Robotic-Assisted Left Upper Lobe Anterior (S3) Segmentectomy

Sublobar resection of small (<2 cm) well-differentiated lung cancers is appropriate, especially in elderly patients, and it preserves useful lung parenchyma, thereby maximizing postoperative lung function [1]. Though minimally invasive anatomic segmental lung resection by video-assisted thoracoscopic surgery is relatively straightforward for resection of the lingular (S4+5), trisegment (S1+2+3), superior (S6), and basilar (S7+8+10) segments, resection of individual segments such as the anterior segment (S3) is rarely performed due to the complexity of the procedure. The dexterity inherent in the surgical robot, however, facilitates delicate dissection of the individual segmental vascular and bronchial structures and allows for the performance of “atypical” segmental resections [2]. Here, the author presents a completely portal robotic segmentectomy of the anterior (S3) segment of the left upper lobe in an 80-year-old man with a small peripheral well-differentiated adenocarcinoma.

Hardware:

• da Vinci Xi^® surgical robot 
• 0 degree scope
• near-infrared imaging
• EndoWrist^® 30 mm  and 45 mm robotic stapler
• fenestrated bipolar (left port, non-dominant hand)
• curved bipolar dissector (dominant hand)
• robotic scissors (right port, dominant hand)
• tip-up fenestrated grasper (posterior port, retraction)
• flexible 14 Fr tracheal suction tubing attached to 5 mm endoscopic suction device for intermittent suctioning, if needed

Key points in the conduct of the procedure include:

Complete portal technique is used with four robotic ports, carbon dioxide insufflation, and no bedside assistant except for specimen extraction.

Initial dissection of mediastinal N1 and N2 lymph nodes is performed, with frozen section pathologic analysis to confirm the absence of metastases.

Dissection of the hilar lymph nodes (10L, 11L, and 12L) facilitates the dissection of the vascular and bronchial structures, and it enables correct identification of the segmental anatomy and the division of the appropriate structures.

Intraoperatively, frequent correlation of the visualized anatomy with the preoperative computed tomography imaging is important to ensure that the correct structures are dissected and divided.

Division of the small arteries to the involved segment is often best accomplished by dividing between ligatures. The bronchus may be either divided by stapler or transected with scissors and sutured closed. A posterior-to-anterior trajectory for the stapler facilitates stapler alignment, and this can be achieved by placing a 12 mm port between the camera port and the posterior (retraction) port.

Once the arterial supply to the involved segment is divided, use of 12.5 mg indocyanine green (ICG) intravenously allows the remaining perfused segments to be visualized under Firefly™ near-infrared imaging, thereby defining the intersegmental planes. Because of eventual parenchymal diffusion of ICG, the initial boundary between perfused and nonperfused regions can be marked on the visceral pleura using electrocautery.

Division of the intersegmental plane can be easily achieved with the robotic stapler, which lessens the amount of air leak compared to traditional parenchymal division with cautery. For “atypical” segmentectomy, it is not strictly necessary to ligate the venous structures. Frequently, the veins will have tributaries that drain adjacent segments, particularly intersegmental veins, and division of these may result in venous congestion of the remnant segments.

References

1. Mery CM, Pappas AN, Bueno R, et al. Similar long-term survival of elderly patients with non-small cell lung cancer treated with lobectomy or wedge resection within the surveillance, epidemiology, and end results database. Chest. 2005;128(1):237-245.
2. Cerfolio RJ, Watson C, Minnich DJ, Calloway S, Wei B. One hundred planned robotic segmentectomies: early results, technical details, and preferred port placement. Ann Thorac Surg. 2016;101(3):1089-1095.