@article{VATS13061,
author = {Naoya Kawakita and Hiroaki Toba and Shiori Matsui and Hiromitsu Takizawa},
title = {Modified fissure-first fissureless left lower lobectomy under robotic assistance for incomplete fissure: a case report},
journal = {Video-Assisted Thoracic Surgery},
volume = {11},
number = {0},
year = {2026},
keywords = {},
abstract = {Background: Incomplete pulmonary fissures increase the risk of postoperative air leak and vascular injury during lobectomy. Fissureless approaches, particularly the fissure-last technique, are widely used to mitigate these risks; however, fissure-first strategies are less common in robotic surgery. The robotic platform provides excellent visualization but limits lung manipulation, making controlled fissure division technically challenging. We report a modified fissure-first, fissureless robotic left lower lobectomy that employs early division of A6 to ensure safe tunneling along the pulmonary artery.Case Description: A 76-year-old woman with clinical stage IB (cT2aN0M0) left lower lobe squamous cell carcinoma and a Craig grade 3 incomplete fissure underwent robotic-assisted thoracoscopic lobectomy using the da Vinci Xi™ system. After exposure of the pulmonary artery, the superior branch (A6) was divided first to establish a stable exit for tunneling. The fused fissure was subsequently divided with staplers in a controlled, parenchyma-sparing manner along the arterial plane. Particular attention was paid to stapler insertion: the stapler tip was positioned at the dissected arterial surface, and the fused parenchyma was gently drawn into the jaws toward the cartridge side under direct vision to avoid pulmonary artery injury. The basal artery, inferior pulmonary vein, and lower lobe bronchus were divided sequentially. The patient’s postoperative course was uneventful, with no prolonged air leak, and she remained well at 8 months of follow-up.Conclusions: Early division of A6 provides a safe tunneling route and compensates for limited lung traction in robotic lobectomy. This modified fissure-first, fissureless technique allows controlled stapler advancement under direct visualization, minimizing the risk of vascular injury and offering a useful addition to the robotic surgeon’s armamentarium for managing incomplete fissures. Importantly, because the fissure-first concept was originally established in video-assisted thoracoscopic surgery (VATS), this modification is not platform-specific and may also be applicable to conventional thoracoscopic surgery in selected anatomical situations.},
issn = {2519-0792}, url = {https://vats.amegroups.org/article/view/13061}
}