Robotic first rib resection for thoracic outlet syndrome.

Robotic resection of the "offending portion" of the first rib in patients with thoracic outlet syndrome (TOS) has been associated with excellent results. The results have been due to (I) a better understanding of the pathogenesis of TOS, and (II) the technical advantages of the robotic platform. This article outlines the recent understanding of the pathogenesis of TOS, and reports the experience with robotic resection of the "offending portion" of the first rib in patients with neurogenic and venous TOS. Patients diagnosed with TOS underwent robotic first rib resection. Diagnosis of TOS was made by magnetic resonance angiography (MRA). On a thoracoscopic platform, the robot was used to dissect the "offending portion" of the first rib. A total of 162 patients underwent robotic first rib resection. Eighty-three patients underwent robotic first rib resection for Paget-Schroetter syndrome (PSS) (venous TOS). There were 49 men and 34 women. Mean age was 24±8.5 years. Operative time was 127.6±20.8 minutes. Median hospitalization was 4 days. There were no surgical complications, neurovascular injuries, or mortality. At a median follow-up of 24 months, all patients had an open subclavian vein (SV) for a patency rate of 100%. Seventy-nine patients underwent robotic first rib resection for neurologic symptoms of the upper extremity (neurogenic TOS). There were 29 men and 50 women. Mean age was 34±9.5 years. Operative time was 87.6±10.8 minutes. There were no intraoperative complications. Hospital stay ranged from 2-4 days with a median hospitalization of 3 days. There were no neurovascular complications. There was no mortality. In patients with neurogenic symptoms, Quick DASH Scores (mean ± SEM) decreased from 60.3±2.1 preoperatively to 5±2.3 in the immediate postoperative period, and 3.5±1.1 at 6 months (P<0.0001). Immediate relief of symptoms was seen in 71/79 (91%) patients. Persistent paresthesia was seen in 9/79 (9%) immediately postop and 3/79 (3.8%) patients at 6 months. Following the appropriate identification of the "offending portion" of the first rib which results in compression of the SV at its junction with the innominate vein by MRA, robotic resection of the "offending portion" of the first rib allows is associated with excellent results.

Robotic Staged Bilateral Selective Postganglionic Sympathectomy for Upper-Extremity Hyperhidrosis.

PURPOSE: The prevalence of compensatory hyperhidrosis (CH) has been reported to be as high as 80% in patients following thoracic sympathectomy for upper-extremity hyperhidrosis. The CH rate is 7.2% with simultaneous bilateral robotic selective dorsal sympathectomy. We reviewed the results in patients who underwent staged bilateral robotic selective dorsal sympathectomy (SBRSS). METHODS: A case series analysis of patients who underwent SBRSS was performed. A surgical robot was used to divide the postganglionic sympathetic fibers and communicating rami to intercostal nerves 2, 3, and 4. The sympathetic chain was left intact. The operation was performed on the dominant side, and the same procedure was then performed on the contralateral side after 4 weeks. The success of the sympathectomy was determined by intraoperative temperature measurement, patient interviews, and the Hyperhidrosis Disease Severity Scale. RESULTS: There were 47 patients (22 men, 25 women), with a mean age of 22 ± 3 years. Minor complications were seen in 4% of patients. One patient had transient heart block. One patient had transient partial Horner's syndrome. Forty percent of patients had transient CH after the first surgery, and 45% had transient CH after sympathectomy on the contralateral side. There were no deaths. The median hospitalization was 3 days. At a mean follow-up of 28 ± 6 months, 46/47 patients (98%) had sustained relief of hyperhidrosis. In one patient (1/47, 2%), hyperhidrosis recurred on the first operated side. One patient (2%) exhibited sustained CH. CONCLUSION: SBRSS is associated with a lower rate of CH than when the procedure is performed bilaterally in a simultaneous fashion. This procedure is associated with the lowest reported rate of CH.

Robotic Lobectomy: Experience with 638 Consecutive Cases.

BACKGROUND: Robotic lobectomy has been evolving over the past decade and has been shown to be an oncologically acceptable procedure. We evaluated our experience with robotic lobectomy for the treatment of early-stage lung cancer. METHODS: We performed a retrospective review of prospectively accrued patients at our institution who underwent robotic lobectomy for early-stage lung cancer from February 2004 to July 2019, RESULTS: Of 3304 consecutive patients who underwent a robotic operation by a single surgeon, 638 underwent robotic lobectomy for early-stage primary non-small cell lung cancer (NSCLC; stages I and II). The 427 (67%) men and 211 (33%) women had a median age of 69 y (range 41-86), and 567 (89 %) were former or current smokers. The median operative time was 176 minutes (range 160-456), the median chest tube time was 3 days (2-8), the median air leak time was 0 days (0-3), and the median length of stay was 3 days (1-26). The median tumor size was 2.6 cm (range 06-3.4). The mean number of nodes recovered was 14 ± 3. Pathologic upstaging was noted in 121 patients (19%). Minor complications were observed in 133 patients (21%). Conversion to thoracotomy occurred in 11 (1.7%) patients. Mortality was 0.5%. CONCLUSION: Robotic lobectomy is a safe, minimally invasive procedure that replicates the oncologic and technical principles of thoracotomy for the treatment of lung cancer.

Robotic First Rib Resection for Thoracic Outlet Syndrome.

PURPOSE: First rib resection is a key component of the treatment of Thoracic Outlet Syndrome (TOS). We report our experience with, and technique for, robotic first rib resection. METHODS: Patients diagnosed with TOS underwent robotic first rib resection of the offending portion of the first rib with disarticulation of the costo-sternal joint. Definitive diagnosis of TOS was made by Magnetic Resonance Angiography (MRA) with maneuvers. RESULTS: A total of 67 patients underwent robotic first rib resection. Neurogenic TOS: 39 patients underwent robotic resection for Neurologic Symptoms of the upper extremity (Neurogenic TOS). There were 14 men and 25 women, with a mean age of 34 ± 9.5 years. Paget-Schroetter Syndrome (PSS) or Venous TOS: 28 patients underwent transthoracic robotic first rib resection for PSS. There were 16 men and 12 women, with a mean age of 24 ± 8.5 years. Operative time was 87.6 ± 10.8 minutes. There were no intraoperative complications. Hospital stay ranged from 2 to 4 days with a median hospitalization of 3 days. There were no neurovascular complications. There was no mortality. In patients with Neurogenic TOS, QuickDASH Scores (mean ± SEM) decreased from 60.3 ± 2.1 preoperatively to 5 ± 2.3 in the immediate postoperative period and to 3.5 ± 1.1 at 6 months (p<0001). Immediate relief of symptoms was seen in 35/39 patients (91%). Persistent paresthesia was seen in 4/39 (9%) immediately postop, and in 2/39 (2.5%) at 6 months. Thirty-seven of 39 (97.5%) patients reported complete relief of symptoms. Among patients with PSS or Venous TOS, 9/28 (32%) required endovascular venoplasty to completely open the subclavian vein after the relief of extrinsic compression. At a median follow-up of 24 months, all patients with PSS had an open subclavian vein, for a patency rate of 100%. CONCLUSIONS: Robotic transthoracic first rib resection allows for minimally invasive resection of the first rib in patients with TOS, with excellent relief of symptoms and no neurovascular complications.

Robotic transthoracic first-rib resection for Paget-Schroetter syndrome.

OBJECTIVES: First-rib resection is a key component in the treatment of Paget-Schroetter syndrome. We report our experience with robotic first-rib resection. METHODS: Patients diagnosed with Paget-schroetter syndrome underwent thrombolysis followed by robotic first-rib resection. The diagnosis was made by preoperative venography (VA) and magnetic resonance venography. The robot was used to dissect the first rib, disarticulate the costosternal joint and divide the scalene muscles. Success of the first-rib resection was assessed by physical examination, venogram and magnetic resonance venography. RESULTS: Eighty-three robotic first-rib resections were performed (49 men and 34 women). The mean age of the patients was 24 years ± 8.5 years. The operative time was 127.6 min ± 20.8 min. The median hospitalization was 4 days. There were no surgical complications, neurovascular injuries or mortality. Patients with a patent subclavian vein on the postoperative venogram (57 of 83 patients, 69%) were anticoagulated with warfarin for 3 months. In the remaining 27 patients with a persistent postoperative occlusion of the subclavian vein, 21 (21 of 83 patients, 24%) underwent angioplasty and were anticoagulated with warfarin for 3 months, and 6 (6 of 83, 7%) required stent placement to achieve complete vein patency. Patients who underwent stent placement received antiplatelet therapy in addition to warfarin anticoagulation for 3 months. At a median follow-up of 24 months, all patients had an open subclavian vein with a patency rate of 100%. CONCLUSIONS: The robotic transthoracic first-rib resection is feasible and allows for a minimally invasive resection of the first rib, while minimizing neurovascular complications.

Long-term Results of Robotic Modified Belsey (Gastroesophageal Valvuloplasty) Fundoplication.

PURPOSE: Nissen fundoplication is associated with poor long-term durability, as well as dysphasia and gas bloat. We report here the long-term results of modified Belsey fundoplication (Gastroesophageal Valvuloplasty; GEV) performed laparoscopically using a surgical robot. METHODS: Patients who underwent robotic GEV were reviewed retrospectively. Operations were performed by laparoscopy and included robotic dissection of the esophageal hiatus, primary closure of the hiatus, followed by intussusception of a 4 cm segment of the esophagus into the stomach for 270°, and suspension of the fundoplication on the hiatal closure. The results were assessed by postoperative endoscopy, contrast esophagography, a Subjective Symptom Questionnaire (SSQ), and objective Visick grading. RESULTS: There were 291 patients (156 male, 135 female, mean age 51±14 years). Indications were intractability (73%) and pulmonary symptoms (27%). Mean operative time was 130 minutes ± 52 minutes. Minor complications were seen in 21%. There was no mortality. Mean hospitalization was 2.8 days ± 1.7 days. Mean follow-up was 85 months ± 7 months. During this period, the mean SSQ score decreased from 8.3 ± 0.6 to 0.7± 0.2 (P < 0.05). There was no long-term dysphasia or gas bloat. Ninety-five percent of patients were Visick I and 5% were Visick II. Hiatal hernia recurred in 7 patients (2%). CONCLUSIONS: Robotic laparoscopic modified Belsey fundoplication (GEV) is associated with excellent long-term durability, reflux control, and low rates of dysphasia and gas bloat. This procedure may represent an alternative to medical antireflux therapy and other surgical antireflux procedures such as Nissen fundoplication.

Long-term results of robotic anatomical segmentectomy for early-stage non-small-cell lung cancer.

OBJECTIVES: Anatomical segmentectomy is advocated for curative resection in select patients. We investigated the long-term results of robotic anatomical segmentectomy with mediastinal nodal dissection in patients with early-stage lung cancer. METHODS: We retrospectively reviewed patients who underwent robotic anatomical segmentectomy for early-stage non-small-cell lung cancer (NSCLC). The follow-up data were obtained to determine survival and statistically significant risk factors in both univariable and multivariable models. RESULTS: Seventy-one patients had clinical stage I NSCLC (36 men, 35 women, mean age 70 ± 12 years). All patients underwent R0 resection. The mean operating time was 134 min. Ten of 71 (14%) patients were upstaged. Eight of 71 (11%) patients were upstaged due to the size of tumour in the pathological specimen, and 2 of 71 (3%) patients were upstaged due to microscopic N2 nodal metastasis. Median hospitalization was 4 days (2-31 days). Complication rate was 29%. There were no complications attributable to the surgical robot. No patient died within 90 days. Mean follow-up was 54 months (range 2 months to 9 years). The overall 5-year survival was 43%, whereas lung cancer-specific 5-year survival was 55%. The 5-year lung cancer-specific survival for pathological stage I disease was 73%. Local or mediastinal recurrence occurred in 4 of 71(5%) patients. Pathological upstaging or recurrence resulted in 0% 5-year survival. The univariable and multivariable analyses showed that advanced age and pathological upstaging were statistically significant risk factors for lung cancer-specific death. CONCLUSIONS: Robotic anatomical segmentectomy with mediastinal nodal dissection is a safe and feasible procedure. Accurate preoperative clinical staging is of critical importance for long-term survival.

Robotic resection of a superior sulcus neurogenic tumor.

Neurogenic tumors do not often occur in the superior sulcus or apex of the chest cavity. Historically, surgical approaches have been dictated by the location of the tumor and its relation to the contiguous structures such as the vertebral bodies, subclavian vessels, and chest wall. Resection is hampered by difficulties with visualization and access within a narrow working space. The shortcomings associated with the traditional surgical approaches create a potential of injury to nearby structures. We present a case of a 43-year-old woman with a superior sulcus neurogenic tumor impinging on the left subclavian vein, who underwent a successful resection without injury to nearby structures. We found that a robotic approach improved visualization of the tumor and nearby structures and increased instrument maneuverability relative to a thoracoscopic approach, along with less pain and recovery time compared with a thoracotomy. This experience suggests that robotics provides a promising alternative for excision of superior sulcus neurogenic tumors, which may reduce associated morbidity.

Robotic selective postganglionic thoracic sympathectomy for the treatment of hyperhidrosis.

BACKGROUND: The surgical management of hyperhidrosis is controversial. Robotic surgical systems with their high-definition magnified 3-dimensional view and increased maneuverability in a confined space may facilitate the technique of selective sympathectomy (ramicotomy). We present a case series of patients undergoing selective postganglionic thoracic sympathectomy using robotic technology. METHODS: This study is a case series analysis of patients who underwent selective postganglionic thoracic sympathectomy from July 2006 to November 2011. The operation was performed on a video-assisted thoracoscopic surgery (VATS) platform. The robot was used for pleural dissection and division of the postganglionic sympathetic fibers and the communicating rami. The success of sympathectomy was assessed by intraoperative temperature measurement of the ipsilateral upper extremity, patient interviews, and scoring of the symptomatic nature of hyperhidrosis based on the Hyperhidrosis Disease Severity Scale. RESULTS: There were 110 sympathectomies performed in 55 patients (25 men, 30 women). Simultaneous bilateral sympathectomy was performed in all patients. Median age was 28 years (range, 16 to 65 years). There was no conversion to thoracotomy. Complications were minor and were seen in 5 of 55 patients (9%). There were no deaths. Median hospital stay was 1 day (range, 1 to 4 days). Of the 55 patients, 53 (96%) had sustained relief of their hyperhidrosis at a median follow-up of 24 months (range, 3 to 36 months), and compensatory sweating was seen in 4 patients (7.2%). CONCLUSIONS: Robotic thoracoscopic selective sympathectomy is an effective, feasible, and safe procedure with excellent relief of hyperhidrosis and low rates of compensatory sweating and complications.

The learning curve of robotic lobectomy.

BACKGROUND: Robotic lobectomy has been shown to be feasible, safe and oncologically efficacious. The actual learning curve of robotic lobectomy has yet to be defined. This study was designed to define the learning curve of robotic lobectomy. METHODS: We performed a retrospective review of prospectively accrued patients at our institution who underwent robotic lobectomy from January 2004 until December 2011. Six scatter graphs were constructed, comparing operative time, conversion rate, morbidity, mortality, length of stay and surgeon comfort with the number of consecutive cases. In each graph, a regression trendline was drawn and the change in the slope of the curve corresponding to the beginning of the plateau defined the learning curve. The overall learning curve was defined as mean ± SD of the sum of the individual learning curves. RESULTS: Based on operative times, mortality and surgeon comfort, the overall learning curve was 18 ± 3 cases. The learning curve based on operative times, mortality and surgeon comfort was 15, 20 and 19 cases, respectively. There was no association between the need for conversion and number of consecutive cases. There was a trend towards lower morbidity and decreased length of stay with greater experience. However, these parameters did not define a specific learning curve. CONCLUSIONS: Operative time, mortality and surgeon comfort were found to be key parameters for the learning curve of robotic lobectomy when performed by surgeons who are experienced with video-assisted thoracic surgery (VATS). The learning curve was 18 ± 3 cases.

Robotic-assisted treatment of celiac artery compression syndrome: report of a case and review of the literature.

BACKGROUND: The surgical management of celiac artery compression syndrome (CACS) is controversial. Controversies include the appropriate surgical technique, the surgical approach, and the utility of postoperative stents. The literature is reviewed, and a case of CACS is presented in which a robotic-assisted division of the median arcuate ligament (MAL) was performed. METHODS: Robotic-assisted treatment of celiac artery syndrome was carried out using six (five 1 cm and one 2 cm) abdominal incisions. The robotic device was used to expose the aorta and celiac artery and divide the median arcuate ligament. RESULTS: Postoperatively, the patient's postprandial abdominal pain subsided. On 16 month follow-up, the patient was doing well, tolerated an unrestricted diet without symptoms, and exhibited weight gain. CONCLUSION: This case is the second reported in the literature and demonstrates that the robotic approach to division of the MAL is feasible, safe, and efficacious.

Robotic en bloc first-rib resection for Paget-Schroetter disease, a form of thoracic outlet syndrome: technique and initial results.

OBJECTIVE: First-rib resection is a key component of the treatment of Paget-Schroetter disease. There are many controversies regarding the management of this disease. We report a safe, effective, minimally invasive robotic transthoracic approach for resection of the first rib. METHODS: Over an 8-month period, five patients underwent robotic first-rib resection. Preoperative assessment included physical examination and bilateral venous angiography. On a thoracoscopic platform using three 2-cm incisions and one 1-cm incision, the robot was used to dissect the first rib and divide the scalene muscles. Success of the first-rib resection was assessed by postoperative venous angiography. RESULTS: There were four men and one woman. Mean age was 34.6 ± 10 years. Mean operative time was 195 ± 24.6 minutes. There were no complications and no mortality. All patients had a patent subclavian vein on the postoperative venogram and were anticoagulated with warfarin for 3 months. At a median follow-up of 12 months, all patients had an open subclavian vein for a patency rate of 100%. CONCLUSIONS: Robotic thoracoscopic first-rib resection represents a feasible minimally invasive approach to en bloc resection of the first rib. This technique minimizes the risk of neurovascular complications that are associated with conventional techniques.

Proposed pathogenesis of Paget-Schroetter disease: impingement of the subclavian vein by a congenitally malformed bony tubercle on the first rib.

AIM: To study and compare the anatomical and clinical pathology of first ribs in patients with Paget-Schroetter Disease (PSD) with first ribs in patients without the disease. METHODS: In a case-control study, normal human cadaver first ribs were compared with first ribs from patients with PSD. Ribs, intraoperative videos of transthoracic en bloc surgical resection of the first rib, and preoperative and postoperative dynamic upper extremity venograms were reviewed. RESULTS: Fifteen first ribs were from patients with PSD and seven normal first ribs were from human cadavers. In all patients (100%) with PSD there was a bony tubercle that corresponded to the area of the subclavian vein groove in the normal ribs. In all controls (100%), there was a normal subclavian groove without the presence of a tubercle. On preoperative venograms in patients with PSD, the tubercle accounted for an extrinsic protuberance that compressed the subclavian vein (100%). Intraoperatively, the abnormal bony tubercle accounted for the extrinsic compression of the subclavian vein in all (100%) patients with PSD. Venograms of the upper extremity obtained after first rib resection showed the disappearance of the extrinsic compression on the subclavian vein (100%) and a patent subclavian vein with elevation of the arm in all patients. CONCLUSIONS: A bony tubercle at the site of the subclavian vein groove in patients with PSD causes extrinsic compression of the subclavian vein at rest.

Novel thoracoscopic approach to difficult posterior mediastinal tumors.

Thoracoscopic resection is the preferred treatment of posterior mediastinal tumors. However, thoracotomy may be necessary if the tumors are large or adherent; if they are demonstrate invasion or intraspinal growth; or if they are located in the superoposterior mediastinum or posterior costodiaphragmatic angle. We describe a case of a large, adherent posterior costodiaphragmatic mediastinal mass that would have been otherwise difficult to resect thoracoscopically if it were not for the three-dimensional visualization, greater dexterity, and accurate dissection offered by the Da Vinci robot.

Post-esophagectomy pseudomembranous inflammation of the interposed colon.

BACKGROUND: Pseudomembranous colitis (PMC) usually is caused by antibiotic-related changes in colonic anaerobic microflora, leading to Clostridium difficile overgrowth and overproduction of toxins. We present the first reported case of PMC affecting the intrathoracic, interposed colon of an esophagectomy patient in the absence of inflammation of the in situ colon. METHODS: Case report and review of pertinent English-language literature. CASE REPORT: A 47 year-old male developed Clostridium difficile-related colitis after in Ivor-Lewis esophagectomy for carcinoma of the esophagus, and rendered asymptomatic after 10 days of therapy with oral vancomycin. Postoperatively, the patient developed a broncho-esophageal fistula, and was reconstructed with a two-stage colonic esophageal colonic interposition three months after the fistula was closed surgically. On postoperative day nine, the patient developed symptomatic PMC of the interposed colon segment, whereas the in situ colon was spared. Therapy with oral vancomycin for three weeks eradicated the infection. CONCLUSIONS: Pseudomembranous colitismay develop in the interposed colon after a esophageal colonic interposition, even absent inflammation of the in situ colon. Previous infection with C. difficile may have increased the risk in this patient.

Outpatient management of post-pneumonectomy and post-lobectomy empyema using the vacuum-assisted closure system.

PURPOSE: The conventional management of a post-pneumonectomy (PPE) and post-lobectomy empyema (PLE) necessitates an open window, wound packing, frequent wound debridement, and prolonged hospitalization. We studied the feasibility of outpatient therapy in this patient population using the vacuum-assisted closure (VAC) therapy system. METHODS: From September 2005 to November 2007, six patients with PPE and PLE with or without a bronchopleural fistula underwent outpatient therapy using a VAC system. After debridement and closure of the bronchial fistula, a VAC system was applied and the patient was discharged. The patient returned for debridement under anesthesia and VAC replacement every 7-10 days. Once the pleural space was cleaned, the residual space was obliterated, and the wound was closed over suction catheters. Of the six patients, two developed recurrent infection after the closure that required repeated VAC dressings and flap closures. RESULTS: The outpatient use of the VAC system in patients with PPE and PLE avoided the need for any daily painful dressing changes and significantly decreased the total length of hospitalization and the time to closure of the empyema space, and thus increased the overall patient satisfaction. CONCLUSIONS: Our results suggest that outpatient VAC therapy of PPE and PLE is feasible and beneficial.

From Jacobeaus to the da Vinci: thoracoscopic applications of the robot.

With the increasing recognition of the benefits of minimally invasive surgery, surgical technology has evolved significantly since Jacobeaus' first attempt at thoracoscopy 100 years ago. Currently, video-assisted thoracic surgery occupies a significant role in the diagnosis and treatment of benign and malignant diseases of the chest. However, the clinical application of video-assisted thoracic surgery is limited by the technical shortcomings of the approach. Although the da Vinci system (Intuitive Surgical) is not the first robotic surgical system, it has been the most successful and widely applicable. After early applications in general and urologic surgery, the da Vinci robot extended its arms into the field of thoracic surgery, broadening the applicability of minimally invasive thoracic surgery. We review the available literature on robot-assisted thoracic surgery in attempt to better define the current role of the robot in pulmonary, mediastinal, and esophageal surgeries.

Robot-assisted lobectomy for early-stage lung cancer: report of 100 consecutive cases.

BACKGROUND: Robotics can facilitate dissection during video-assisted thoracoscopic (VATS) lobectomy. This study describes a hybrid minimally invasive lobectomy procedure consisting of two phases: robotic vascular, hilar, and mediastinal dissection, and then VATS lobectomy. METHODS: Over a 54-month period, 100 consecutive patients with stage I and II (T1 or T2N0, and T1 or T2N1) lung cancer (42 men, 58 women; mean age 65 +/- 8 years) underwent robotic VATS lobectomy. RESULTS: Lobectomies were right upper (29), right middle (7), right lower (17), left upper (31), and left lower (16). Mean operating room time was 216 +/- 27 minutes. Tumor type was adenocarcinoma (57), squamous cell carcinoma (25), 7 adenosquamous carcinoma (7), bronchoalveolar (3), large cell (1), poorly differentiated (3), carcinoid (2), mucoepidermoid (1), spindle cell (1). Pathologic upstaging was noted in 17 patients (10 to stage IIB, 7 to stage IIIA). There was no emergent conversion to a thoracotomy. Median hospitalization was 4 days. Complications included atrial fibrillation (13), atelectasis (5), prolonged air leak (4), pleural effusion (3), pulmonary embolus (3), incisional bleeding (1), hydropneumothorax (1), dural leak (1), liver failure (1), pneumonia (1), respiratory failure (1), and cardiopulmonary arrest (1). There was no intraoperative death. Postoperative mortality was 3%. There were no deaths among the last 80 patients. At a median follow-up of 32 months (range, 1 to 59), 1 patient (1%) died of his cancer, 6 (6%) had distant metastases, and 2 (2%) had a second lung primary cancer. There was no local recurrence. CONCLUSIONS: Robotics are feasible for mediastinal, hilar, and pulmonary vascular dissection during VATS lobectomy.

Bronchial stump reinforcement with an azygous vein flap.

Bronchial stump reinforcement has been shown to significantly reduce the incidence of bronchopleural fistulas. Various coverage techniques have been described in the literature. While the azygous vein flap is an easy, safe and effective reinforcement option for right-sided bronchial stumps, the flap is not widely adopted, with little mention in the literature, partly due to surgeons' uneasiness with the technique. In this report, we describe an easy-to-adopt approach to azygous vein bronchial reinforcement.