Robotic Right Upper Lobe Anterior (S3) Segmentectomy: Case Discussion and Technical Aspects

The advent of low dose CT scans for lung cancer screening has resulted in increased detection of small lung nodules concerning for malignancy. Based on the location, some of these nodules may not be amenable to diagnostic transthoracic biopsy or wedge resection. In this scenario, a segmentectomy may be performed for diagnostic purposes.

In-depth knowledge of the venous and arterial anatomy is crucial when performing segmental operations. Specifically for right upper lobe anterior segmentectomies, one should be vigilant during dissection of the minor fissure and visualize the central vein and posterior segmental veins prior to division of the anterior segment vein and completion of the fissure. The authors believe that the success of this operation is contingent upon identifying and preventing injury to these critical structures, and thus avoiding the need for a more extensive resection.

The authors describe the case of a 76-year-old male with a significant smoking history, who presented with an anterior right upper lobe nodule on CT scan. The patient underwent a transthoracic needle biopsy, as well as a transbronchial biopsy, which were both non-diagnostic. Based on the location of the nodule, the aim was to perform a robotic-assisted right upper lobe anterior segmentectomy (S3) for diagnosis and proceed with a completion right upper lobectomy if the intra-operative pathology confirmed malignancy. Technical details of the operation and relevant anatomical considerations are described in the video. Once a pathological diagnosis of NSCLC was confirmed, completion right upper lobectomy and mediastinal lymph node dissection were performed. The patient had an uneventful postoperative course. Final pathology revealed moderate to poorly differentiated squamous cell carcinoma, pathological stage T1c N0, for which no adjuvant therapy was recommended.

In conclusion, for small central nodules not amenable to diagnostic biopsy or wedge resection, a segmentectomy may be initially performed for pathological confirmation of malignancy, prior to oncologic lobectomy.

References

1. Nomori H, Okada M. Illustrated Anatomical Segmentectomy for Lung Cancer2012:237-242.
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3. Toker A, Kaba E, Ayalp K, Özyurtkan MO. Robotic lung resections: video-assisted thoracic surgery based approach. J Vis Surg. 2017;3:15.
4. Wei B, Cerfolio RJ. Robotic Lobectomy and Segmentectomy: Technical Details and Results. Surg Clin North Am. 2017;97:771-782.

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