Robotic-Assisted Left Upper Lobectomy in Non-Small Cell Lung Cancer With N1 Disease

This video demonstrates a procedure performed for a 56-year-old woman with a cT1BN1M0 stage IIB adenocarcinoma of the left upper lobe. She underwent endobronchial ultrasound for mediastinal staging, which ruled out N2/N3 disease and confirmed the diagnosis by guided sampling of a level 10L node in the left hilum. A robotic-assisted approach can be helpful to complete the lymph node dissection during lobectomy and compares favorably to video-assisted thoracoscopic approaches (1). Here, the author demonstrates a left upper lobectomy using the da Vinci Xi Surgical System™ with robotic stapling.<br>The case is performed with standard thoracoscopic setup, double lumen intubation, and lateral position flexed at the hip. Trocar placement consists of one 12 mm robotic trocar in the seventh intercostal space (ICS) anterior axillary line, next to the costal margin. This is followed by three 8 mm robotic trocars placed in the same seventh ICS, spacing them 8 cm apart. A second 12 mm robotic trocar for the assistant and for posterior placement is then placed in the ninth ICS posterior axillary line, directly inferior to the trocar in arm three, in order to share the robotic arm during stapling maneuvers (Figure 1). The instruments consist of a tip-up grasper in arm four, a curved bipolar dissector in arm three, the 8 mm Xi camera in arm two, and a Cadiere forceps in arm one.The procedure starts with the lymph node dissection. The author begins by dividing the inferior pulmonary ligament, reflecting the lung anteriorly, and dissecting the posterior hilum and the posterior level 10L and 11L nodes. The focus is then on resecting the known N1 disease on the more proximal 10L nodes along the left main bronchus. The fissure is divided if well-developed, and the artery is visible. The author then divides the posterior segment pulmonary artery branch, and dissects the hilar nodes further to expose the apical and lingular arteries. The lingular artery is then divided with a vascular staple load, which then facilitates dividing the anterior aspect of the fissure. At this point, the lung is reflected posteriorly in order to isolate and divide the superior pulmonary vein, using the assistant 12 mm trocar to obtain a posterior stapling access. Lastly, the first branch of the pulmonary artery is divided to isolate and divide the left upper lobe bronchus with a green load robotic stapler. The author completes the node dissection, resecting the level 5 aortopulmonary window nodes.<br>One chest tube and one small pigtail catheter were placed, and the main chest tube was removed on postoperative day one. The accessory drain, which was left clamped, was removed on postoperative day two, and the patient was discharged home. Final pathology showed a pT1cN1M0 stage IIB non-small cell lung cancer, with 4 of 14 nodes positive in the 10L and 11L station.<br>

<strong>Reference</strong>Velez-Cubian FO, Rodriguez KL, Thau MR, et al. Efficacy of lymph node dissection during robotic-assisted lobectomy for non-small cell lung cancer: retrospective review of 159 consecutive cases. <em>J Thorac Dis</em>. 2016;8(9):2454-2463.Dr Herrera is a speaker and instructor for Intuitive Surgical, Inc.

本视频演示了针对一名56岁女性左上叶cT1BN1M0 ⅡB期腺癌患者的手术操作流程。患者此前接受了纵隔分期支气管内超声（endobronchial ultrasound）检查，排除了N2/N3淋巴结病变，并通过对左侧肺门10L组淋巴结的引导穿刺活检明确了诊断。机器人辅助手术方案在肺叶切除术中完成淋巴结清扫时具有显著优势，其疗效优于电视辅助胸腔镜手术方案(1)。本视频中，术者展示了使用达芬奇Xi手术系统（da Vinci Xi Surgical System™）结合机器人吻合器完成左上肺叶切除术的操作。

本次手术采用标准胸腔镜手术布局，实施双腔气管插管，患者取髋关节屈曲侧卧位。套管穿刺置入方案如下：于腋前线第7肋间、肋缘旁置入1枚12mm机器人手术套管；随后在同一第7肋间置入3枚间距为8cm的8mm机器人手术套管。随后于腋后线第9肋间、臂3套管正下方位置，置入第2枚12mm机器人手术套管供助手操作及后置器械使用，此举可在吻合操作时共享机械臂(图1)。手术器械配置为：臂4搭载上翘抓钳，臂3搭载弯形双极电凝分离钳，臂2搭载8mm Xi镜头，臂1搭载Cadiere钳（Cadiere forceps）。

手术首先从淋巴结清扫开始。术者先切开下肺韧带，将肺叶向前牵拉，分离肺门后方组织及10L、11L组后纵隔淋巴结。随后重点处理左主支气管近端已知的N1病变相关10L组淋巴结。若肺裂发育完整，则先行切开肺裂，暴露肺动脉。术者随后切断后段肺动脉分支，进一步分离肺门淋巴结以显露尖段动脉及舌段动脉。随后使用血管吻合钉匣切断舌段动脉，此举可辅助切开肺裂前侧部分。此时将肺叶向后牵拉，以隔离并切断肺上静脉，借助助手操作的12mm套管获得后方吻合通道。最后切断肺动脉第一分支，以绿色钉匣式机器人吻合器完成左上肺叶支气管的离断。术者完成剩余淋巴结清扫，切除了主动脉肺动脉窗5组淋巴结。

术中放置1根胸管及1根小型猪尾引流管，主胸管于术后第1日拔除。夹闭的辅助引流管于术后第2日拔除，患者顺利出院。术后病理提示为pT1cN1M0 ⅡB期非小细胞肺癌，10L及11L组共14枚淋巴结中4枚可见癌转移。

**参考文献**
Velez-Cubian FO, Rodriguez KL, Thau MR, 等. 机器人辅助肺叶切除术治疗非小细胞肺癌的淋巴结清扫疗效：159例连续病例的回顾性分析. 《J Thorac Dis》（胸部疾病杂志）. 2016;8(9):2454-2463.
Herrera医生为直觉外科公司（Intuitive Surgical, Inc.）的演讲嘉宾及培训讲师。