Multiportal Robot-Assisted Extended Lower Left Segmentectomy: Superior Segment S6 With Lateral S9 Resection

This video demonstrates a multiportal, robot-assisted left segmentectomy combining the superior segment (S6) with segment S9. A 68-year-old man had a 29 mm left lower lobe mass. His medical history included orthotopic liver transplantation on lifelong immunosuppression, chronic renal insufficiency, and prior contralateral lobectomy. Preoperative function was limited (forced expiratory volume in one second [FEV1] at 38 percent predicted; diffusing capacity for carbon monoxide [DLCO] unobtainable; peak volume of oxygen consumed [VO2] at 12.2 mL·kg⁻¹·min⁻¹), favoring complex segmentectomy over lobectomy. A computed tomography (CT) showed a lesion bridging adjacent segments without nodal or pleural disease. Three dinmensional (3D) planning defined a 2 cm margin and guided the selection of segment 6 and segment 9. Key steps included the dissection of vein six (V6), fissure completion, lymphadenectomy; vascular control with stapling of artery six (A6) and artery nine (A9); division of bifid bronchus nine (B9) with a blue load; stapling of bronchus six (B6); and division of V6. Indocyanine green delineated the intersegmental plane for the S6 and S9 parenchymal staple line. A fibrin sealant patch and a 21-French chest drain was used to complete the procedure. The patient was discharged on postoperative day four. Pathology showed a 23 mm adenocarcinoma with a 10 mm margin. The one-month follow-up was uneventful. 

References

1. Saji H, 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. The Lancet. 2022. PMID: 35461558.
2. Altorki NK, et al. Lobar or Sublobar Resection for Peripheral Stage IA Non–Small-Cell Lung Cancer (CALGB 140503). N Engl J Med. 2023. PMID: 36780674.
3. Peeters M, et al. The use of intravenous indocyanine green in minimally invasive segmental lung resections: a systematic review. Transl Lung Cancer Res. 2024. PMID: 3860144

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