MIS - ROBOTIC - OPEN
Lobectomy port placement
Placement is essentially the same for each side. The camera port is the first port I place. Typically this is placed 9 cm below the tip of the scapula as far lateral as possible (mid axillary line). This can be confirmed by marking the sterno-xyphoid junction and spine and meeting at the mid point.
This consistently places the camera at the 8th interspace. The remaining ports are placed 9 cm apart and end up in more or less a straight line. This may or may not be in the same interspace.
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Tip -- patients with larger BMIs will force the diaphraghm up and may require moving all ports superior.
We utilize one or two 12 mm stapler ports. Obtaining a safe vector to divide the vein or artery can be difficult with just one anterior stapler port.
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Tip -- We will change out a 8.5 mm port if necessary rather than starting with two 12 mm ports.
1.
Exploration and lymph node dissection
2.
Inferior pulmonary ligament to inferior vein (Station 9)
3.
Posteriorly on right to station 8 and 7 at level of bronchus intermedious.
4.
Station 11 between the RUL and bronchus intermedious. This opens the fissure posteriorly
5.
Station 4 on right above the azygous, lateral to the SVC.
6.
Assess the fissure and expose artery. Complete fissure as needed for exposure
7.
Isolate vein. Divide artery followed by venous branches and bronchus
Lymph Node Dissection
One of the most significant advantages of the robot is the degree of lymph node dissection that can be performed. Better visualization and two handed surgical technique with an energy device facilitate the process. We will typically utilize a bipolar instrument, however the spatula or hook can be of great value. This all depends on comfort level and likely should progress from bipolar to monopolar as experience improves. The advantage to the monopolar approach is a more consistent application of energy and better hemostasis at times. This is countered with an inability to grasp or manipulate the tissue as well as the bipolar.
Right
Right nodal dissection starts with the inferior pulmonary ligament and proceeds posteriorly. Station 8 (paraesophageal) and station 7 (subcarinal) are easily identified.
Tip: Care should be taken with the Station 7 nodes. They will bleed and meticulous dissection with energy will help avert this. Bipolar evergy here helps to avoid thermal damage to the bronchus intermedious.
The triangle above the azygous and posterior to the SVC holds the station 4 lymphnodal packet.
The Station 11 or sump node is between the takeoff of the RUL and bronchus intermedious. Removing this node greatly facilitates the completion of the fissure and division of the bronchus in upper or lower lobectomy.
