Robotic-assisted Left Pneumonectomy For Vanishing Lung Syndrome

In this video, we present a case report of a robotic left pneumonectomy. This was the case of a previously healthy 41-year-old African American male. He was a current smoker who presented with dyspnea on exertion.

Chest x-ray and CT chest showed severe bullous disease of the left lung, concerning for vanishing lung syndrome with compression of the heart and right lung. FEV1 and DLCO were about 30%of predicted. Quantitative perfusion scan demonstrated 2.5%perfusion of the left lung.

Right heart cath demonstrated mildly elevated right heart pressures. Vanishing lung syndrome usually involves one lobe, and resection allows for re-expansion of a viable lung parenchyma. However, in this case, the entire left lung was involved, and the decision was made to perform a robotic left pneumonectomy.

This robotic approach involved using four standard ports in the eighth intercostal space and an assistant port just above the diaphragm. Once we inserted the camera, we encountered giant bullous with no functional lung parenchyma. We performed a 30 minute lysis of pleural adhesions.

We began our dissection by dividing the inferior pulmonary ligament, which guides us to the inferior pulmonary vein. We then continued dissection of the inferior pulmonary vein using adequate counter tension to help visualize the dissection planes. This next part is not shown, but we then continue dissection of the posterior hilum, including the left main bronchus and the left main pulmonary artery as it enters the posterior major fissure.

Then the dissection was carefully carried counterclockwise to the superior hilum. The lung was retracted inferiorly to expose the superior hilum, which provides access to the posterior side of the left main pulmonary artery and the aorta pulmonary window. Dissection proceeded cautiously, and care was taken to not injure the recurrent laryngeal nerve.

We made liberal use of blonde dissection to safely skeletonize the major structures, and electrocautery was only utilized when thin membranes could be identified. And as the dissection proceeds to find the window behind the vein, the assistant should prepare the vessel loop and the white load stapler. The lung was then retracted posteriorly to expose the anterior hilum.

In a similar fashion, the left superior pulmonary vein was dissected and encircled. This was divided first with the white load robotic stapler to expose the anterior surface of the left main pulmonary artery. We then completed our anterior dissection of the left main pulmonary artery and encircled it with the tip subs grasper, since it is a longer blunt instrument for passing around larger vessels.

The stapler was passed and closed, and hemodynamics were observed for hypotension, arrhythmias, and desaturations. And in their absence, the left main pulmonary artery was then divided. Next, using the vessel loop and the white load stapler, the inferior pulmonary vein was divided.

This was done in order to prevent engorgement of the lung with venous blood. We continued our bronchial dissection to expose the left main bronchus. This was clamped with the green load stapler under intraoperative bronchoscopy to ensure as short of a bronchial stomp as possible.

After we divided the bronchus, we tested for air leak, and it was negative. We then harvested a vascularized fat pedicle using tissue from the aorta pulmonary window, as it was available with two arterial branches perfusing it. The bronchial st stump was reinforced with interrupted 4-0 Vicryl suture and covered with the fat pedicle.

The specimen was removed through a five centimeter incision at the assistant port location, and toilet bronchoscopy was performed at the conclusion of the We routinely placed a balancing chest tube to allow for controlled shifts of the heart and right lung, and to monitor for bleeding. The patient did well postoperatively. These were his post-operative chest x-rays.

His chest tube was removed on post-op day one, and his diet was advanced. His chest x-rays from post-op day zero to post-op day two showed a gradual shift of the mediastinum back to midline. He was discharged home on post-op day three, with nicotine patches and tobacco cessation counseling.

Final pathology was negative for incidental malignancy. Robotic assisted pneumonectomy is a viable and effective surgical option for patients with vanishing lung syndrome, who have severe disease and inadequate response to medical treatment. This case highlights the potential advantages of robotic surgery, including reduced morbidity, improved precision, and faster recovery.

Given the rarity of vanishing lung syndrome and the complexity of its management, further studies are warranted to determine the long-term outcomes and the role of minimally invasive techniques in the treatment of this condition.