Robotic Left Upper Lobectomy and Pulmonary Artery Arterioplasty

A. Conner¹, S. Raja², S. Murthy^2
1Cleveland Clinic, Cleveland Heights, Ohio ²Cleveland Clinic, Cleveland, Ohio

Please explain the educational or technical point that this video addresses.: This video demonstrates a technique for obtaining proximal and distal control of the left pulmonary artery. We show that it is possible and safe to do so while maintaining a robotic-assisted approach. We also show an arterioplasty of the pulmonary artery following sharp dissection of bulky, metastatic disease off the ongoing pulmonary artery. These same principles can be applied to other, similar surgical scenarios with even more disease involvement of the artery. Additional key technical points include ensuring adequate circumferential dissection of the proximal left main pulmonary artery while being mindful of important anatomic structures, such as the left recurrent laryngeal and phrenic nerves, and obtaining vascular control before dividing the bronchus. This case also underscores early recognition of the need to obtain vascular control of the pulmonary artery.

Please provide a 250 word summary of the surgical video being submitted.: In this video, we demonstrate a robotic-assisted lysis of pleural adhesions, left upper lobectomy, hilar and mediastinal lymph node dissection, and arterioplasty of the proximal left pulmonary artery. The patient was a 55-year-old female with a history of metastatic rectal cancer who had previously undergone a sub-lobar resection of a metastatic nodule in her left upper lobe. She later developed a recurrence of her metastatic rectal cancer to the left upper lobe with hilar lymph node involvement and was planned for completion left upper lobectomy and mediastinal lymph node dissection. She was found to have extensive pleural symphysis, and the case began with extensive lysis of adhesions, which were undertaken using a robotic-assisted approach. She was additionally found to have metastatic adenopathy adherent to the ongoing pulmonary artery, necessitating the requirement for arterioplasty of the proximal pulmonary artery. This was done after dividing the left superior pulmonary vein, obtaining vascular control of the pulmonary artery proximal and distal to her pathology, and dividing the left upper lobe bronchus. We demonstrate our approach to getting control of the artery and performing an arterioplasty, which was suture closure of a left pulmonary artery branch stump. This video highlights principles that could be applied to similar cases with disease involvement of the pulmonary artery that may require even more complicated vascular reconstruction and reviews relevant anatomy for performing a left upper lobectomy and obtaining control of the proximal pulmonary artery.