Intraoperative Contralateral Tension Pneumothorax During a Robotic Left Lower Sleeve Lobectomy

Several studies have demonstrated the superiority of pulmonary resections coupled with bronchoplasty due to the possibility of preserving lung parenchyma in the context of a possible pneumonectomy. Likewise, the role minimal invasion has had in this approach has become significantly more prominent, with robotic assisted thoracic surgery (RATS) being the most promising. This is a case in which a typical carcinoid tumor was resected in the left lower bronchus orifice followed by a v-anastomosis through RATS.

The Surgery

A sixty-eight-year-old obese woman with a large hiatal hernia was diagnosed with a carcinoid tumor in the left lower bronchus as an incidental finding on a chest CT scan. It was decided that the optimal approach to treating her was a left lower lobectomy along with a bronchoplasty between the left upper bronchus and the left main bronchus to preserve as much parenchyma as possible. Both the location of the tumor and the complexity of the technique led surgeons to decide that the use of RATS for this case would be beneficial for the patient.

The intervention began with a lymphadenectomy, obtaining critical adenopathies. Later, the lower left pulmonary artery was sectioned. It is important to mention that at this point the patient desaturated below 40 percent with unsuccessful retake despite the various pharmacological and mechanical rescue attempts by the anesthesia team. Given the suspicion of a contralateral pneumothorax, a chest X-ray was performed, which confirmed it. This complication was resolved with a right apical chest tube, which allowed the patient to stabilize and continue with the procedure. 

Once saturation was recovered, the team proceeded to section the left inferior pulmonary vein. Finally, after locating the tumor, it was resected. During this, it was possible to preserve the upper edge of the upper bronchus orifice in order to facilitate a v-anastomosis with the main left bronchus.

Conclusion

Carrying out a pulmonary resection coupled with a bronchoplasty via RATS is a feasible option for central lung tumor resection. This approach provides greater compliance for the surgeon, allows better exposure, and facilitates the surgical technique compared to its counterparts. Furthermore, in the context of an intraoperative contralateral pneumothorax, immediate action is critical due to its elevated morbimortality.

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