Robotic Assisted Right Apical S1 Anatomical Segmentectomy for NSCLC

This video illustrates a robotic assisted right apical S1 lung anatomical segmentectomy and radical lymphadenectomy for non-small cell lung cancer (NSCLC) performed with the DaVinci Xi surgical system.

The video highlights the importance of using 3D reconstruction to guide the surgical procedure and face the anatomical and technical challenges of lung complex segmentectomies approached by robotic technology.

The authors’ institution performs a 3D reconstruction for almost every lung segmentectomy, which is obtained with a contrast-enhanced CT scan of the thorax. These virtual models are furnished by the Visible Patient company and are accessible by both computer and smartphone (1, 2).

The 3D reconstruction is crucial to define the localization of the lesion, calculate the appropriate margins of resection, and plan the resection of the involved lung segments. It is also crucial to clearly identify the anatomy of the bronchi, the arteries, and the veins that must be resected (3).

The Patient

The case described in this video concerned a nonsmoker seventy-one-year-old asymptomatic woman with a peripheral, spiculated, part-solid lung nodule of the right upper lobe suspected of NSCLC staged cT1bN0M0 (TNM eight edition). Previous relevant history of the patient included systemic arterial hypertension and fibromyalgia. 

The lung nodule was first detected in 2019 during a CT scan performed for investigating asthenia and dyspnea. At that time, the nodule was part solid and measured 6 mm in diameter. At the patient’s 2023 CT scan, the nodule had grown to 11 mm. The 18 F FDG PET CT revealed a low local fixation without hilar or mediastinal lymphadenopathy. A respiratory function test showed a FEV1 of 90 percent and a DLCO of 84 percent. Due to the high suspicion of malignancy and the subsolid nature of the tumor, which could make an eventual biopsy challenging, a multidisciplinary decision was made to perform upfront surgical sublobar resection for diagnostic and therapeutic purposes. Following a 3D anatomical reconstruction, an apical S1 right segmentectomy with lymph node radical resection was planned.

The Surgery

To begin, the patient was put in the lateral decubitus position. The port positioning followed the four arms robotic approach for robotic portal lung resections (RP-4) (4, 5). Five incisions were made, including an 8 mm port for the 30 degree robotic camera, located on the seventh intercostal space about the length of a hand below from scapula’s tip and on the projection of the middle axillary line.

The other ports were then placed on the same intercostal space, including a 12 mm trocar incision on the anterior axillary line for arm number four (right hand), a 12 mm trocar incision on the midaxillary line for arm number two (left hand), and an 8 mm trocar incision laterally to the paravertebral line for arm number one.

Under visual control, a 12 mm trocar incision was also made two intercostal space downward, in the ninth intercostal space, for the assistant port with CO2 insufflation using AirSeal technology.
During the procedure, the surgeon could consult the 3D anatomical reconstruction to recognize and resect the proper bronchovascular structures (1-3). Intersegmental plan detection was then performed using fluorescence Firefly robotic technology with intravenous indocyanine green injection (12.5 mg bolus at a concentration of 2.5 mg/ml) following segmental arteries and veins resection.

The patient’s postoperative course was uneventful. The chest tube was removed on postoperative day (POD) two and the patient discharged on POD three. The pathological report showed an invasive lung adenocarcinoma (mucinous type) staged pT1aN0, and the resection status was R0 with a 3 cm margin from the nearest stapler line. The visceral pleura was not invaded, but the tumor spread through air space (STAS) and the G12D mutation of K-RAS was identified. At four months of follow-up, the patient was doing well.

References

1. Seguin-Givelet A, Grigoroiu M, Brian E, Gossot D. Planning and marking for thoracoscopic anatomical segmentectomies. J Thorac Dis. 2018 Apr;10(Suppl 10):S1187-S1194. doi: 10.21037/jtd.2018.02.21.
2. Gossot D. Atlas of Endoscopic Major Pulmonary Resections. Cham: Springer International Publish
3. Nomori H, Okada M. Illustrated Anatomical Segmentectomy for Lung Cancer. Tokyo: Springer Japan, 2012.
4. Wei B, Cerfolio RJ. Robotic Lobectomy and Segmentectomy: Technical Details and Results. Surg Clin North Am. 2017 Aug;97(4):771-782. doi: 10.1016/j.suc.2017.03.008.
5. Mattioni G, Palleschi A, Mendogni P, Tosi D. Approaches and outcomes of Robotic-Assisted Thoracic Surgery (RATS) for lung cancer: a narrative review. J Robot Surg. 2023 Jun;17(3):797-809. doi: 10.1007/s11701-022-01512-8.

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