Robotic Left Upper Lobe Posterior Segmentectomy Using ICG and Navigational Bronchoscopy

The use of the robotics in thoracic surgery, including segmentectomy, has increased substantially over the last decade. In the authors’ experience, for small pulmonary nodules, pulmonary segmentectomy allows for a safe and oncologically effective resection, while preserving parenchyma, which potentially limits complications and accelerates recovery when compared to lobectomy. Importantly, the authors believe that the robot allows for an efficient and complete lymph node dissection. The robot equally allows for the efficient use of adjunctive technologies, such as navigational bronchoscopy-guided indocyanine green (ICG) localization.

As shown in this video, segmentectomy involves precise delineation and ligation of the artery, bronchus, vein, and parenchyma of the resected segment. Subcentimeter pulmonary nodules, those with ground glass opacity, or nodules deep to the pleural surface are often difficult to localize by visualization or palpation. For this reason, the authors have found that localization using ICG with navigational bronchoscopy is a valuable adjunct to robotic segmentectomy. Their method of delivering ICG involves mixing 10 mL of normal saline to a 25 mg vial of ICG powder. They inject 1 mL of this solution into the bronchus, adjacent to the nodule, using navigational bronchoscopy. The remainder is given intravenously to identify the intersegmental plane.

The authors have found that segmentectomy is safe, effective, and offers excellent postoperative outcomes with a low rate of recurrence.

Reference

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):1089-1096.

Dr Cerfolio discloses the following consultant relationships: Intuitive Surgical, C-SATS, Bovie, Ethicon, Covidien/Medtronic, Community Health Services, Davol/Bard, Myriad Genetics, KCI, Acelity Company, Verb Surgical, and Pinnacle. He is the president of ROLO-7 consulting firm.