Robotic Lobectomy: Left Upper Lobectomy Benjamin Wei, MD, Robert James Cerfolio, MD, MBA, FACS, FCCP  Operative Techniques in Thoracic and Cardiovascular Surgery  Volume 21, Issue 3, Pages 230-248 (September 2016) DOI: 10.1053/j.optechstcvs.2017.02.002 Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 1 Port placement for robotic left upper lobectomy. A = assistant port; C = camera port; MAL = midaxillary line; 2 = left robotic arm port; 1 = right robotic arm port; 3 = fourth robotic arm port. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 230-248DOI: (10.1053/j.optechstcvs.2017.02.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 2 Docking of the robot for left upper lobectomy (da Vinci Si system). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 230-248DOI: (10.1053/j.optechstcvs.2017.02.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 3 The inferior pulmonary ligament (I) is divided to facilitate the removal of lymph node station 9. Robotic arm number 4 (fourth) sweeps the lower lobe anteriorly and keeps it out of the way. A suction device is used by the assistant to help retract the lung also. The level 9 lymph node (9) is resected. LLL = left lower lobe; A = aorta. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 230-248DOI: (10.1053/j.optechstcvs.2017.02.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 4 The nodes in station 8 are then removed. Station 7 (7) is accessed in the space between the inferior pulmonary vein (IPV) and the lower lobe bronchus (LLB). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 230-248DOI: (10.1053/j.optechstcvs.2017.02.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 5 Robotic arm 4 is then placed on the left upper lobe (LUL) and the lung is retracted anteriorly. The level 11 lymph node (11) between the ongoing pulmonary artery to the lower lobe (PA-LL) and the posterior branch of the artery to the left upper lobe (PA-LUL) is dissected out and removed. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 230-248DOI: (10.1053/j.optechstcvs.2017.02.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 6 The 10L lymph node (10L) and level 6 lymph node are then resected, avoiding the left vagus nerve (VN) and recurrent laryngeal nerve (not pictured). The posterior ascending branch of the LUL (PA-post) is clearly visible. LUL = left upper lobe. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 230-248DOI: (10.1053/j.optechstcvs.2017.02.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 7 As the dissection continues anteriorly over the hilum, the level 5 lymph node (5) becomes visible and is resected. Either robotic arm number 4 or the assistant can hold down the left upper lobe (LUL) during this process. The space between the left superior pulmonary vein located anteriorly (not visible in this photo) and the pulmonary artery is developed. Left main pulmonary artery (PA). The assistant is using a long empty ring forceps to help retract the lung. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 230-248DOI: (10.1053/j.optechstcvs.2017.02.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 8 The posterior branch to the LUL (PA-post) is encircled, and a vessel loop is passed around it, and stapled. This can be done either through the assistant port or for the Xi, with the left robotic arm. LUL = left upper lobe; LLL = left lower lobe. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 230-248DOI: (10.1053/j.optechstcvs.2017.02.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 9 Robotic arm 4 lifts the left upper lobe (LUL) up while the right and left robotic arms are used to dissect out the fissure between the LUL and the left lower lobe (LLL). Robotic arm 4 (not pictured but located above the LUL) approaches from above the right part of the screen. As this dissection proceeds, the pulmonary artery branches to the lingula become visible in the fissure. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 230-248DOI: (10.1053/j.optechstcvs.2017.02.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 10 The fissure is also dissected anteriorly. The assistant (off below the screen) retracts the left lower lobe (LLL) while robotic arm 4 (fourth) retracts the left upper lobe (LUL). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 230-248DOI: (10.1053/j.optechstcvs.2017.02.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 11 A medium-height staple wire can be used to divide the fissure anteriorly. This can be the done by the assistant or through the left robotic arm port. LUL = left upper lobe; LLL = left lower lobe. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 230-248DOI: (10.1053/j.optechstcvs.2017.02.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 12 Division of the fissure exposes the lingular artery or arteries (PA-ling). This artery is then encircled with a vessel loop and divided. LUL = left upper lobe; LLL = left lower lobe. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 230-248DOI: (10.1053/j.optechstcvs.2017.02.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 13 The lung is then retracted posteriorly and away from the hilum by robotic arm 4. The pleura overlying the anterior hilum is dissected. The superior and inferior pulmonary veins are clearly identified. The bifurcation between the veins is developed, and the superior pulmonary vein (SPV) is freed anteriorly off of the left upper lobe bronchus (B). The upper lobe vein is isolated and divided either in its entirety, or if large (as in this case), at the level of the segmental veins. It is easiest to staple the vein via the right robotic arm port, which is located posteriorly. We do not transect the vein first because it can lead to vascular engorgement and increased bleeding. Transected end of lingular vein (LV), upper division vein (UDV). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 230-248DOI: (10.1053/j.optechstcvs.2017.02.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 14 The left upper lobe bronchus (B) is isolated from the anterior segmental artery, which usually is behind it from the perspective of the camera. In certain patients, transection of the bronchus with the robotic scissors followed by division of the apical or anterior trunk is simpler than trying to isolate or staple it. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 230-248DOI: (10.1053/j.optechstcvs.2017.02.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 15 All that remains now is the anterior and apical segmental arteries. These can be isolated and stapled or stapled en masse to avoid avulsion (latter shown here). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 230-248DOI: (10.1053/j.optechstcvs.2017.02.002) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 16 The left upper lobe bronchus (B) is held anteriorly by the robotic instruments and stapled shut. The specimen is then placed in a specimen bag and removed via the assistant port, which usually needs to be enlarged during this process. An occlusive dressing is applied and the port is reintroduced through the dressing to help maintain carbon dioxide insufflation. The chest is irrigated with normal saline, hemostasis is confirmed, and a chest tube is placed via the most anterior port (left robotic arm port for left upper lobectomy). The robotic arm ports are removed under direct vision with insufflation discontinued to confirm the absence of bleeding. The camera port is removed. The robot is undocked. The fascial layer for the assistant port is closed, followed by the skin layer. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 230-248DOI: (10.1053/j.optechstcvs.2017.02.002) Copyright © 2017 Elsevier Inc. Terms and Conditions