Thoracoscopic Left Superior Segmentectomy Using Indocyanine Green

This video demonstrates a thoracoscopic left superior segmentectomy. The patient is a fifty-eight-year-old woman with a superior segmental FDG avid lung nodule, concerning for pulmonary malignancy. The use of indocyanine green (ICG) in identifying the intersegmental plane is also demonstrated.

There has been recent enthusiasm for the use of limited resection for the management of early stage non-small cell lung cancer (NSCLC). For decades, lobectomy has been considered the gold standard for management of lung cancer (1). Recent meta analyses have shown that, compared to segmentectomy, lobectomy demonstrated superior survival for stage I and IA lung cancer, but there were no significant differences in oncological outcomes for tumors less than or equal to 2 cm in size (2). Indeed, a recently published randomized controlled trial has demonstrated that sublobar resection is noninferior to lobectomy for small tumors without nodal disease (3). Other randomized controlled trials have even demonstrated improved survival in select patients treated with segmentectomy for early stage NSCLC (4).

ICG fluorescence imaging can be a useful adjunct during surgery for delineating vascularized anatomy and is safe and effective for verifying anatomic lung segments during video assisted thoracoscopic surgery (5). This video demonstrates the utility of ICG in identifying the intersegmental plane for demarcating resection margin following the division of segmental pulmonary artery and vein.

References

1. Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg. 1995 Sep;60(3):615-22; discussion 622-3. doi: 10.1016/0003-4975(95)00537-u. PMID: 7677489.
2. Winckelmans T, Decaluwe H, De Leyn P, Van Raemdonck D. Segmentectomy or lobectomy for early-stage non-small-cell lung cancer: a systematic review and meta-analysis. Eur J Cardiothorac Surg. 2020;57(6):1051-1060.
3. Altorki N, Wang X, Kozono D, et al. Lobar or Sublobar Resection for Peripheral Stage IA Non-Small-Cell Lung Cancer. N Engl J Med. 2023;388(6):489-498.
4. Saji H, Okada M, Tsuboi M, et al. Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial. Lancet. 2022;399(10335):1607-1617.
5. Pischik VG, Kovalenko A. The role of indocyanine green fluorescence for intersegmental plane identification during video-assisted thoracoscopic surgery segmentectomies. J Thorac Dis. 2018;10(Suppl 31):S3704-S3711.

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