Single-Port Robot-Assisted Left Lower Lobe Common Basal Segmentectomy With Systematic Lymph Node Dissection

Robotic thoracic surgery provides superior precision and enhanced ergonomics compared to video-assisted thoracoscopic surgery, primarily due to its three-dimensional visualization and wristed instruments. These advantages facilitate meticulous dissection and more comprehensive lymphadenectomy in complex resections, ultimately contributing to improved surgical outcomes (1). 

As an advanced evolution of minimally invasive surgery, single-port robotic surgery offers several advantages over multiport robotic approaches and other minimally invasive techniques. The use of a single incision is associated with reduced postoperative pain, improved cosmetic outcomes, and faster recovery. Furthermore, it allows for enhanced instrument maneuverability within confined anatomical spaces, thereby increasing surgical precision. In addition, lower rates of infection and overall complications have been reported compared to conventional approaches (2, 3). 

Segmentectomy has been demonstrated to be oncologically comparable to lobectomy in patients with peripheral cT1a–bN0M0 lung adenocarcinoma, even in the presence of aggressive histological subtypes (4). Moreover, Toker et al. emphasized that segmentectomy represents a favorable option for benign lesions that are not amenable to wedge resection (5). 

Accordingly, in the authors’ practice, segmentectomy is preferentially performed for preoperatively undiagnosed lesions that are not suitable for wedge resection. 

A 51-year-old female patient with no history of smoking or prior malignancy presented with a 13 mm pulmonary nodule located in the common basal segment of the left lower lobe on computed tomography. Positron emission tomography demonstrated a maximum standardized uptake value (SUVmax) of 4.1. Given the lesion’s proximity to the bronchus, wedge resection was deemed unsuitable, and a common basal segmentectomy was planned. 

The procedure was initiated with dissection of the inferior pulmonary ligament, station 9 lymph nodes, and the inferior pulmonary vein. This was followed by fissure dissection and identification of the segmental arterial branches. The arteries supplying the common basal segments were divided first, followed by the division of the corresponding vein and bronchus. Stapler insertion through the assistant port can be technically challenging; however, the use of a 12 mm ROSI port (suction and irrigation) is generally sufficient, as the grey chamber of the access port can rotate 270 degrees on its axis. 

Indocyanine green (ICG) fluorescence imaging was utilized to delineate the intersegmental plane between the preserved and devascularized segments. Following clear visualization, the intersegmental plane was divided. The specimen was subsequently retrieved, hemostasis was secured, intercostal nerve blocks were administered, and a chest drain was placed. The port sites were then closed in a standard fashion. 

The postoperative course was uneventful. The chest tube was removed on postoperative day one, and the patient was discharged on postoperative day three. Final pathological examination revealed that the tumor was a sclerosing pneumocytoma. 

References

1. Davini F, Ricciardi S, Zirafa CC et al. Treatment of pulmonary nodule: from VATS to RATS. J Vis Surg. 2018;12;4:36. doi: 10.21037/jovs.2018.01.19.
2. Rassweiler JJ, Autorino R, Klein J, et al. Future of robotic surgery in urology. BJU Int. 2017;120(6):822-841. doi: 10.1111/bju.13851.
3. Franco A, Ditonno F, Manfredi C et al. Robot-assisted Surgery in the Field of Urology: The Most Pioneering Approaches 2015-2023. Res Rep Urol. 2023 Oct 9;15:453-470. doi: 10.2147/RRU.S386025.
4. Lula LJ, Huang L, Barreda CF et al. European prognosisevaluation of early-stage lung adenocarcinoma patterns after lobectomy versus segmentectomy based on clinical stage settings. (JTCVS Open 2026;101687).
5. Toker A , Ayalp K, Uyumaz E et al. Robotic lung segmentectomy for malignant and benign lesions. J Thorac Dis. 2014 Jul;6(7):937-42. doi: 10.3978/j.issn.2072-1439.2014.06.40.

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