Robotic Intrapericardial Left Pneumonectomy

J. Barron, S. Raja, S. Murthy
Cleveland Clinic, Cleveland, Ohio

Please explain the educational or technical point that this video addresses.: This video highlights a robotic technique for intrapericardial control of the left main pulmonary artery and superior pulmonary vein, when performing left pneumonectomy for a locally advanced left upper lobe adenocarcinoma in a patient that had received both induction chemoimmunotherapy and chemoradiation. Specifically, we demonstrate how the reflection of serous pericardium overlying the vessels may be in incised, without need for longitudinal opening of the entire pericardium. Furthermore, we discuss tips relevant to intrapericardial pneumonectomy, including considerations when stapling the intrapericardial pulmonary artery (don't impinge the main PA) and the importance of avoiding a long bronchial stump. Such an approach is particularly relevant present day, as advances in systemic therapies render more patients with locally advanced disease candidates for surgery, such that complex resections may be performed with increasing frequency.

Please provide a 250 word summary of the surgical video being submitted.: A 60-year-old male was found to have a 6.4 cm left upper lobe adenocarcinoma with mediastinal invasion and encasement of the left main pulmonary artery and superior pulmonary vein (cT4N0, Stage IIIA). He underwent neoadjuvant chemoimmunotherapy, followed by chemoradiation, with slight decrease in tumor size. This was followed by robotic-assisted left pneumonectomy. Due to the tumor’s proximity to the hilum and severe inflammation post induction therapy, this required intrapericardial dissection and division of the superior pulmonary vein and left main pulmonary artery. Additionally, tedious dissection was required to separate the tumor from the aortic arch. The left bronchial stump was divided at an optimal length of 5-10 mm and covered with a pedicled thymic flap. The patient recovered well without complication and was discharged home on postoperative day six on room air.
In summary, the intrapericardial approach to the hilar vessels during pneumonectomy is a safe technique for circumferential control when faced with severe inflammation or a locally advanced hilar tumor. As advances in lung cancer therapy render more patients’ with locally advanced tumors surgical candidates, familiarity with this approach may prove invaluable for many thoracic surgeons. Importantly, extreme care must be taken when dividing the left main pulmonary artery intrapericardially, as it is possible to impinge on the main pulmonary artery and obstruct right heart outflow. Test clamping prior to stapling, to ensure continued hemodynamic stability, may help avoid this catastrophic complication.