Two different methods of bronchial dissection and coverage in robotic bilobectomy for advanced lung cancer

Due to its many technical advantages, the scope of robot-assisted thoracic surgery (RATS) is expanding to include extended pulmonary resection. Among such procedures, right bilobectomy is one with a high risk of inducing development of a bronchial stump fistula.

The pericardial fat pad case involved a 71-year-old man with a 31-mm adenocarcinoma in the right lung that had progressed to the intermediate bronchus. During lower bilobectomy, to confirm the tumor margin, an L-shaped stapler was used with stapling only at the oral side, and the bronchus was cut using a scalpel blade grasped with robot forceps. After confirming a negative stump, the pericardial fat was collected at the pedicle and sewn onto the stump. The intercostal muscle (ICM) flap case involved a 61-year-old man with a 16-mm nodule shadow in the lower lobe of his lung and swollen #11i and 7 lymph nodes. Intraoperatively, the #7 lymph node was diagnosed as non-small-cell lung cancer by frozen sections, and lower bilobectomy was performed. The bronchus was divided using a stapler with a green cartridge, and the ICM flap was harvested by changing the direction of the camera to a look-up view and positioning the camera at the 5th intercostal site. His numeric rating score (NRS) at 30 and 90 days post-surgery was 2 and 0, respectively.

Our RATS technique was useful for harvesting the ICM flap. More cases should be accumulated to extend the surgical indication for RATS.