Robotic Assisted S3b Subsegmentectomy for Pulmonary Artery Aneurysm

D. C.. Rice
The University of Texas MD Anderson Cancer Center, Dept. of Thoracic, Houston, Texas

Please explain the educational or technical point that this video addresses.: Idiopathic peripheral PA aneurysm is a rare entity. This video describes two methods of treatment (coil embolization and surgical resection). The case was complex due to poor underlying lung function which necessitated a limited resection. The video demonstrates the performance of a subsegmentectomy of the LUL anterior segment (LS3b), performed robotically. It demonstrates the surgical technique as well as the preoperative planning that utilized 3D CT reconstruction to help guide anatomic dissection intraoperatively.

Please provide a 250 word summary of the surgical video being submitted.: Pulmonary artery (PA) aneurysms are uncommon with an estimated incidence of 1 in 14,000 individuals. Most aneurysms occur in the proximal pulmonary artery and peripheral location is rare. The etiology is often unclear but may be associated with congenital heart disease, pulmonary hypertension, malignancy, infection, vasculitis or iatrogenenic. Progressive enlargement or presence of clinical symptoms such as hemoptysis are indications for treatment that may be either surgical or by percutaneous embolization.

A 49-year-old woman with a history of obesity, type 2 diabetes, childhood asthma and COPD, and limited pulmonary reserve who had previously undergone coil embolization of the PA aneurysm, presented 4 months later with hemoptysis. A robotic anatomical subsegmentectomy of LS3b was performed, guided by preoperative 3D CT reconstruction to define the anatomy. The daVinci Xi robot was used with 4 robotic ports and a 5mm assist port. The lung was retracted posteriorly and the superior pulmonary vein skeletonized. Anatomy was correlated with the 3D reconstructed images and the vein draining the LS3b segment divided. The technique of vascular division was ligation using silk ligatures as the vessels were too small to use stapling devices. The bronchus to the involved subsegment was divided sharply and closed with 4-) absorbable monofilament suture. The artery was then divided between ligatures and the aneurysm exposed, Indocyanine green defined the non-perfused parenchyma, which was excised using linear staplers. Ex vivo examination of the specimen revealed erosion of the coils through the airway, explaining the hemoptysis. The patient's recovery was uneventful.