Robot-Assisted Lobectomy for Lung Cancer Complicated by Lymphangioleiomyomatosis

Lymphangioleiomyomatosis (LAM) is a rare systemic disease characterized by progressive cystic destruction of the lung parenchyma, resulting in extreme parenchymal fragility. Surgical treatment of lung cancer in patients with LAM is technically challenging due to the high risk of intractable air leaks. We report a case of robot-assisted thoracoscopic surgery (RATS) for lung cancer in a patient with LAM, highlighting a strategic hybrid approach to managing the exceptionally fragile lung tissue.

A 56-year-old woman with tuberous sclerosis complex-associated LAM was diagnosed with Stage IA1 adenocarcinoma in the left upper lobe. We performed a RATS left upper lobectomy using the da Vinci Xi system (Intuitive Surgical, Sunnyvale, CA, USA). To protect the exceptionally fragile lung, a "no-touch" retraction technique was employed using rolled gauze and blunt-tipped robotic instruments. A fissureless technique was applied to minimize parenchymal injury. Crucially, for the division of the incomplete interlobar fissure and the bronchus, we utilized manual staplers equipped with bioabsorbable reinforcement material (buttressed staplers) deployed by a bedside assistant, which provided superior sealing for the fragile lung compared to the robotic staplers available at that time. Despite these precautions, a pinhole air leak occurred in the S8 segment, likely due to unintentional contact with a robotic joint, illustrating the extreme sensitivity of the LAM lung. This was identified via a meticulous sealing test and repaired with polyglycolic acid sheets and fibrin glue. The patient was discharged on POD 5 without persistent air leaks. At 1 year post-surgery, her respiratory function was well-preserved, exceeding predicted values.

RATS offers superior visualization for lung cancer surgery in patients with LAM. However, given the extreme fragility of the lung, the selective use of manual buttressed staplers is a vital adjunct to prevent postoperative air leaks. Optimal outcomes depend on a constant awareness of lung fragility, a hybrid technical strategy, and a rigorous intraoperative sealing test to identify and repair even minor pleural injuries.