Modified fissure-first fissureless left lower lobectomy under robotic assistance for incomplete fissure: a case report

Introduction

Incomplete fissures (Craig grade 3 or 4) are frequently encountered during lobectomy and are associated with an increased risk of prolonged air leak and pulmonary artery injury (1). In the Craig classification, grade 3 indicates a largely fused fissure with only minor clefts, while grade 4 represents a completely fused fissure. Fissureless techniques, particularly the fissure-last approach, have been widely adopted to mitigate these risks (2-6). Fissure-first strategies have also been described, most notably the tunnel technique introduced by Decaluwe et al. during video-assisted thoracoscopic surgery (VATS), which enables stapler division along the arterial plane in fissureless lungs (7). However, this concept has not been well characterized in robotic surgery. Robotic pulmonary resection has been increasingly adopted in recent years, although intraoperative vascular complications remain a critical concern that requires careful surgical planning and technique (8). When these branches are closely approximated, the arterial crotch becomes narrow, limiting the working space for safe tunneling and stapler insertion along the pulmonary artery. Here, we describe a modified fissure-first, fissureless robotic left lower lobectomy tailored for an incomplete fissure with a close relationship between A6 and A1+2c. We present this article in accordance with the CARE reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-2026-1-0007/rc).

Case presentation

A 76-year-old woman with a smoking history was referred for clinical stage IB (cT2aN0M0) non-small cell lung cancer of the left lower lobe. Her medical history was notable for hypertension. She was a former smoker with a 30 pack-year smoking history. Her performance status was 0. Pulmonary function testing showed a vital capacity of 2.24 L, forced expiratory volume in 1 second (FEV1.0) of 1.4 L, and diffusing capacity of the lung for carbon monoxide (DLCO) of 67.2%. The 32-mm squamous cell carcinoma was located in segment 8 (Figure 1A). Computed tomography (CT) demonstrated an incomplete fissure consistent with Craig grade 3 (Figure 1A-1D), which was confirmed intraoperatively. Preoperative positron emission tomography (PET)/CT showed no evidence of nodal or distant metastasis. Three-dimensional reconstruction showed a single A6 running in close proximity to A1+2c (Figure 1E,1F). Robotic-assisted thoracoscopic surgery using the da Vinci Xi™ system was planned. The patient was placed in the right lateral decubitus position. A 12-mm robotic port was placed in the 8^th intercostal space (ICS) along the anterior axillary line and was used for robotic stapler insertion. Three 8-mm robotic ports were placed at the same intercostal level: one in the midaxillary line, another in the posterior axillary line, and the third 5 cm lateral to the spinal processes. A 12-mm assistant port using an AirSeal™ trocar (ConMed, Largo, FL, USA) was inserted at the 10th ICS between the midaxillary and posterior axillary lines.

Figure 1 Preoperative enhanced CT and three-dimensional reconstruction. (A-C) Axial CT images showing the fused fissure (red arrows) and the tumor in segment 8 (red arrowhead). (D) Sagittal CT image showing minor clefts on the ventral and dorsal aspects of the fused fissure (red arrows) and the tumor in segment 8 (red arrowhead), with the majority of the fissure fused, consistent with Craig grade 3. (E) Three-dimensional reconstruction of the left pulmonary vessels and bronchi (anterior-caudal view) showing the close proximity of A6 and A1+2c. (F) Posterior view of the same reconstruction confirming that A6 is a single, distinct branch. CT, computed tomography.

After port placement, the robotic instruments used were fenestrated bipolar forceps in arm 1, a 30° endoscope in arm 2, a long bipolar grasper in arm 3, and Cadiere forceps in arm 4. The pulmonary ligament was divided and the posterior mediastinal pleura was opened to expose the pulmonary artery. Because the fused fissure limited safe anterior tunneling and the A6 and A1+2c branches were closely approximated, A6 was selectively encircled and divided first using a stapler (Figure 2A,2B). This created an initial opening along the pulmonary artery that facilitated controlled tunneling. Hilar dissection proceeded anteriorly, exposing the inferior pulmonary vein and lower lobe bronchus, followed by removal of station #11 lymph nodes and identification of A8 and the lingular artery (Figure 2C,2D). The fissure was divided along the pulmonary artery using a parenchyma-sparing stapling technique (Figure 2E-2H). During stapling, the stapler tip was positioned along the dissected pulmonary arterial surface, and the fused parenchyma was gently drawn toward the cartridge side under direct visualization to avoid inadvertent pulmonary artery injury. Fissure division was performed using a SureForm™ curved-tip 45-mm robotic stapler (Intuitive Surgical, Sunnyvale, CA, USA). Stapler cartridges were applied sequentially to develop the fissure tunnel along the pulmonary artery. In total, eight stapler firings were required to complete fissure division. As dissection was advanced from the anterior hilum in a subadventitial plane along the pulmonary artery, the A6 stump became visible at the distal end of the tunnel (Figure 3A). A Penrose drain was then gently advanced along the exposed arterial plane under direct visualization of the A6 stump (Figure 3B), after which the remaining fused fissure was divided using additional stapler applications (Figure 3C,3D). The basal segmental artery, inferior pulmonary vein, and lower lobe bronchus were then individually divided using a stapler (Figure 3E), followed by systematic lymphadenectomy. A minor dorsal fissure air leak detected during the sealing test was treated with a polyglycolic acid sheet and fibrin glue. The total operative time was 3 hours and 17 minutes, with a console time of 2 hours and 36 minutes. Estimated blood loss was 10 mL. Final pathology revealed squamous cell carcinoma measuring 31 mm in maximum diameter without visceral pleural invasion. Surgical margins were negative. A total of 13 lymph nodes were harvested, and no nodal metastasis was identified. The final pathological stage was pT2aN0M0 (pStage IB). The patient’s postoperative course was uneventful. No prolonged air leak occurred, and the chest drain was removed on postoperative day 2. The patient was discharged home on postoperative day 4. At 8 months of follow-up, the patient remained well without postoperative complications or evidence of recurrence. All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Tokushima University Hospital Institutional Review Board (No. 3672). Publication of this case report and accompanying images was waived from patient consent according to the institutional review board.

Figure 2 Intraoperative images: step 1. (A,B) A6 is encircled and divided with a stapler from the posterior hilar view. (C,D) IPV, station #11 LNs, A8, and the lingular artery are identified from the anterior hilum. (E-H) The fused fissure is divided sequentially along the pulmonary artery using a stapler in a tunneling fashion. IPV, inferior pulmonary vein; LN, lymph node.

Figure 3 Intraoperative images: step 2. (A) The A1+2c branch and the A6 stump are visualized at the distal end of the fissure tunnel. (B) A Penrose drain is passed through the tunnel to facilitate further dissection. (C,D) The remaining fused fissure is divided using a stapler. (E) Completion of fissure division reveals the underlying pulmonary artery.

Discussion

This case demonstrates a modification of the fissure-first, fissureless approach under robotic assistance to address the technical challenges posed by a severely incomplete fissure. Early division of A6 provided a starting point that enabled a controlled tunneling process, particularly useful in the anatomically narrow configuration formed by the close approximation of A6 and A1+2c. This maneuver created working space along the arterial plane and reduced the need for excessive lung manipulation.

Although robotic systems offer excellent visualization, they provide limited capacity for wide parenchymal retraction. Early division of A6 stabilized the distal opening of the fissure tunnel, which supported a more controlled stapling trajectory under these constraints. Port placement in the anterior axillary line also facilitated a favorable angle for stapler insertion. Stapling was performed only along clearly exposed arterial surfaces, gently drawing fused parenchyma toward the cartridge side to minimize unrecognized arterial traction.

Because pulmonary arterial branching patterns vary, the feasibility of early A6 division depends on accurate anatomical assessment. In the present case, three-dimensional reconstruction suggested a single A6 branch, which was confirmed intraoperatively by direct visualization of the posterior arterial surface before stapling. If additional segmental branches arise from A6 or if the anatomy is unclear, this maneuver should be avoided. Therefore, this strategy should be considered anatomy-dependent rather than universally applicable.

Although the fissure-first tunneling concept was originally described in VATS, robotic assistance may facilitate its execution in anatomically constrained fissures. The articulated instruments allow precise dissection along the pulmonary artery in narrow spaces, and the stable three-dimensional visualization helps maintain the correct subadventitial plane during tunneling. These features may be advantageous when developing a controlled arterial tunnel while minimizing traction on fused lung parenchyma. The fissure-first tunneling concept has been described in VATS (7), where it enables an inside-out approach and may reduce blind stapling across fused lung tissue. Although our report is limited to one patient, similar principles may be applicable in robotic surgery, particularly when a hilum-first strategy is challenging. Examples include central tumors, bulky hilar lymphadenopathy, or anterior trunk bleeding (7), in which a fissure-first pathway may offer an alternative route for controlled dissection. Importantly, the fissure-first strategy itself was originally established in the VATS era, and the present modification does not rely on robot-specific functions but rather on anatomical understanding and controlled tunneling along the pulmonary artery. Therefore, although this technique is demonstrated under robotic assistance, it should also be considered transferable to VATS practice in selected patients with severely incomplete fissures and complex pulmonary artery anatomy.

Our patient had an uncomplicated recovery; however, conclusions about safety or effectiveness cannot be drawn from a single case. This experience suggests that a fissure-first, fissureless strategy may serve as a practical option in selected anatomical configurations where fissure-last techniques are difficult to perform. Although the present case involved a left lower lobectomy, the fissure-first tunneling concept has also been described in right-sided anatomical resections in the VATS literature (7). However, because the present report describes only a single left-sided case, the applicability of this modified approach to right-sided lobectomy remains uncertain and requires further clinical experience. Various strategies have been proposed for managing incomplete fissures, including the widely adopted fissure-last technique to reduce postoperative air leak (2-6). The present approach represents an alternative fissure-first strategy within the fissureless concept when the anatomical configuration makes conventional fissure-last dissection technically challenging.

Conclusions

Robotic-assisted fissure-first, fissureless lobectomy may be feasible when tailored to patient-specific pulmonary artery anatomy. Although generalization is not possible from this single case, early vascular management and controlled tunneling may represent a useful option for managing selected incomplete fissures in robotic surgery.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-2026-1-0007/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-2026-1-0007/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-2026-1-0007/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by the Tokushima University Hospital Institutional Review Board (No. 3672). Publication of this case report and accompanying images was waived from patient consent according to the institutional review board.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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