Control before crisis: A six-step robotic approach to pulmonary artery management

Graphical Abstract

Six-step robotic proximal and distal PA control.

Central Message.

In complex robotic lung resections, a 6-step approach to preemptive proximal and distal PA control is safe and reproducible, and allows minimally invasive completion of challenging cases.

Lung cancer continues to be the leading cause of cancer-related death in the United States, with more than 234,920 new diagnoses and 122,500 deaths in 2025 alone.¹ Advances in molecular testing, immunotherapy, and targeted therapy, including agents for epidermal growth factor receptor, tyrosine kinase inhibitors, anaplastic lymphoma kinase inhibitors, and immune checkpoint inhibitors, have dramatically changed the landscape of treating lung cancer, particularly in patients with stage III or IV disease.^2,3 These advancements have improved patient survival and increased the pool of patients with advanced disease who now have resectable cancer.^4,5 As a result, the frequency of surgical intervention in patients with complex disease and locally advanced lung cancer has significantly increased.⁶

Thoracic surgeons are faced with a unique set of complex technical surgical challenges that are specific to these patients. These include centrally located disease, postinduction chemoimmunotherapy or radiation, fibrosis, extensive adhesions due to reoperation, obliteration of surgical planes between the pulmonary artery (PA), airway, and lymph nodes. These challenges require thoracic surgeons to elevate their robotic surgical skill set and to develop more advanced techniques to avoid potentially disastrous complications such as pulmonary vascular injury.

Incidence and Predictors of Pulmonary Vascular Injury

Major complications from robotic surgery have been reported as 2.9 to 4.3% and are most commonly seen with lower preoperative forced expiratory volume in 1 second, previous radiation therapy, more advanced disease, low-volume centers, left upper lobectomy or bilobectomy, and pneumonectomy.^7,8 The same risk factors are associated with intraoperative catastrophes, which occur in approximately 1.9% of robotic pulmonary resections. The most common catastrophic event is hemorrhage from the PA, followed by airway injury and pulmonary vein injury. Patients experiencing intraoperative catastrophes have significantly higher perioperative mortality (5.7% vs 0.5%).⁹ This can be due to adherent hilar lymphadenopathy in the setting of treated lymph nodes after induction therapy, tumor involvement, calcified or granulomatous tissue, or bulky lymph nodes.¹⁰

There is a paucity in the literature regarding robotic PA injury and repair. Cerfolio and colleagues^E1 reported an incidence of 2.4% (15/632 patients) major vascular injuries among patients who underwent robotic lung resection. Thus, to avoid emergency conversion to open thoracotomy, we propose that preemptive PA control is crucial when indicated. We describe our robotic operative technique for preemptive PA control to prevent any major vascular injury. Video 1, Video 2, Video 3, Video 4, Video 5, Video 6, Video 7, Video 8, Video 9, Video 10, Video 11 accompany each section to demonstrate the key maneuvers.

Techniques of Pulmonary Artery Control

In our practice, if we encounter any of the below listed indications, we have a low threshold to perform proximal and distal control. The indications we use to control the PA based on clinical and radiographic findings are as follows:

• •large tumors close to the hilum (and therefore to the PA);
• •patients who received preoperative chemoimmunotherapy and had positive nodes with response to treatment, particularly if those nodes are adherent to both the airway and PA;
• •planned pneumonectomy;
• •intraoperative PA injury; or
• •locally advanced disease (stage IIIA, IIIB, IIIC, or treated stage IV).

Six-Step Approach: Left-Sided Proximal and Distal Pulmonary Vascular Control

• Step 1Hilar exposure and intrapericardial access

The left upper lobe is retracted posteriorly using the fourth robotic arm with a tip-up fenestrated grasper while the bedside assistant retracts the left lower lobe posteriorly and inferiorly. The phrenic nerve is identified to guide the site of pericardial entry. The pericardium is opened below the phrenic nerve using a long bipolar grasper and extended inferiorly to allow complete exposure of the left superior pulmonary vein (LSPV) and artery (Video 1).

Video 1

Left-sided hilar exposure and intrapericardial access. Video available at: https://www.jtcvs.org/article/S2666-2507(26)00140-9/fulltext.

• Step 2LSPV vein control

With adequate exposure, the LSPV is carefully dissected, encircled with a 12-cm vessel loop and secured with a medium Hem-o-Lok clip. When a left upper lobectomy is planned, early division of the LSPV with a stapler will facilitate proximal PA control. This can be performed inside or outside the pericardium (Video 2).

Video 2

Left-sided extrapericardial superior pulmonary vein control or division. Video available at: https://www.jtcvs.org/article/S2666-2507(26)00140-9/fulltext.

• Step 3Left inferior pulmonary vein control

Distal venous control can be obtained early in the operation after division of the inferior pulmonary ligament and completion of levels 9 and 8 lymph node dissection. The left inferior pulmonary vein is dissected using a long bipolar grasper and encircled with a vessel loop that is passed around the vein and secured with a medium Hem-o-Lok clip (Video 3).

Video 3

Left-sided inferior pulmonary vein control. Video available at: https://www.jtcvs.org/article/S2666-2507(26)00140-9/fulltext.

• Step 4Left PA control

The mediastinal pleura inferior to the left PA is opened to establish the initial dissection plane. Care is taken to identify the right PA (RPA) to ensure it is not being compromised. Minimal dissection is then carried out superiorly, and once an adequate tunnel is developed, the tip-up fenestrated grasper is used to encircle the main left PA. Instrument advancement is performed incrementally while assessing tissue resistance and completing additional dissection as needed. After the PA is encircled, a 12-cm vessel loop is placed around the left PA, double-looped, and secured with a medium Hem-o-Lok clip (Video 4).

Video 4

Left-sided pulomnary artery control. Video available at: https://www.jtcvs.org/article/S2666-2507(26)00140-9/fulltext.

• Step 5Temporary vascular occlusion and decompression

Temporary vascular control is achieved using atraumatic vascular bulldog clamps. Clamp size is selected based on vessel diameter (Figure 1). The bedside assistant introduces a straight bulldog clamp, which is positioned robotically using a fenestrated grasper. The left inferior pulmonary vein is clamped first, followed by placement of a bulldog clamp directly on the left PA. Care is taken to ensure that the clamp is applied directly to the arterial wall rather than over the vessel loop. If bleeding is encountered after the PA is opened, there are 2 possibilities: (1) nonocclusive proximal main PA clamp needing readjustment or (2) additional distal PA control is needed. Temporary occlusion decompresses the PA, facilitating safer dissection between the vessel and the adherent tumor, airway, and fibrotic lymph nodes (Video 5).

Figure 1.

Atraumatic vascular bulldog clamps of varying sizes used for PA occlusion.

Video 5

Left-sided temporary vascular occlusion and decompression. Video available at: https://www.jtcvs.org/article/S2666-2507(26)00140-9/fulltext.

• Step 6Clamp release and reperfusion

After completion of PA repair or reconstruction, the venous clamp is released first to allow for back-bleeding and deairing. The proximal PA clamp is then released to restore flow. In our experience, PA occlusion times of up to 60 minutes are well tolerated without routine systemic heparinization (Video 6).

Video 6

Left-sided clamp release and reperfusion. Video available at: https://www.jtcvs.org/article/S2666-2507(26)00140-9/fulltext.

Six-Step Approach: Right-Sided Proximal and Distal Pulmonary Vascular Control

• Step 1Anterior hilar exposure

The lung is retracted posteriorly using the fourth robotic arm with a tip-up fenestrated grasper. The mediastinal pleura is opened anteriorly, and the dissection is carried out between the right superior pulmonary vein (RSPV) and the RPA. Development of this plane is critical for safe exposure of the proximal RPA and facilitates subsequent vascular control (Video 7).

• Step 2RSPV control or division

The RSPV is carefully dissected using a long bipolar grasper and encircled with a vessel loop. The middle lobe vein is identified first to avoid injury and to define the venous anatomy. Dissection is initiated to establish the plane between the RSPV and RPA. The vein is gently retracted with a vessel loop. When a right upper lobectomy is planned, early division of the RSPV with a stapler will facilitate safe circumferential exposure and proximal control of the RPA (Video 7).

Video 7

Right-sided anterior hilar exposure and superior pulmonary vein control or division. Video available at: https://www.jtcvs.org/article/S2666-2507(26)00140-9/fulltext.

• Step 3Right inferior pulmonary vein control

Distal venous control can be obtained early in the operation after division of the inferior pulmonary ligament and completion of levels 9 and 8 lymph node dissection. The right inferior pulmonary vein is circumferentially dissected and encircled with a vessel loop (Video 8).

Video 8

Right-sided inferior pulmonary vein control. Video available at: https://www.jtcvs.org/article/S2666-2507(26)00140-9/fulltext.

• Step 4Proximal RPA control

Dissection behind the RPA is initiated using a long bipolar grasper. A rolled sponge held by the surgeon facilitates gentle countertraction and exposure. The long bipolar grasper is then exchanged for a tip-up fenestrated grasper to complete circumferential passage around the vessel. Two maneuvers facilitate safe proximal control. First, the space between the RPA and the airway is cleared by removing lymph nodes and creating a safe exit plane. Second, when a right upper lobectomy is planned, early division of the anterior truncus (A1–3) and, when necessary, the RSPV will improve exposure and allow safer circumferential dissection. Once adequate mobilization is achieved, a vessel loop is double looped around the RPA and clipped (Video 9).

Video 9

Right-sided proximal pulmonary artery control. Video available at: https://www.jtcvs.org/article/S2666-2507(26)00140-9/fulltext.

• Step 5Temporary vascular occlusion

Temporary vascular control is obtained using atraumatic vascular bulldog clamps. The right inferior pulmonary vein is clamped first, followed by the RSPV division with a stapler. The proximal RPA is then occluded with a vascular bulldog clamp. Similar to the left side, care is taken to ensure that the clamp is applied directly to the arterial wall rather than over the vessel loop to allow for effective occlusion (Video 10).

Video 10

Right-sided temporary vascular occlusion. Video available at: https://www.jtcvs.org/article/S2666-2507(26)00140-9/fulltext.

• Step 6Clamp release and reperfusion

After completion of PA repair or reconstruction, the venous clamps are released first to allow for back-bleeding and deairing. The PA clamp is then released to restore flow (Video 11).

Video 11

Right-sided clamp release and reperfusion. Video available at: https://www.jtcvs.org/article/S2666-2507(26)00140-9/fulltext.

Discussion

The changing paradigm of lung cancer treatment has resulted in an increasing number of patients presenting for resection after induction therapy. Dense hilar fibrosis, adherent lymphadenopathy, centrally located tumors, and distorted anatomy significantly increase the risk of PA injury. Preemptive control in these situations may be the difference between a good outcome versus one that requires thoracotomy or transfusion and results in multisystem organ failure or death. Although robotic technology provides enhanced visualization and dexterity, safe expansion of robotic surgery to complex oncologic cases depends on thoughtful surgical judgment, experience, and preparation.

This report describes a standardized 6-step approach to preemptive proximal and distal pulmonary vascular control during complex robotic lung resection. The technique includes systematic hilar exposure, strategic pulmonary vein control or division, proximal PA mobilization, temporary vascular occlusion, and controlled reperfusion. The accompanying Video 1, Video 2, Video 3, Video 4, Video 5, Video 6, Video 7, Video 8, Video 9, Video 10, Video 11 illustrate not only the operative steps but also the decision-making and rationale for each maneuver. These principles parallel established concepts in cardiac and vascular surgery, emphasizing preparation, exposure, and controlled reconstruction in a minimally invasive robotic approach.

Early proximal and distal vascular control decompresses the PA, which allows for safer dissection, allowing the procedure to progress in a more controlled fashion. A systematic, reproducible approach to robotic pulmonary vascular control is essential for surgeons performing complex robotic lung resections.

Our approach to this was based on already established norms for vascular control in open surgery. Our thought process was to expand this to a robotic setting if possible. Our initial knowledge and approach to this stemmed from dealing with intraoperative hemorrhage scenarios where obtaining proximal and distal control is critical. We then took this experience and started applying it more broadly to these complex lung cancer scenarios. What we learned was that we expanded our ability to perform these surgeries safely with robotics and did not need to convert to open thoracotomy. Most other studies, including Checkmate 816, highlight the safety of pulmonary resection after induction treatments but with open thoracotomy or video-assisted thoracoscopic surgery.^E2,E3 We believe that incorporating these techniques lessens the need for open thoracotomy and almost always prevents bleeding. Our experience has shown that this is a safe, feasible, and reproducible strategy when applied properly.

Conclusions

These 6 reproducible steps outline a practical approach to preemptive PA control during complex robotic lung resection. The technique is outlined in detail through video vignettes and highlights safe surgical approaches. In our opinion, these techniques highlight a very important skill set that will allow thoracic surgeons to perform complex lung resection more safely, with less bleeding and without open thoracotomy.

Conflict of Interest Statement

Dr Zervos reports financial relationship with Intuitive Surgical that includes speaking, lecture fees, and training courses. Dr Cerfolio reports equity in Fruit Street, Informed Inc, and NovaNav; intellectual property related to Tego; consulting and advisory roles with Informed Inc, NovaNav, Commend Corporation, Intuitive Surgical, and Johnson & Johnson. He serves as CEO of Rolo-7, C⁴, and Coop-Lor-Corporation and is an editor for Frontiers in Surgery. Dr Bizekis reports honoraria from Medtronic, Steris, and Boston Scientific. All other authors reported no conflicts of interest.

The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.