Robotic tracheal resection/reconstruction under extracorporeal membrane oxygenation after rigid bronchoscopy

Tracheal resection/reconstruction is among the most technically demanding procedures in thoracic surgery, traditionally requiring open approaches with complex airway management. The emergence of robotic-assisted surgery combined with venovenous extracorporeal membrane oxygenation (VV-ECMO) offers a minimally invasive alternative providing enhanced surgical precision, reduced postoperative morbidity and optimal apnoeic operative conditions. We report a robotic tracheal resection/reconstruction under VV-ECMO in a 65-year-old patient with a tracheal mucoepidermoid carcinoma following endoscopic debulking with incomplete margins. Key surgical highlights include a percutaneous VV-ECMO enabling complete apnoeic conditions, lymph node dissection to initiate progressive tracheal exposure, preserving the vagus nerve and tracheal vascularization, an original fluorescence-guided transillumination technique for intraoperative resection margin identification, and end-to-end anastomosis using three continuous V-Loc sutures. The patient was discharged on postoperative Day 7 with no major complications. Resection was finally complete, and anastomotic integrity was confirmed at two-month bronchoscopy. Given the rarity of this tumour and the steep learning curve of robotic airway surgery, a step-by-step video tutorial was necessary to establish a reproducible, didactic framework for this combined approach.