Robotic LUL Apicoposterior (S1 + S2) Segmentectomy

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Recent trials, including CALGB and JCOG0802, have established the noninferiority of sublobar resection compared to lobectomy for early-stage non-small cell lung cancer (NSCLC) patients with tumors less than two centimeters (1, 2).  As such, segmentectomy procedures are becoming more common in practice for tumors restricted to specific bronchopulmonary segments. These procedures are beneficial for patents with borderline pulmonary function or those with prior pulmonary resections, as they allow for a greater degree of pulmonary preservation compared to lobectomy (3). 
 
The apicoposterior segmentectomy is a technically demanding procedure given the degree of anatomic variation in the upper segments, particularly on the left side (4, 5). Due to these challenges, multiple adjuncts are utilized in both the preoperative setting and intraoperative settings for optimal surgical planning. These include CT-based 3D reconstruction models, targeted ventilation techniques, intraoperative bronchoscopy, and indocyanine green to delineate segmental borders and bronchovascular anatomy (6, 7, 8). In this video, the authors report a case of left upper lobe adenocarcinoma restricted to the apicoposterior segments, which was resected via a robotic-assisted approach with the utilization of indocyanine green to delineate the intersegmental plane. 
 
The patient was a 71-year-old female with a 40-pack-year smoking history. She had a prior history of malignancy, which included metastatic NSCLC treated with a right middle lobe wedge resection and local treatment for brain metastasis. She presented after a seven-year disease-free interval with an enlarging, heterogeneous left upper lobe lesion that was restricted to the S1 and S2 segments. After a nondiagnostic navigational bronchoscopy, the decision was made to proceed with surgical resection for diagnosis and treatment, given concerns of either recurrence or a second primary malignancy.
 
The procedure began with lung mobilization and mediastinal lymph node dissection. The posterior pleural and hilar dissections then proceeded without difficulty. The apicoposterior (V1+2), anterior (V3), and lingular (V4+5) veins were identified. There was concern that if the venous ligation were performed in this case, there would be difficulty with integrating the stump into the surgical specimen. Therefore, an artery-only approach was pursued. Next, the arterial supply to the apicoposterior segment was delineated, and the lateral/horizontal branch of the apicoposterior artery (A1+2c) is first ligated, followed by the posterior branch (A1+2a+b). The trunk supplying the anterior segment (A3) was left in situ. Following arterial division, the apicoposterior bronchus (B1+2) was isolated, which was confirmed by bronchoscopy before and after clamping, and after division, confirming a patent anterior segmental bronchus (B3). After visualization and scoring of the intersegmental plane between the anterior segment and the devascularized apicoposterior segment using indocyanine green (ICG), the intersegmental plane was divided. The specimen was then extracted, hemostasis was achieved, intercostal nerve blocks were administered, and a chest tube was placed. The port sites were then closed, and the procedure was concluded. Her postoperative course was uncomplicated, with chest tube removal on postoperative day one and discharge on postoperative day two. The final pathology indicated negative lymph nodes, and the specimen was notable for mixed lepidic and acinar adenocarcinoma with a 3.2 centimeter negative margin. She was seen in the clinic one week after the procedure, at which time she was noted to be recovering well from the procedure. 

References

1. Altorki N, Wang X, Kozono D, et al. Lobar or Sublobar Resection for Peripheral Stage IA Non–Small-Cell Lung Cancer. New England Journal of Medicine. 2023;388(6):489–498. doi:doi:10.1056/NEJMoa2212083
2. 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. Apr 23 2022;399(10335):1607–1617. doi:10.1016/s0140-6736(21)02333-
3. Tane S, Nishio W, Fujibayashi Y, et al. Thoracoscopic left S1 + 2 segmentectomy as a good resolution for preserving pulmonary function. Interact Cardiovasc Thorac Surg. Sep 1 2020;31(3):331–338. doi:10.1093/icvts/ivaa10
4. Deng Y, Cai S, Huang C, et al. Anatomical variation analysis of left upper pulmonary blood vessels and bronchi based on three-dimensional reconstruction of chest CT. Front Oncol. 2022;12:1028467. doi:10.3389/fonc.2022.1028467
5. Nomori H, Okada M. Segmentectomy of the Left Upper Lobe. Illustrated Anatomical Segmentectomy for Lung Cancer. Springer Japan; 2012:137–191.
6. Ueno H, Setogawa T, Makita A, et al. Influencing Factors on Intersegmental Identification Adequacy in Segmentectomy with Intraoperative Indocyanine Green (ICG) Intravenous Administration. Cancers (Basel). Dec 17 2023;15(24)doi:10.3390/cancers15245876
7. Wu WB, Xu XF, Wen W, et al. Three-dimensional computed tomography bronchography and angiography in the preoperative evaluation of thoracoscopic segmentectomy and subsegmentectomy. J Thorac Dis. Oct 2016;8(Suppl 9):S710–s715. doi:10.21037/jtd.2016.09.43
8. Kobayashi M, Imai S, Ishibashi H, Okubo K. “Selective bronchus-blowing” method for effective inflate-deflate line identification in lung segmentectomy. J Thorac Dis. May 2020;12(5):2146–2152. doi:10.21037/jtd.2020.04.35

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