Robotic Right Anterobasal (S8) Segmentectomy

A 73-year-old male with a 30-pack-per-year smoking history was found to have a 1 cm spiculated nodule in the right lower lobe on a lung cancer screening CT chest. His workup included a PET-CT scan, which demonstrated low FDG avidity in the nodule, and an endobronchial ultrasound (EBUS) with transbronchial biopsy of both the nodule and lymph nodes. Histopathology confirmed the diagnosis of adenocarcinoma. Preoperative pulmonary function tests revealed adequate FEV1 and DLCO values, suggesting favorable pulmonary reserve for surgery. The surgeons proceeded with an anatomic anterobasal (s8) segmentectomy in lieu of a lobectomy. Studies have demonstrated that anatomic sub-lobar resections are noninferior to lobectomy in terms of long-term survival in early-stage lung cancer. The robotic platform was leveraged for its high degree of dexterity, precision, and enhanced visualization while navigating a technically challenging operative field. Preoperative imaging, including CT and PET scans, identified the location of the nodule of interest. Four working ports were placed in the 8th intercostal space, including an 8mm port for a 30-degree camera. An additional assistant port was placed in the 10th intercostal space. The procedure began with cranial retraction of the lung and division of the inferior pulmonary ligament to mobilize the hilum. Station 9 lymph nodes were identified and sampled for analysis. The anterior hilum was further explored, and additional lymph nodes were sampled. Subsequently, paratracheal lymph node sampling was performed. Critical anatomical landmarks were noted, including the azygous arch inferiorly and the superior vena cava (SVC) with the phrenic nerve medially, which were crucial for safe lymph node dissection. 

A fissure-first technique was employed to divide the interlobar fissure. Dissection of the interlobar lymph nodes facilitated the identification and isolation of the segmental pulmonary artery branch. The artery was encircled with a red vessel loop and divided using a 45 mm white load stapler. Similarly, the B8 bronchus was identified and isolated with a red vessel loop, then divided using a blue load stapler. The segmental pulmonary vein was dissected and divided in a similar fashion. Intravenous indocyanine green (ICG) was administered to demarcate the devascularized segment, and the intersegmental plane was identified. The anterobasal (S8) segment was then resected with the use of robotic assistance for precise tissue handling and resection. 

Final pathology revealed a 1 cm T1aN0, moderately differentiated acinar adenocarcinoma, with no pleural involvement and a 2.9 cm surgical margin. All lymph nodes were negative for malignancy. The patient tolerated the procedure well, had an uneventful postoperative course, and was discharged the following day. 

References

1. Altorki, N. et al. (2023) ‘Lobar or Sublobar resection for peripheral stage ia non–small-cell lung cancer’, New England Journal of Medicine, 388(6), pp. 489–498. doi:10.1056/nejmoa2212083.
2. Lee, B.E. and Altorki, N. (2023) ‘Sub-lobar resection: The new standard of care for early-stage lung cancer’, Cancers, 15(11), p. 2914. doi:10.3390/cancers15112914.
3. Yutaka, Y. et al. (2022) ‘Fissure-last technique for left upper lobe lung cancer with Interlobar invasion: How to do it?’, General Thoracic and Cardiovascular Surgery, 70(9), pp. 828–831. doi:10.1007/s11748-022-01841-3.

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