Endoscopic lung volume reduction with endobronchial valves (LVRV) is an established treatment option for patients with severe emphysema and little to no collateral ventilation (CV). However, approximately 10% of patients fail to achieve meaningful target lobe volume reduction (TLVR) despite appropriate CV assessment and repeated revision bronchoscopies, suggesting alternative mechanisms such as pleuroparenchymal constraints or limitations of the Chartis® evaluation.

We report a stepwise surgical salvage strategy in a patient with severe emphysema treated with valves in the right upper lobe (RUL), who showed no TLVR despite two revision bronchoscopies. A sequential robot-assisted thoracoscopic approach combining complete adhesiolysis, repeated intraoperative reventilation testing, and surgical interruption of the fissure resulted in a partial atelectasis of the RUL. At 3 months, although the intended volume reduction target was not fully achieved, TLVR reached 50.6%, with clinically meaningful functional improvement. This sequential strategy could therefore constitute a future therapeutic solution in this setting.