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branch angles. The patient was consented for robotic bronchoscopy with localisation, possible biopsy, and immediate robotic anatomical resection on confirmation of malignancy.
Procedure Anaesthesia was induced in theatre with a total intravenous technique and muscle relaxation. A single-lumen endotracheal tube was placed at induction, with a bronchial blocker available for use during the resection phase. The patient was positioned supine for the bronchoscopy. Professor Santis advanced the Ion catheter
through the single-lumen tube and into the target sub-segmental bronchus along the pre- planned route. Position was confirmed using
the shape-sensing display and intra-procedural integrated cone-beam CT. Cone-beam CT was particularly valuable in this case, allowing the catheter-to-lesion relationship to be checked directly and the target to be updated in real time before sampling or marking. Because the lesion was non-solid, biopsy yield from a pure ground-glass nodule is known to be lower, and the primary intent at this nodule was localisation rather than tissue sampling. A fiducial coil was deployed transbronchially within the centre of the lesion, providing a radiopaque target for the surgical phase. Sub- millimetre catheter precision was essential. The lesion would otherwise have been invisible and impalpable to the surgeon.
For the peripheral solid nodule, direct
anatomical resection was planned. Endobronchial ultrasound staging of the accessible nodal stations was performed in the same setting, with rapid on-site evaluation (ROSE) by the attending cytopathologist confirming adequacy of nodal sampling in real time. ROSE can be used throughout the bronchoscopic phase in preference to frozen section, giving an immediate, actionable answer and avoiding the time penalty of formal frozen- section processing for samples that did not require it. This is an important efficiency point in single-anaesthetic pathways: ROSE limits the number of specimens sent for frozen section to those that genuinely change the surgical plan. Once localisation and intra-operative staging
were complete, the Ion system was undocked. The patient was then repositioned into the lateral decubitus, and the Da Vinci Xi robot was brought to the table. The transition from bronchoscopy to surgery added only the time required for repositioning and docking. In a staged pathway the same patient would have required a second admission, a second induction of anaesthesia, a second period of single-lung ventilation, and an interval of two to three weeks during which the nodule’s biology and the patient’s anxiety would have continued to evolve.
Mr Bille performed a tissue-sparing robotic
Figure 1. Da Vinci Firefly near-infrared fluorescence imaging during anatomical sublobar resection in the index case. Indocyanine green, administered to delineate the segmental plane, fluoresces brightly at the marked lesion, allowing the parenchymal margin to be planned around the target rather than blindly through it. Cadiere forceps (arm 1), permanent cautery spatula (arm 2), 30° endoscope (arm 3), and fenestrated bipolar forceps (arm 4) are shown on the console interface.
anatomical resection. The fiducial coil was identified on Firefly near-infrared imaging, allowing the parenchymal margin to be planned around the lesion rather than blindly through it (Figure 1). The peripheral solid lesion, marked with
indocyanine green and identifiable on the white- light console view, was resected in continuity with its anatomical segment (Figure 2). Hilar and mediastinal lymphadenectomy was performed according to standard oncological principles. ROSE was used intra-operatively where it added value, and selective frozen section was used to confirm margin clearance. Final pathology reported primary lung adenocarcinoma at both sites, staged as early- stage disease, with negative margins and no nodal involvement. The patient was extubated in theatre and
recovered initially on the high dependency unit before transfer to the thoracic ward. The intercostal drain was removed on the first postoperative day. There were no surgical or anaesthetic complications. A transient mild cerebrovascular event during
Figure 2. Intra-operative Da Vinci Xi console view (white light) from the index case. The lesion is identifiable on the lung surface, with the indocyanine-green pleural marker visible adjacent to the planned resection margin. Cadiere forceps (arm 1) and fenestrated bipolar forceps (arm 4) are in view; a small surgical gauze marks the working field.
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convalescence, judged by the clinical team to be unrelated to surgery or anaesthesia, was managed conservatively. The patient made a full recovery at home with no long-term sequelae and is under structured oncological surveillance.
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