Right VATS S7 and S8 Segmentectomy

The Patient

This video presents a detailed demonstration of right VATS segmentectomy of segments 7 and 8 of the lung. The patient is a sixty-four-year-old woman who is a current smoker with no respiratory symptoms. She had a past medical history of breast cancer, which was treated by mastectomy, chemotherapy, and radiotherapy. She had a positive family history strong for breast cancer and her performance was status WHO0.

The patient’s lung function test showed FEV 1 1.28 L (82 percent) predicted, FVC 109 percent predicted, TLCO 66 percent predicted, and KCO 76 percent predicted. Her chest CT scan showed a 16 mm spiculated soft tissue mass lesion located in the anterolateral segment of the right lower lobe. Additionally, a PET scan showed intense FDG uptake of the lesion with SUV max 7.66. The lesion was suspected to be primary lung cancer, likely stating T1B N0 M0 or metastasis.

The multidisciplinary team made the decision that the imaging strongly suggested presence of cancer. There were no suspicious left nodes and the patient health status supported surgical intervention. Consequently, she was referred for surgical resection.

The Surgery

The patient was first positioned in the lateral position. Surgeons employed the Edinburgh posterior approach to perform the operation. First, the utility port incision was made at the fifth intercostal space, anterior to latissimus dorsi muscle. The posterior port was then positioned at the fifth intercostal space within the auscultatory triangle. The camera port was positioned at the eighth intercostal space, aligned with a line running perpendicular to the tip of the scapula.

The segmentectomy began by dissecting the inferior pulmonary ligament and the lesion was identified in the anterolateral segment of the lower lobe. Next, a wedge resection of the lesion was completed. The specimen was sent for a frozen section which came back to be primary adenocarcinoma.

Next, the oblique fissure was dissected and completed. A meticulous section to expose the right lower lobe artery was done. The station 11 lymph node was then dissected and sent for a frozen section, which came back to be negative for cancer. Based on the results obtained from the frozen section, the decision was made to proceed with the segmentectomy.

A meticulous dissection to expose segmental branches of the right lower lobe artery was done. Next, another dissection was performed to reveal the segmental arterial branches of segment seven and eight and the segmental Venus branches of segments seven and eight were carefully exposed.

Next, segmental arteries were stapled, followed by the segment of veins. A sling was then employed to secure the segmental bronchial branches and the stapler was placed across the segmental bronchi. Before completing the stapling process, surgeons used inflation and deflation technique to clearly identify the intersegmental planes. To further delineate these planes, markings were carefully made using LigaSure, guiding the procedure with precision.

Finally, segmentectomy of segment seven and eight was completed. A systemic mediastinal lymph node dissection was also performed. A warm wash was done, and absence of an air leak was insured. A single drain was then inserted and surgeons insured complete long inflation, affirming the success and completion of the procedure.

The patient was extubated in operating room and was hemodynamically stable. The drain was connected to the present machine with a negative section -2KPA, which showed no air leak. The drain was then safely removed on postoperative day one.

The patient was discharged on postoperative day two. At the patient’s two month follow-up, she was found in good health and her chest x-ray was normal. Her histopathology report came back to be PT1B, PN0, PMx, R0, and the postoperative MDT decision was that no further treatment was required.

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