Lung-Sparing Surgery for Treatment of Pulmonary Metastases: VATS Right Anterior Segmentectomy (S3) and RLL Wedge Resection

The lungs are a common target-organ for metastases in most of cancers. Pulmonary metastasectomy can potentially be a curative surgical option as long as selection criteria of patients are rigorously met. These essential requirements include control of the primary tumor, no other distant metastatic disease, a limited number of pulmonary metastases so that a complete resection can be accomplished, and adequate performance status of the patient (1).

Operative Steps
In this video, the authors present the clinical case of a 67-year-old woman with an oncological history of endometrial stromal sarcoma treated with surgery and adjuvant chemotherapy who underwent several pulmonary metastasectomies in practically all the pulmonary lobes during the last eight years. In the last computed tomography scan, two new pulmonary nodules were detected in the right lower lobe (RLL) and right upper lobe (RUL). Operative steps are listed below:

Preparation:
General anesthesia was induced and endotracheal intubation was performed with a double lumen tube. The patient was placed in a lateral decubitus position. Draping was prepared in the usual manner. A prophylactic dose of Cefazolin was administered.

VATS Approach:
The thorax was approached by performing the biportal technique. The utility port (3 cm) was done in the fifth intercostal space at the level of the anterior axillary line. An additional port (1 cm) was placed in the eighth intercostal space at the level of the posterior axillary line. The entire procedure was performed under video-assisted visualization using a high definition 30-degree thoracoscopic camera.

RLL wedge resection:
After ruling out pleural metastases, the pulmonary ligament and several pleuropulmonary adhesions were sectioned with an energy device in order to mobilize the lung and facilitate the digital palpation of the parenchyma. Once the RLL nodule was identified by palpation, a wedge resection was performed.

Right anterior segmentectomy (S3):
In this particular case with some anatomical variants, the authors follow the next sequence--dissection and exposure of the anterior hilar structures, especially the right upper pulmonary vein and its main branches.

Division of the minor fissure between the middle lobe and the RUL:
Before passing the dissector from the anterior to the posterior side crossing the fissure, the pulmonary artery in the fissure should be dissected and exposed. Usually, several lymph nodes should be previously removed at this level.

Dissection and section of the venous branch (V3) for the anterior segment:
Sometimes two independent venous branches (V3a and V3b) can be identified arising from the central vein.

Dissection and section of the bronchial branch (B3) for the anterior segment:
Before cutting B3, it should be clamped and the RUL should be ventilated in order to confirm it. Alternatively, an intraoperative bronchoscopy can be performed visualizing internally the B3 bronchus.

Dissection and section of the arterial branch (A3) for the anterior segment:
Division of the intersegmental plane between S1, S2, and S3 through the predetermined demarcation line. The specimen was removed using a retrieval bag and sent to the Pathology Department for frozen section.

Completion:
The RUL was inflated in order to check the viability of the remaining segments and discard possible air leaks. Finally, a 28 F chest tube was inserted into the pleural cavity and the skin was closed with a subcuticular stitch.

Preference card
Harmonic ACE®+7 . Ethicon ™. Ohio, USA.
Echelon Flex Powered Vascular Stapler. Ethicon ™. Ohio, USA.
Endo Gia. 45 and 60 mm medium/thick articulating reload with Tri-staple technology. Covidien ™. USA.

Tips and Pitfalls

Advantages:
The main goal for lung metastasectomy with curative intent is excision of all detectable lesions, allowing optimal margins and preserving as much functional parenchyma as possible. Wedge resection is preferred for small and peripheral metastatic lesions. By contrast, centrally located lesions usually require more extensive resections which may be necessary to obtain a complete excision. In these cases, lung-sparing techniques are preferable so as to preserve healthy pulmonary tissue and decrease minimally the pulmonary function in case future pulmonary resections are needed. Anatomical segmentectomy is a suitable surgical alternative for deep tumors. Regarding the approach, Video-assisted thoracic surgery (VATS) provide several well-known benefits in comparison with open procedures such as less postoperative pain, lower postoperative complications rate, shorter hospital stay, and quicker recovery (2). The biportal technique is an excellent alternative for VATS anatomical segmentectomies. This technique allows the surgeon to switch the camera and the surgical instruments in two different ports. Consequently, the hilar structures can be visualized from several perspectives, and most importantly, staplers can be inserted from different angles, decreasing the tension over the segmental vessels.

Caveats:
Right anterior segmentectomy is one of the most challenging sublobar resections due to the variability of vascular and bronchial branches. The knowledge of the anatomy and possible variants, which is highly frequent in segmental and subsegmental branches, is essential in order to avoid sectioning wrong structures. Additionally, minimally invasive procedures can make palpation of the lung difficult due to limited access to the chest. The surgeon must be able to palpate the lung, especially in sarcomas, in order to explore, identify, and remove any radiologically occult lesions and thereby achieve a macroscopically complete resection. An expert consensus document approved by the Society of Thoracic Surgeons (STS) in 2019 defended that pulmonary metastasectomy can be considered with a preference for minimally invasive surgery if goals of R0 and pulmonary parenchymal sparing are not accomplishable (3).

References

1. Petrella F, Diotti C, Rimessi A, Spaggiari L. Pulmonary metastasectomy: an overview. J Thorac Dis. 2017;9(Suppl 12):S1291-S1298.
2. Wang Z, Pang L, Tang J, Cheng J, Chen N, Zhou J1, et al. Video-assisted thoracoscopic surgery versus muscle-sparing thoracotomy for non-small cell lung cancer: a systematic review and meta-analysis. BMC Surg. 2019 Oct 15;19(1):144. doi: 10.1186/s12893-019-0618-1.
3. Handy JR, Bremner RM, Crocenzi TS, Detterbeck FC, Fernando HC, Fidias PM, et al. Expert consensus document on pulmonary metastasectomy. Ann Thorac Surg. 2019;107:631–649.

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