Uniportal robot-assisted resection and reconstruction of the left bronchial secondary carina in a pediatric patient

Abstract

Background

Bronchial carcinoid tumors are rare in children and often present central airway involvement, posing challenges for lung-sparing surgery. Robotic systems enable enhanced precision and dexterity, but their application in pediatric airway reconstruction remains limited.

Case presentation

A 13-year-old boy presented with a left secondary carinal bronchial carcinoid. After bronchoscopic tumor debulking, definitive surgery was performed using a uniportal robot-assisted approach with the da Vinci Xi system (Intuitive Surgical Inc., Sunnyvale, CA, USA). A single 4-cm incision was made at the fifth intercostal space along the midaxillary line. The secondary carina was resected, and airway continuity was reconstructed using three separate continuous 3-0 barbed sutures. The postoperative course was uneventful, and bronchoscopy at three months confirmed a patent, well-healed anastomosis.

Conclusions

This case demonstrates the feasibility and safety of uniportal robot-assisted secondary carina reconstruction in a pediatric patient, providing a minimally invasive option for complex airway surgery.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13019-026-04261-z.

Introduction

Bronchial carcinoid tumors are uncommon neoplasms in children, representing approximately 5–10% of pediatric pulmonary malignancies [1]. Owing to their central location, surgical management often requires bronchoplastic or carinal resection to achieve complete removal while preserving lung parenchyma.

Conventional approaches have involved thoracotomy or multi-port video-assisted thoracoscopic surgery (VATS). The advent of robotic technology allows enhanced visualization, tremor filtration, and articulating instruments, improving precision in confined spaces [2, 3]. However, pediatric applications of robotic airway reconstruction are extremely limited due to anatomical constraints and the rarity of such tumors.

We report, to our knowledge, the first documented pediatric case of uniportal robot-assisted resection and reconstruction of the left secondary carina. The case illustrates technical nuances, intraoperative decision-making, and the feasibility of this approach in a developing thoracic cavity.

Case presentation

A 13-year-old boy was referred with recurrent left upper lobe pneumonia. Chest computed tomography (CT) and bronchoscopy revealed a 2 × 1 cm vascular endobronchial lesion obstructing the left upper lobe bronchus (Fig. 1A, B). A preoperative bronchoscopic biopsy demonstrated a neuroendocrine tumor consistent with carcinoid, characterized by nests of uniform cells with a rich vascular network and focal calcification. Initial bronchoscopic argon plasma coagulation was performed to relieve obstruction, followed by definitive surgical planning. After multidisciplinary discussion, a lung-sparing bronchoplastic procedure was chosen.

Fig. 1.

CT (A) and bronchoscopy (B) revealed tumor located at the secondary carina

Surgical preparation and technique (video 1)

Patient positioning and port placement

Under general anesthesia with double-lumen endotracheal intubation, the patient was placed in the right lateral decubitus position for single-lung ventilation. A single 4-cm incision was made in the fifth intercostal space at the midaxillary line, serving as both the camera and working port. The da Vinci Xi robot (Intuitive Surgical Inc., Sunnyvale, CA, USA) was docked. Arms 1, 2, and 3 carried a Maryland bipolar forceps, fenestrated bipolar, and 3D camera, respectively; arm 4 was undocked to avoid interference.

Dissection and exposure

The interlobar fissure was opened to expose the pulmonary artery branches. During fissure dissection, a lingular pulmonary artery branch arising from the basilar artery was identified. Because this branch limited exposure of the upper lobe bronchus and secondary carina through the anterior hilar route, it was divided to improve operative access. The superior pulmonary vein and pulmonary artery trunk were then looped with silk tapes and gently suspended to further optimize exposure.

Bronchial resection and reconstruction (Fig. 2)

Fig. 2.

Intraoperative airway reconstruction procedure. (A) View of the operative field after tumor resection, demonstrating the defect at the secondary carina. (LUB, left upper bronchus, LMB, left main bronchus, LLB, left lower bronchus, LPA trunk, left pulmonary artery trunk, LSPV, left superior pulmonary vein, LIPV, left inferior pulmonary vein) (B) Posterior membranous anastomosis between the left main bronchus and the left lower lobe bronchus using continuous barbed sutures. (C) Posterolateral anastomosis between the left main bronchus and the left upper lobe bronchus. (D) Completion of the anterior cartilaginous anastomosis between the left upper and lower lobe bronchi, completing the reconstruction of the secondary carina

The posterior mediastinal pleura was dissected, and stations 10 and 7 lymph nodes were removed. The left upper and lower lobe bronchi were transected at sites selected to obtain macroscopically adequate margins while preserving as much normal bronchus as possible. The left main bronchus was then divided proximally after sufficient exposure of the secondary carina. Intraoperative frozen-section analysis confirmed negative bronchial margins.

Airway continuity was then restored using three separate continuous 3-0 barbed sutures. The first suture was applied to join the membranous portions of the left main and lower lobe bronchi, followed by the second suture connecting the cartilaginous portion of the main bronchus with the membranous portion of the upper lobe bronchus. The third suture completed the anterior cartilaginous wall between the upper and lower bronchi. All barbed sutures were tied and reinforced with intermittent 3-0 Vicryl stitches at potential weak points. The anastomosis was performed entirely under direct vision without intraoperative bronchoscopy, as the lesion extent and transection levels were considered adequately defined after preoperative bronchoscopy and direct surgical exposure. The thoracic cavity was irrigated with warm saline, and an air-leak test at 25 cm H₂O confirmed airtight integrity. A schematic illustration of the resection and reconstruction of the left secondary carina is shown in Fig. 3.

Fig. 3.

Schematic illustration of left secondary carinal resection and reconstruction. The upper panel shows the tumor located at the left secondary carina with the planned resection margins (dashed line). The lower panels illustrate the final configuration of bronchial reconstruction

The upper panel shows the tumor located at the left secondary carina with the planned resection margins (dashed line). The lower panels illustrate the the final configuration of bronchial reconstruction.

Postoperative course

The patient was extubated in the operating room and discharged on postoperative day 5 without complications. Final pathology confirmed a typical bronchial carcinoid with no lymph node metastasis. At 3 months postoperatively, bronchoscopy demonstrated a patent, well-healed anastomosis without stenosis or granulation tissue.

Discussion

This report demonstrates that complex airway reconstruction can be safely performed in pediatric patients using a uniportal robotic approach. The da Vinci Xi system offers superior 3D visualization and instrument articulation, which are advantageous for precise suturing in small pediatric bronchi [2, 4]. Compared with adult airway reconstruction, pediatric bronchoplasty is more technically demanding because of the smaller bronchial caliber, thinner bronchial wall, and narrower operative space. In addition, lung preservation is particularly important in children because of future growth and long-term functional considerations. These features may make the robotic platform especially useful in pediatric airway reconstruction.

In this case, the uniportal technique minimized tissue trauma and improved cosmetic outcomes while maintaining complete surgical control. Suspension of the pulmonary vein and pulmonary artery provided adequate space for suturing within the narrow hilar region, avoiding excessive traction on the airway. Compared with a posterior hilar approach, the anterior hilar route provided more direct exposure of the secondary carina in this case and reduced the need for extensive dissection of the left main bronchus, which may help decrease the risk of bronchial devascularization or traction injury. However, this approach also had potential drawbacks. During fissure dissection, a lingular pulmonary artery branch arising from the basilar artery had to be divided to improve exposure of the upper lobe bronchus and secondary carina. Therefore, the benefit of improved anterior hilar route must be balanced against the possibility of vascular sacrifice and its potential impact on lingular perfusion. In selected patients, a posterior approach may better preserve vascular anatomy, although it may require broader bronchial mobilization. Careful preoperative and intraoperative assessment is therefore essential when choosing between anterior and posterior hilar approaches. Preoperative 3D reconstruction was not performed in this case, but it may be helpful in future cases with complex bronchovascular anatomy or suspected vascular variation. Another limitation of this procedure was the omission of intraoperative bronchoscopy, which may limit precise endoluminal confirmation of the transection level and reconstruction.

Adult cases of secondary carina reconstruction using open or VATS approaches have been reported, demonstrating the feasibility of complex bronchoplasty. Toshinori Fukutomi et al. described an open surgical reconstruction of the left secondary carina for the treatment of a bronchial carcinoid [5], while Yan Hu et al. reported the feasibility of performing secondary carinal reconstruction via VATS [6]. In addition, Gonzalez-Rivas et al. described uniportal fully robotic secondary carinal reconstruction [2]. However, none of these cases involved pediatric patients. The present case extends the application of these techniques to children, emphasizing the potential for future adaptation of robotic systems to smaller thoracic cavities.

This case confirms the feasibility of uniportal robotic surgery for complex pediatric airway tumors. While more experience and follow-up are needed, this approach offers a promising direction for minimally invasive thoracic surgery in children.

Supplementary Information

Below is the link to the electronic supplementary material.

Author contributions

Diego Gonzalez-Rivas and Chang Li performed the surgical procedure and contributed to the operative planning and technical interpretation. Ziyi He drafted the manuscript and integrated all revisions. Guangbin Li and Xiaochen Lu collected clinical data, prepared figures, and assisted in the literature review. Haitao Huang and Jun Zhao supervised the study, critically revised the manuscript, and approved the final version. All authors read and approved the final manuscript.

Funding

This study was supported by the Complex Technology Fund of the First Affiliated Hospital of Soochow University (Grant No.: 0499980301033) and the Boxi Clinical Fund of the First Affiliated Hospital of Soochow University (Grant No.: BXLC2024030).

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

This study was approved by the Institutional Review Board of The First Affiliated Hospital of Soochow University (Approval No. 2025831). Written informed consent for participation and treatment was obtained from the patient’s legal guardians.

Consent for publication

Written informed consent for the publication of anonymized clinical data, images, and intraoperative video was obtained from the patient’s legal guardians.

Competing interests

The authors declare no competing interests.