Robotic Anterior Basilar Segmentectomy

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Objective: 

Segmentectomy for peripheral early-stage non-small cell lung cancer (NSCLC) has become common in many institutions. Anterior basilar, or S8 segmentectomy, is one of the most challenging pulmonary segmentectomies to perform. Variable peripheral bronchovascular anatomy and identifying the intersegmental plane make this procedure difficult. However, salvaging functional lung tissue is especially important in patients with poor pulmonary function. The authors present a robotic approach to right anterior basilar segmentectomy. 

Methods: 

The patient was a 71-year-old former smoker with a history of chronic obstructive pulmonary disease (COPD) and asthma who underwent a computed tomography (CT) chest for workup of symptoms of long COVID-19 infection. A small subcentimeter right lower lobe ground glass opacity was identified. She underwent regular surveillance imaging, and two years later, the lesion was found to have grown to 1.2 cm with a new solid component and fissural tethering on CT. Positron emission tomography (PET) imaging demonstrated a small PET avid lesion in the right lower lobe (RLL) with a standardized uptake valve (SUV) of 1.8 with no other suspicious findings. Image-guided biopsy demonstrated adenocarcinoma. Following discussion with a multidisciplinary tumor board, the patient underwent a robot-assisted anterior basilar segmentectomy. 

Results: 

Preoperative planning for this case included an interactive 3D reconstruction of her chest CT imaging, which was utilized to confirm the segmental bronchovasculature. She underwent an uncomplicated right-sided robotic anterior basilar segmentectomy. Indocyanine green (ICG) was utilized to identify the intersegmental plane following division of the segmental vasculature. Lymph node dissection was completed at levels 4R, 7, 9, 12, and 13. The patient recovered well and was discharged on postoperative day one. Pathology demonstrated a grade 2, 1.2 cm adenocarcinoma of the lung, which was negative for lymphovascular invasion and spread through air spaces (STAS). All margins and lymph nodes were negative for carcinoma. The patient was referred for a follow-up chest CT at six months postoperatively. 

Conclusions: 

The robotic approach to anterior basilar segmentectomy is safe and feasible. 3D CT reconstruction allowed for precise preoperative planning and intraoperative confirmation of the segmental bronchovascular anatomy. This technology may facilitate the completion of difficult segmental resections, which may be important in patients with limited pulmonary function. 

References

1. Pardolesi A, Park B, Petrella F, Borri A, Gasparri R, Veronesi G. Robotic anatomic segmentectomy of the lung: technical aspects and initial results. Ann Thorac Surg. 2012;94(3):929-934.
2. Wei B, Cerfolio R. Technique of robotic segmentectomy. J Vis Surg. 2017;3:140. Published 2017 Oct 14. doi:10.21037/jovs.2017.08.13

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