone, we want to just go ahead and take that. And it's just second nature that you want to take tension off the lobe as soon as it's firing on a vessel. Always have a sponge stick in your hand. Always assume that it didn't cut completely. Take it out gently. If there's a little bridge in there, you don't want to rip that apart. Take the vessel loop too please. All right, so we've got our critical structures divided. The next thing to do just before we take the fissures, we're gonna create a little bit more room off of the PA so we can get our stapler underneath here with a really good margin. Really just kind of make sure all this specimen is elevated off the keeper structures as much as you can. So it's gonna give you your nice parenchymal margin. Can you suction down here please? It's like the bronchus has a little bronchial bleeder. Maybe it's just pooling. Okay. So that seems to be about what we can do there. We have a black load next and can we give the ICG? So yeah, this is gonna be a little bit of a challenge. So where, where are we gonna? It looks like that we can at least just take a little wedge here. Do me a favor, just don't give the ICG just yet. Lemme see the black load. Yeah. All right, so we're gonna take a little wedge of the upper lobe here. Make sure we get a margin. We'll need another one after this. It can be a blue load. We'll take a blue load. And this is what I mean by always assume there's a little bridge left. You can just - I'll just use the Maryland for this. Okay it does look like staplers went to the end of the specimen here, so I'm just gonna cut that. Now here's our minor fissure, which in her as in most people is, it's incomplete. But we could probably, if we wanted to - get down in there and find the, can you clean the camera please? Yeah. So on the one hand we have things set up to just bring our stapler in and fire underneath all this stuff. I'm gonna make just one attempt to, get right down on the PA there and create just this bridge and then it'll be easier to do that, hopefully give us just a little bit better margin. You can almost always just follow a lymph node. I feel pretty confident it's gonna take you down to a PA. Can we call this 11R lymph node? So that dropped us right down onto that PA dissection that we did before, which is why it just kind of opened up. It looks like a posterior sending branch that goes to the upper lobe. Can I have a blue load please? Oh it looks like she's actually got another middle lobe artery in there that I missed. Alright, I'll take this on the Maryland, please. And you see that little tiny branch there, that that's actually going to her middle lobe. So that'll get taken in this parenchyma. I would say having multiple middle lobe arteries is pretty common. It's also pretty common to have branches that come off the basilar pulmonary artery and recur to the middle lobe. So we're gonna be much happier with our margin now. All right, you can give the ICG please. So we'll give some ICG dye just to demonstrate that that is indeed the fissure and that we've taken all the relevant structures to it. And it just makes for a nice picture. Can even see those little collateral veins with flow in them. Okay, black, we'll take a blue load actually. All right, take another one except hold on a second. We've got some bleeding. Why don't you bring back in the Cadiere please. So I think there was a tiny little vein branch there that I tore with the traction of the... Where that blue load was a little bit thick for it. Do we have a clip? Yeah. Yeah, I'll go back and look at it in a minute. All right. I'll take another blue load please. What's that? No, I was just stopping. Hold on. You can put this one on the... Maryland? Maryland, please. Cadiere's coming back. We're gonna need one more. 24 French. And let's get some, we'll get rid of these sponges. We'll get a new sponge 'cause that thing is still bleeding.

CHAPTER 8

How many do we have in there? Three? Three are in. It's right here. Yep. Take it. That's what I'm talking about. Back in the subcarinal node face. Make sure it's not really bleeding. You take this please. Back up here. You know it's not overflowing so we feel pretty good about that.

CHAPTER 9

You can take this sponge please and then we'll come in with a bag. Just to review the anatomy before we lose it. Here's our middle lobe vein. Middle lobe bronchus. Middle lobe artery. There was another arterial branch in here. It's okay. No, just go ahead. Okay, bag that up. All right, undock please. For permanent. No, no.

CHAPTER 10

Yeah, so this is our right middle lobe specimen. Here's our tumor. This was the en bloc part of the upper lobe that I took out 'cause I was just in, in retrospect, now that I can feel it, the tumor's not that close, but it's always better to be safe. And then this is our cut middle lobe bronchus, middle lobe vein, middle lobe artery. And then this was the, this was the orientation of it in situ where this is the minor fissure. This part was stuck up to the upper lobe. That's anterior hilum there.

CHAPTER 11

All right, we're ready to start ventilating this right side please. Can you pull back a little bit, Jess, so we can see the, hold on. Just do 20 and hold. You got some atelectasis to work outta the upper lobe. Okay, that's good. Just ventilate both sides please. All right, thanks very much everyone.

CHAPTER 12

I would say it went about as you would expect a middle lobectomy to go. We did a bottom up approach, created our fissure first, our major fissure between the middle lobe and the lower lobe. And then we're able to work up towards the minor fissure. What was interesting about this case is as expected, she had very prominent granulomatous lymph nodes and I thought the case illustrated very nicely a principle in thoracic surgery, which is all the lymph nodes that we see are between critical structures. And by completely resecting them, you really get a nice view of the anatomy. So in her, we were able to resect a lot of those hilar lymph nodes along the critical structures of the middle lobe. And in doing so, define them very nicely and then dividing them was trivial after that. So it illustrates that principle that if you're ever sort of wondering what to do in thoracic surgery, if you just start taking out lymph nodes, the anatomy really presents itself nicely. One thing that was unexpected is her tumor was quite prominently involving, was at least close to the minor fissure, and some of the upper lobe was adherent to the area where the tumor was. Now we don't have a lot of tactile feedback when we're working with the robot, so we're relying on a lot of visual cues. And here I felt like it was best to take just a little bit of a wedge of the upper lobe rather than risk having a positive parenchymal margin there. And so before dividing the minor fissure, we had divided a little portion of the upper lobe and kept it on en bloc with the specimen.