Robotic Left Upper Division Trisegmentectomy for Lung Adenocarcinoma

This video presents the case of a 76-year-old male with a significant smoking history who underwent a robotic left upper division trisegmentectomy for a suspicious nodule in the left upper lobe (LUL). Imaging demonstrated a ground-glass opacity (GGO) with an increasing solid component. Positron emission tomography (PET) imaging revealed mild fluorodeoxyglucose (FDG) uptake without evidence of FDG-avid lymphadenopathy or metastatic disease. Preoperative testing indicated that the patient had excellent exercise capacity and acceptable pulmonary function tests (PFTs), making him a suitable candidate for surgical resection. The patient underwent robotic-assisted left upper division trisegmentectomy, beginning with a wedge resection for diagnosis. Upon confirmation of adenocarcinoma from pathology, a left upper division trisegmentectomy was performed with systematic lymphadenectomy. 
 
Key technical steps included the dissection of the fissure to visualize the interlobar artery and the identification and preservation of the lingular vein and artery.  Sequential lymph node dissection was performed, including levels 9, 7, and the aortopulmonary window nodes. There was complete visualization of structures during parenchymal division to ensure the preservation of the lingular vasculature.  Parenchymal division was achieved using blue and green load staplers, followed by Progel application for staple line reinforcement. 

The final pathology confirmed lung adenocarcinoma staged as pT1aN0M0, with negative surgical margins and lymph nodes. The patient's postoperative course was complicated by a prolonged air leak, necessitating discharge on postoperative day seven with a Heimlich valve in place. Follow-up visits demonstrated successful chest tube removal and an uneventful recovery. 

Conclusion 

This case highlights a safe and effective robotic approach to left upper division trisegmentectomy with careful anatomical dissection, parenchymal division, and comprehensive lymphadenectomy. This technique provides a valuable framework for teaching and improving outcomes in segmental lung resection, emphasizing the balance between preserving important structures while ensuring adequate lung division for tumor resection. 

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