The Exclusion Technique: An Approach to Parenchymal Division During Complex Robotic Segmentectomy

Anatomic segmentectomy has emerged as an effective option for the management of early-stage lung cancer; however, the division of intersegmental parenchyma remains technically challenging. The authors describe and illustrate the exclusion technique, a bronchus-last strategy that utilizes an endoleader catheter to guide parenchymal division and simplify segmentectomy.

Methods

The exclusion technique involves dissection and division of the segmental artery or arteries, followed by dissection and isolation of the segmental bronchus, which is intentionally left intact during parenchymal division.  

An endoleader catheter was positioned between the airway and the lung parenchyma, creating a tunnel to guide stapler passage (Figure 1). This technique is demonstrated across three robotic segmentectomy cases selected to highlight a range of anatomic challenges. In all cases, indocyanine green (ICG) was used following arterial division to demarcate the parenchyma prior to division. The segmental bronchus was divided last in each case to preserve orientation and facilitate safe, controlled dissection.

Results

Case 1 

A right lower lobe composite basilar segmentectomy was performed. After division of the basilar pulmonary artery and vein, the endoleader was positioned between the basilar bronchus and lung parenchyma. ICG confirmed a clear boundary between the superior (S6) and the basilar segments (S7-10). Guided by the catheter, parenchymal stapling was performed without complication. Bronchial division completed the resection.

Case 2 

A left lower lobe anteromedial basilar segmentectomy was performed in a patient with suspected interstitial lung disease. Following division of the segmental artery and vein and dissection of the bronchus, the exclusion technique was used to guide division of the parenchyma (Figure 1). Sequential stapling from the diaphragmatic surface upward was facilitated by the endoleader, which ensured proper stapler positioning despite poor visibility. Parenchymal division was completed safely, followed by bronchial division and confirmation of perfusion to the remaining lower lobe.

Case 3 

A left upper lobe apical trisegmentectomy was conducted. The arterial branches supplying the apical trisegment were dissected and divided. The segmental airway was then dissected circumferentially and confirmed via bronchoscopy. After ICG demarcation, the endoleader was passed between the airway and parenchyma. Parenchymal division was performed using the exclusion technique, this time taking the segmental veins along with the parenchyma.

Conclusion

The exclusion technique offers an effective method for parenchymal division during robotic segmentectomy and is particularly useful in complex cases with deep segmental planes and challenging visualization. Key advantages include:  

• Simplification of parenchymal division by using the intact segmental bronchus and the endoleader to create a guiding tunnel 

• Protection of nearby vasculature from the stapler tip 

• Optimized bronchial stump stapling 

Figure 1: The exclusion technique for segmentectomy parenchymal division. (A) Positioning the endoleader catheter between the segmental airway and parenchyma of the left anteromedial basilar segment and (B) subsequent stapling of the parenchyma.  

References

1. Nomori H. Anatomical Segmentectomy for Lung Cancer. 1st ed. Springer; 2024. doi:https://doi.org/10.1007/978-981-99-5857-3 

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