Totally thoracoscopic robotic lobectomy with pulmonary artery vasculoplasty: an alternative technique for safe vascular control

Introduction

Lung resections by robotic-assisted thoracic surgery (RATS) have become increasingly utilised. Pulmonary artery (PA) resection and reconstruction during lobectomy is rare, estimated to be required in no more than 2% of all lobectomies (1). PA vasculoplasty is a recognised technique to preserve lung parenchyma and avoid pneumonectomy (1), most commonly performed via thoracotomy. Video-assisted thoracic surgery (VATS) approach is reported but typically deemed technically demanding, whereas a reported robotic approach required a mini-thoracotomy for proximal control of the PA (2). A report from 2025, describes a total portal technique for arterioplasty for a right sided resection using bulldog clamps (3). VATS approaches utilizing bulldog clamps have also been reported (4). Here we describe our approach to a left upper lobe lung cancer, invading the PA, using a nylon vascular tape secured with a snugger for proximal PA control via totally thoracoscopic robotic-assisted approach. The accompanying video covers the procedural steps and techniques (Video 1). We present this article in accordance with the SUPER reporting checklist (available at https://shc.amegroups.com/article/view/10.21037/shc-2026-1-0008/rc).

Preoperative preparations and requirements

A 69-year-old male presented with a PET-avid mass in the left upper lobe invading the PA at the interlobar fissural level (Figure 1). Diagnosis was obtained via endobronchial ultrasound (EBUS) guided biopsy and provisionally reported as squamous cell carcinoma of the lung. The patient was discussed at a multidisciplinary team (MDT) meeting and deemed suitable for surgical treatment, clinical staging was T2a N0 M0. The indication for surgical treatment was a biopsy confirmed non-small cell lung cancer with an appropriate clinical staging. Background medical history included chronic obstructive pulmonary disease (COPD), hypertension, diabetes, and stroke. The patient’s suitability for surgery was assessed considering medical background, functional status and pulmonary function tests. Forced expiratory volume in 1 second (FEV1) was 1.9 L (74% of predicted) and diffusing capacity of the lungs for carbon monoxide (DLCO) was 53% of predicted. The patient was estimated to be performance status 1. Due to reduced lung function a parenchymal sparing procedure was preferred over pneumonectomy. There were no contraindications to totally thoracoscopic lobectomy with PA vasculoplasty. Pre-operative computed tomography (CT) scan indicated invasion of the PA which would require arterial resection and reconstruction to achieve a satisfactory oncological outcome while maintaining lung parenchyma. The tumour was invading the PA at the fissural level extending at the origins of the anterior basal and lateral basal segmental arteries (A8 + A9). In order to achieve adequate margins, the resection required the arteriotomy to partially include the base of A8 + A9. Reconstruction was required to re-establish lower lobe perfusion. All procedures performed in this article were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Informed consent was obtained from the patient for publication of this article, accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

Figure 1 CT scan demonstrates tumour in the left upper lobe invading the pulmonary artery. Superior extent of PA involvement (A) and inferiorly involving the interlobar PA (B). CT, computed tomography; PA, pulmonary artery.

Surgical technique

The procedure was performed in a tertiary hospital with a dedicated thoracic surgical department. The surgical team included consultant surgeons, consultant anaesthetist, bedside assistant, scrub nurse and circulating nurses. All team members were experienced in robotic thoracic surgery and have completed relevant standardised training.

The procedure was performed under general anaesthesia with the patient in the right lateral decubitus position. A standard four-arm RATS configuration was used (da Vinci X System, Intuitive Surgical). An additional 12-mm CO₂-tight assistant port was placed in the fourth intercostal space at the anterior axillary line, allowing introduction of a flexible suction catheter and external control of a nylon vascular tape and snugger. Port placement is illustrated in Figure 2. The position of the assistant port brings two advantages. It allows a natural angle onto the main PA for a vascular tape to be clamped outside the thorax. It also gives easy access to the main PA in the event of major bleeding or clamp failure. In this scenario external compression could then be achieved for temporary control while the robot is undocked before proceeding to an anterior thoracotomy.

Figure 2 Position of robotic ports. 2 mm × 12 mm instrument ports (arm 1 and 3) used for Cadiere and Maryland forceps, 2 mm × 8 mm ports for camera and retraction (arm 2 and 4). A: assistant port used for vascular control.

Standard instruments for robotic lung resection were used: Cadiere forceps in arms 1 and 4, and a Maryland dissector in arm 3.

Systematic mediastinal and hilar lymph node dissection was performed before commencing the lobectomy to improve access to hilar structures and reduce tension during dissection.

The anterior fissure was divided to enhance exposure. The superior pulmonary vein was dissected cranially to expose the main PA anteriorly, which was then dissected proximally from the posterior aspect (01:37). A plane was created between the main PA and the left main bronchus. Using the tip-up fenestrated grasper (preferred for its length and reach) the PA was encircled from anterior to posterior and double-looped with a vascular tape (01:40). Intravenous heparin (5,000 IU) was administered. Proximal control was achieved with a snugger advanced over a nylon vascular tape via the assistant port and clamped externally with an artery forceps, producing complete and reversible occlusion under direct vision. The snugger used was not a commercially available product. We repurposed a 15-cm length of soft plastic tubing, the same calibre widely used for purse string control during aortic cannulation. CO₂ insufflation was maintained throughout the procedure via the sealed assistant port at a pressure of 6 mmHg (01:49).

The truncus anterior was divided with a vascular stapler, followed by division of the upper lobe vein and bronchus (02:01–02:22). Distal control of the interlobar PA was initially achieved using a vascular tape secured with sliding hemolocks. The arteriotomy was begun anteriorly, extending around the area of tumour invasion (02:42). The distal PA tape was subsequently replaced with a vessel loop around the inferior pulmonary vein to optimise access while maintaining distal control (03:15). The arterial resection was completed posteriorly, and remaining parenchymal attachments were divided with a stapler to complete the lobectomy (03:55).

The vascular defect was assessed and reconstructed using a patch of autologous pericardium soaked in heparinised saline. This was excised after the lobectomy was completed using non-cauterising scissors taking care to visualise and avoid phrenic nerve injury. The patch was appropriately sized to cover the defect (04:03). As the defect extended a few millimetres beyond the take off of segment 8 artery, this was re-constructed first (04:16) by reattaching it to the main interlobar PA using a continuous 5-0 Prolene suture. This artery was not fully detached thus the medial wall remained intact throughout (04:36). The interlobar PA defect was repaired with the pericardial patch, which was first secured at the superior end of the defect (05:00) before the anterior and then the posterior rim of the defect were sutured with two 5/0 Prolene sutures in a continuous pattern (04:51–06:07). The ends were tied off at the inferior end of the defect, and to the previous suture from the segment 8 repair (06:03). Finally, the remaining small defect at the take off of the segment 9 arterial branch was reconstructed using a single 5-0 Prolene suture, which was tied after removal of vascular control to permit de-airing (06:23). The repair was inspected under direct vision, confirming haemostasis and vessel patency. A schematic of the vasculoplasty reconstruction is shown in Figure 3. Total operative time was 287 minutes, with estimated blood loss of 150 mL. The pericardial defect was closed primarily using 3-0 Prolene sutures. A 32f chest drain was inserted before closure of the robotic ports.

Figure 3 Schematic to demonstrate the position of the pericardial patch for PA reconstruction. PA, pulmonary artery.

Postoperative considerations

The patient was extubated in theatre and a chest X-ray was performed to confirm adequate lung expansion (Figure 4). The patient returned to the ward and was monitored according to a standard post-operative protocol. The postoperative course was free of major complications. Discharge was delayed to postoperative day 10 due to lower respiratory tract infection and air leak (chest drain removed on day 8). Standard post-surgical follow-up at 2 months was satisfactory and the patient was discharged with the MDT decision of standard surveillance (Figure 5). The patient remains disease free at time of reporting. Final pathology report demonstrated pleomorphic carcinoma with squamous cell carcinoma and the presence of an intravascular tumour plug giving a final stage of pT3N0, R0 (TNM 9^th edition).

Figure 4 Day 0 post-operative chest X-ray demonstrates good lung expansion and absence of pleural collection.

Figure 5 Satisfactory chest X-ray at 2 months post-operatively.

Discussion, tips and pearls

Lobectomy with PA resection and reconstruction preserves lung parenchyma and avoids pneumonectomy in selected patients (5). This is usually performed via a thoracotomy, which is associated with higher morbidity than minimally invasive VATS or RATS approach (6). A hybrid approach utilizing RATS combined with a mini-thoracotomy has been previously described (2) as well as a totally thoracoscopic approach using bulldog clamps (3). We propose an alternative total thoracoscopic robotic approach for proximal PA control and vasculoplasty, and we identify three main advantages of the technique described.

Firstly, the position of the CO₂-tight assistant port was modified and deliberately placed in the fourth intercostal space along the anterior axillary line, providing a direct trajectory over the main PA in case urgent access is required for suction or compression.

Secondly, proximal control of the main PA was achieved using a snugger introduced via the same assistant port. This configuration allowed combined internal and external control of the snugger, enabling complete and reversible occlusion of the vessel without the need for robotic clamps. In the technique described by Sumiya et al. (3) bulldog clamps were used for proximal PA control; however, this approach requires advancing the back blade of the bulldog around the posterior aspect of the main PA, a manoeuvre that some surgeons may find challenging due to the absence of haptic feedback and fear the risk of causing catastrophic bleeding in the least accessible aspect of the PA. In contrast, our technique avoids this risk while maintaining a totally thoracoscopic approach, providing secure proximal control under direct vision and permitting immediate conversion to an anterior thoracotomy through the same assistant port if vascular control were to be compromised.

In addition, we believe that this technique of proximal PA control may not only allay concerns around the safety of the manoeuvre, but also allow for extended utilisation with or without vasculoplasty when facing complex anatomical configurations that might require immediate clamping.

Thirdly, internal distal control was achieved using a vessel loop secured with sliding hemolocks. This provided reliable occlusion of the distal PA branches without the need for bulldog clamps, further simplifying the procedure and reducing instrument exchanges within the thoracic cavity.

The main contribution of this manuscript is the robotic adaption of lobectomy requiring vascular reconstruction utilizing an alternative technique for proximal vascular control and why this may have advantages over previously reported minimally invasive techniques. We believe the robotic platform makes this complex procedure more accessible and reduces the technical demand compared to previously described VATS approaches.

A potential limitation of the robotic approach is the risk of suture damage during vascular reconstruction. The fine calibre and delicate nature of prolene sutures, combined with the absence of haptic feedback may theoretically predispose to fraying or rupture when manipulated by robotic instruments. This was a concern for the authors at the inception of the technique. However, this issue was not encountered in practice. No suture breakage was observed, and the robotic platform provided excellent precision and stability during suturing. These findings suggest that despite the absence of tactile feedback, the enhanced visualisation and dexterity afforded by the robotic system allow for safe and controlled vascular reconstruction.

Another potential limitation of performing PA reconstruction via a robotic platform is operative time. Increased operative time compared to an open procedure may have implications for issues relating to single lung ventilation. Operative time in this case was 287 minutes. However, in our experience with other complex robotic techniques there is a learning curve that quickly reduces the operative time, and it is our expectation that a similar learning curve can be anticipated with this technique.

Our centre has a well-established robotic programme with over 2,000 lobectomies performed. We believe extensive experience in robotic thoracic surgery is an essential prerequisite when considering complex vascular resections. Although it is difficult, given the scarce literature on the topic, to provide an exact number, we believe a minimum of 100 major procedures performed to be a reasonable estimate.

We believe however that in experienced hands the technique described not only appears feasible and safe, but might also improve execution and reproducibility compared to other VATS or RATS approaches, thus extending the potential benefits of minimally invasive surgery whilst maintaining satisfactory outcomes.

Conclusions

Totally thoracoscopic, robotic-assisted lobectomy with PA reconstruction is potentially feasible and safe approach that can be performed without the need for thoracotomy or hybrid access. The use of an externally controlled snugger via an aptly positioned CO₂-tight assistant port provides reliable and reversible proximal control of the main PA, while a sliding hemolock on a vessel loop offers effective distal control without the need for intrathoracic bulldog clamps. The robotic system demonstrated excellent precision and stability during vascular suturing. This technique may represent a useful addition to the minimally invasive armamentarium for complex pulmonary resections, offering the potential to further reduce morbidity while maintaining oncological integrity.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://shc.amegroups.com/article/view/10.21037/shc-2026-1-0008/rc

Peer Review File: Available at https://shc.amegroups.com/article/view/10.21037/shc-2026-1-0008/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://shc.amegroups.com/article/view/10.21037/shc-2026-1-0008/coif). R.B. has received speaker and proctor fees from Intuitive. The other authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this article were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration and its subsequent amendments. Informed consent was obtained from the patient for publication of this article, accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Vannucci J, Matricardi A, Potenza R, et al. Lobectomy with angioplasty: which is the best technique for pulmonary artery reconstruction?. J Thorac Dis 2018;10:S1892-8. [Crossref] [PubMed]
2. Uchida S, Matsunaga T, Takamochi K, et al. Hybrid robotic-assisted and minithoracotomy for pulmonary arterioplasty using autologous pulmonary vein graft. JTCVS Tech 2023;20:166-8. [Crossref] [PubMed]
3. Sumiya R, Uchida S, Matsunaga T, et al. Robotic portal right upper sleeve lobectomy with pulmonary arterioplasty. Gen Thorac Cardiovasc Surg 2025;73:718-21. [Crossref] [PubMed]
4. Gonzalez-Rivas D, Delgado M, Fieira E, et al. Double sleeve uniportal video-assisted thoracoscopic lobectomy for non-small cell lung cancer. Ann Cardiothorac Surg 2014;3:E2. [Crossref] [PubMed]
5. Schiavon M, Comacchio GM, Mammana M, et al. Lobectomy With Artery Reconstruction and Pneumonectomy for Non-Small Cell Lung Cancer: A Propensity Score Weighting Study. Ann Thorac Surg 2021;112:1805-13. [Crossref] [PubMed]
6. Veluswamy RR, Whittaker Brown SA, Mhango G, et al. Comparative Effectiveness of Robotic-Assisted Surgery for Resectable Lung Cancer in Older Patients. Chest 2020;157:1313-21. [Crossref] [PubMed]