Robotic extended middle lobectomy with tangential pulmonary artery stapling after induction therapy

Neoadjuvant chemoimmunotherapy often results in dense hilar fibrosis and nodal scarring, making minimally invasive pulmonary resection technically challenging. We present an extended robotic right middle lobectomy with tangential pulmonary artery stapling in a 70-year-old man with locally advanced adenocarcinoma (cT4N2a) after induction treatment with carboplatin, pemetrexed and nivolumab. Following posterior hilar dissection and subcarinal lymphadenectomy, dense fibrosis behind the azygos vein prevented safe paratracheal nodal dissection. Division of the azygos vein allowed en bloc removal of stations 2R and 4R. Severe fibrosis around the station 11 nodes and the origin of the middle lobe pulmonary artery precluded circumferential arterial dissection; therefore, tangential stapling of the arterial origin was performed, preserving interlobar arterial continuity and distal perfusion. An extended parenchymal resection including the anterior segment ensured adequate oncological margins. The procedure was completed robotically without conversion or significant blood loss. Frozen section confirmed negative vascular margins, and final pathology showed complete resection with ypT1cN2a disease. This video tutorial illustrates reproducible technical strategies for safely managing complex hilar fibrosis while maintaining a minimally invasive approach.