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Robotic Right Middle Sleeve Lobectomy For Endobronchial Carcinoid Tumor.
John K. Sadeghi, MD, Charles T. Bakhos, MD, MBA, MS.
Temple University Health System, Philadelphia, PA, USA.

BACKGROUND: Lung cancer with endobronchial involvement in proximity to the mainstem bronchi historically required pneumonectomies, open sleeve lobectomies, or VATS sleeve lobectomies. In the past, the threshold for pneumonectomy was low for cancer abutted the central airways. The robotic platform provides an easier approach to these lesions and raises the threshold for a pneumonectomy. Here, we share the crucial components to our standardized technique of performing a robotic sleeve lobectomy (RSL) for cancer.
METHODS: A 45-year-old man with a 15-pack year smoking history presented with complete atelectasis of his right middle lobe. He was taken for a bronchoscopy which showed an obstructing lesion of the RML bronchus. The lesion was biopsied, and laser ablated. Pathology showed a carcinoid tumor. The lesion was PET avid and stations 4R and 7 were negative on EBUS biopsy. He was taken to the operating room for a robotic right middle sleeve lobectomy. In this video we highlight the technique of anastomosing the remaining bronchi with barbed absorbable suture. Post-operatively, the patient did well and was discharged from the hospital after 3 days. He did not have any complications from the procedure and was in good health on follow-up. Final pathology showed negative margins and a positive level 8 lymph node.
RESULTS: Key steps of the entire procedure include utilization of 4 robotic arms, completion of the fissures, proximal and distal mobilization of the airway segment of the planned sleeve resection, negative margins on frozen pathology prior to the anastomosis, stay sutures to approximate the ends of the airway, running 2 unidirectional barbed absorbable sutures starting at the cartilaginous side, coverage with a tissue flap, and extubation in the OR.
CONCLUSIONS: RSL for lung cancer is technically safe and feasible. It presents many advantages over open and VATS sleeves, namely the angulating wrist motion and 3-D magnification paired with running two barbed absorbable sutures. RSL may be the optimal approach to lesions that are near the main bronchi to best preserve patientsí lung functions.


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