Sequential robotic-assisted thoracic surgery and transmanubrial approach for optimal resection of superior sulcus...

Superior sulcus tumors invading the chest wall and major mediastinal vessels present significant surgical challenges. The transmanubrial approach (TMA) has been widely adopted for such tumors. However, the exposure of the dorsal side, particularly of the apex of the lung, can be limited when performing a TMA alone. This hybrid approach of TMA with robotic thoracic surgery improves visualization and resection safely. The clinical significance of this hybrid approach has received little attention. Here, we report a case of post-immunochemotherapy surgery using combined robotic-assisted thoracic surgery (RATS) and a TMA to achieve safe resection and vascular reconstruction of a tumor invading the right brachiocephalic vein.

A 59-year-old man was diagnosed with right upper lobe squamous cell carcinoma (cT4N0M0, stage IIIA) invading the anterior apex and mediastinal structures, including the right brachiocephalic vein. Following four cycles of immunochemotherapy (carboplatin, nab-paclitaxel, and pembrolizumab), significant tumor regression was observed, and post-immunochemotherapy surgery was planned. A RATS lobectomy was first performed, in the left lateral decubitus position, using the da Vinci Xi system with a five-port setup using port placement only, without mini-thoracotomy, which allowed detailed hilar and apical dorsal dissection. Subsequently, the patient was placed in a supine position, and the TMA was used to resect and reconstruct the invaded right brachiocephalic vein using a synthetic graft. The total operative time was 12 h and 8 min, and the total blood loss was 1,120 mL. The postoperative course was uneventful. The chest tube was removed on postoperative day 4, and no major complications such as prolonged air leak, pneumonia, or recurrent laryngeal nerve palsy were observed. And the patient was discharged on postoperative day 12. The pathological examination findings revealed that the staging was ypT2bN0M0 stage IIA. The patient has remained recurrence-free for 6 months following the surgery.

This case demonstrates that a hybrid approach combining RATS and the TMA is a safe and effective strategy for the resection of superior sulcus tumors with vascular invasion. RATS enhances surgical visualization and facilitates apical dissection, thereby optimizing safety and surgical outcomes when followed with the TMA.