Robotic S9-S10 Segmentectomy Assisted by Multimodal Reconstruction Imaging System

This presentation is about a robotic S9-S10 segmentectomy assisted by a multimodal reconstruction imaging system. In the literature, several series report experiences of robot-assisted segmentectomy for benign or malignant pathologies. However, they were either common to the basal segments interesting segments 7 to 10, or the segment of the Fowler (segment 6). In the series from Cerfolio and colleagues, basal segmentectomies were for the upper, basilar, or posterior segment. The case shown here is an S9 and S10 robotic segmentectomy. The authors report on a 24-year-old woman, with no previous medical history, who presented with a 5 mm nodule located in the S9 segment that was discovered on a chest computed tomography (CT) scan made in 2015, and which increased in size by 40% on follow-up CT scan in 2018.

On the different sections of the thoracic CT, the nodule was very well defined, with a size of almost 14 by 12 mm. There were no other nodules in the ipsilateral or contralateral lung. The tumor extension assessment was negative. On investigation with a multimodal reconstruction imaging system, to achieve complete resection with free margins of 2 cm the resection needed toinclude both segments 9 and 10. The authors could then study each system separately: the pulmonary arteries to be cut, the pulmonary veins draining the S9 and S10 segments, as well as the bronchi. An overview of the tumor, vessels, bronchi, and pulmonary segments to resect could be made with the 3D reconstruction and view.  The differential diagnoses were: hamartoma (but the density of the mass was -40 Hounsfield units on the chest CT scan), a carcinoid tumor of the lung, and lung carcinoma (this was unlikely).

The patient was placed in the left lateral decubitus position, and four trocars were used. The procedure was started by the section of the triangular ligament to the base of the right inferior pulmonary vein. Using the multimodal reconstruction imaging system, the veins for the S9 and S10 segments were identified after excluding bronchial and arterial divisions. The addition of the reconstructions of the segments S9 and S10 made it possible to individualize the veins to be cut. The lymph node dissection was not radical, but an oriented dissection was performed. The first lymph node was negative on frozen section examination, and the lesion did not fix on TEP and had a slow evolution.

After controlling the A9 and A10 arteries, the authors applied a vascular automatic stapler. Below the arterial plane, they dissected the bronchi for the lower lobe, among which they identified B9 and B10. The latter was cut using an automatic stapler. The identification of the section plane of the pulmonary parenchyma was facilitated after injection of indocyanine green. Areas that did not take the green color corresponded to segments to resect. The sectional plan was easily identified by the Firefly technology. The authors applied the stapler then following the marked areas.  They took care not to step over the other segments, as well as the vessels and the corresponding bronchi. After completing the segmental resection, the operative specimen was placed in an endobag before being extracted through one of the trocar orifices. A plate of hemostatic gauze was applied to the areas of pulmonary suture. After reventilation, the remnants of the lower right lobe segments (Nelson, segment 7, and segment 8) inflated properly. The procedure concluded with placement of a chest drain.

The postoperative course was simple. The patient was discharged two days after the surgery with a normal chest radiograph. One month later, the patient was doing well, and she had returned to normal activity and to work.

References

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