Demonstration of a Right VATS 9 and 10 Bisegmentectomy

The patient in this case is a sixty-eight-year-old male with a background of bowel adenocarcinoma (pT3aN1a) resected in 2019. Follow-up surveillance demonstrated two suspicious, enlarging non-fluorodeoxyglucose lesions in the right lung, one affecting the lateral basal (S9) and posterior basal (S10) of the right lower lobe, and the other within the right middle lobe abutting the horizontal fissure. The patient’s past medical history included a benign parotid nodule and a smoking history of fifty packs per year. His lung function test demonstrated an FEV1 of 87% and FVC of 104%.  

A parenchyma sparing intervention was determined to be the most appropriate approach for this patient because, radiologically, the tumors were likely to be metastatic in origin. Because of the anatomical location of the tumors within the right lower lobe, a wedge resection was not feasible. Therefore, an anatomical segmental (S9, S10) resection was chosen with a wedge resection for the lesion in the right middle lobe. In recent years, evidence suggests survival for patients undergoing a segmentectomy compared to those undergoing a lobectomy in non-small cell lung cancer are at least comparable (1) or better (2), provided the margins are clear.  

In this video, following a two-port access (4cm incision with a soft tissue retractor, 1cm instrument ports), a right middle lobe wedge resection and an S9 and S10 segmentectomy were performed. The video describes in detail the instruments used and the procedure steps. The patient had an uneventful recovery, and the drain was removed on postoperative day 1 (POD1). He was then discharged home on POD3. The final pathology showed a necrotic nodule measuring 85 x 35 x 20mm within the right middle lobe wedge resection. This was well clear of the staple line and the visceral pleura. The S9, S10 bisegmentectomy sample contained a 150 x 70 x 85mm mass that was well circumscribed and clear of bronchial and vascular markings by 20mm. Colorectal adenocarcinoma was confirmed on both samples immunohistochemically. Lymph nodes 7, 8, and 12 were reactive.  

References

1. Bedetti B, Bertolaccini L, Rocco R, Schmidt J, Solli P, Scarci M. Segmentectomy versus lobectomy for stage I non-small cell lung cancer: a systematic review and meta-analysis. J Thorac Dis. 2017 Jun;9(6):1615-1623. doi: 10.21037/jtd.2017.05.79. PMID: 28740676; PMCID: PMC5506148.
2. Suzuki K, Saji H, Aokage K, Watanabe SI, Okada M, Mizusawa J, Nakajima R, Tsuboi M, Nakamura S, Nakamura K, Mitsudomi T, Asamura H; West Japan Oncology Group; Japan Clinical Oncology Group. Comparison of pulmonary segmentectomy and lobectomy: Safety results of a randomized trial. J Thorac Cardiovasc Surg. 2019 Sep;158(3):895-907. doi: 10.1016/j.jtcvs.2019.03.090. Epub 2019 Apr 9. PMID: 31078312.

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