Preservation of the right internal thoracic artery graft in robotic-assisted right middle lobectomy

SESSION TITLE: Cardiovascular Abnormalities and Interventions SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/11/2023 09:40 am - 10:25 am INTRODUCTION: Since the introduction of robotic-assisted techniques in the early 2000s, robotic-assisted thoracic surgery (RATS) lobectomy has been shown to be a safe and efficient approach to lung cancer resection. RATS lobectomy has similar perioperative morbidity and mortality outcomes to that of video-assisted thoracic surgery (VATS) lobectomy, and is superior when compared to lobectomy via thoracotomy Lobectomy after previous cardiac surgery, such as coronary artery bypass grafting (CABG), represents one of those situations. The severe adhesive disease between the graft and surrounding tissues at times necessitates leaving behind a sliver of lung parenchyma attached to the graft to prevent damage to the graft . While the graft is preserved, there remains some concern regarding local tumor recurrence. Here, we report a unique case of RATS right middle lobectomy after CABG with a right internal thoracic artery (RITA) graft in a patient with lung adenocarcinoma. CASE PRESENTATION: The patient was a 72-year-old male who presented with a growing right middle lobe (RML) lung nodule. He had undergone coronary artery bypass grafting (CABG) four years before for severe triple vessel disease using a RITA graft to the left anterior descending coronary artery (LAD). The LITA was not used at the time at the cardiac surgeon's discretion due to concerns for subclavian steal syndrome. Upon review of the patient's pre-operative cardiac catheterization for lobectomy, the patient was determined to be RITA-dependent. Chest computed tomography (CT) findings demonstrated a 1.5-cm solid lung mass within the right middle lobe, but no other findings. Positron emission tomography (PET) imaging showed the nodule to be PET-avid. The RML mass was biopsied and found to be primary adenocarcinoma. In anticipation of severe adhesive disease in addition to the possible serious consequence of injuring the graft, a robotic approach was chosen and cardiopulmonary bypass machine were on standby. A RATS right middle lobectomy was performed. Upon entry into the chest cavity, there were multiple adhesions throughout the right chest cavity, most severe medially adjacent to the bypass graft. Using the robotic camera in conjunction with bipolar forceps, the adhesions were taken down without compromising the RITA the dominant blood supply. Once the lung parenchyma was freed from the graft, lobectomy was performed with removal of mediastinal lymph nodes. The patient was discharged on post-operative day 3 without complications. The final histopathological report confirmed TMN stage of T1bN0M0 adenocarcinoma as specimens sent had negative margins and no positive lymph nodes. DISCUSSION: By taking advantage of the RATS approach, the patient was surgically treated for stage 1A right primary lung adenocarcinoma with previous CABG with RITA graft. Any caliber of injury to this dependent graft could lead to catastrophic consequences. Although leaving behind a margin of lung parenchyma was an option as suggested by several studies with minimal reported oncologic compromise and infection risk, we believe that the robotics approach provided the optics and dexterity required to complete an oncologic dissection of the right middle lobe with no compromise to the RITA graft. CONCLUSIONS: Robotic Lobectomy can be safely done in presence of RITA graft. REFERENCE #1: Linsky P, Wei B. Robotic lobectomy. J Vis Surg. 2017;3:132. REFERENCE #2: Funaki S, Inoue M, Shigemura N, Okumura M. Thoracoscopic lobectomy for lung cancer after coronary artery bypass grafting using internal thoracic artery. Interact Cardiovasc Thorac Surg. 2012;15(5):928-929. REFERENCE #3: Wei B, Broussard B, Bryant A, Linsky P, Minnich DJ, Cerfolio RJ. Left upper lobectomy after coronary artery bypass grafting. J Thorac Cardiovasc Surg. 2015;150(3):531-535. DISCLOSURES: No relevant relationships by Ryanne Dugan No relevant relationships by Yaron Perry No relevant relationships by Kaity Tung