Robotic Right Apicoposterior S1 and S2 Anatomic Segmentectomy

Much is being discussed about how far surgeons need to go with lung resection among ground glass opacities (GGO) and part-solid lesions. However, one thing that is becoming well accepted is the improved quality of anatomical lung resections with new technological perspectives. 

This video presents a case of a forty-five-year-old woman, nonsmoker, with no medical records. She underwent a CT scan because of COVID-19 suspicions and ground-glass opacity on the right upper lobe measuring 15 mm was found, without any other relevant finding. It was decided to a follow-up in six months, which showed an increase in size to 20 mm with a small excavated area and consolidation tumor ratio (CTR) < 0.5. Therefore, regarding the high probability of primary lung adenocarcinoma, and after discussing the possibilities with the patient, the medical team opted to perform an upfront surgery. PET scan and brain MRI showed no distant metastasis and no lymph node uptake. 

The Surgery

Given the localization of the lesion on the transition to S1 and S2, to guarantee oncology margin the surgeons performed a robotic-assisted thoracoscopic (RATS) right S1 + S2 apicoposterior segmentectomy using a Da Vinci Xi® surgical platform with four ports of 8 mm for the robotic arms and one 15 mm port for the assistant on a right-side approach.

The surgery began with the dissection of the pulmonary ligament, opening the posterior mediastinal pleura to the azygous vein and contiguous lymphadenectomy with all nodes negative in frozen section. The meticulous dissection of the sump node is important since it is the ending of the tunnel for the posterior fissure.

The dissection of the hilum showed a V1 and a central vein with early bifurcation on V3b. The hilar artery branches segmentated on A1 and Rec. A2 was dissected and immediately stapled and the V1.

On the fissure, the surgeons aimed to find the pulmonary artery and started on the adventitia plane toward the posterior plane to join the sump node dissection. It was also made sure to safely open the posterior fissure. Next, the ascending A2 was dissected and stapled, and an unusual accessory V6 draining to the interlobar central vein was found. This was preserved (1), and the dissection of V2a+b and V2c began. Then, bronchial dissection and stapling of B1 + B2 was performed, followed by the injection of 10 mg of Indocyanine green with the Firefly™ Fluorescence Imaging Scope to determinate the intersegmental plane of the robotic platform and finish the lung parenchyma division.

The procedure was uneventful, and the patient was discharged on the second postoperative day. The final anatomopathological result confirmed primary lung adenocarcinoma with lepidic and acinar patterns. The parenchymal and bronchial margins distance was 2.9 cm and 3.5 cm respectively. The final staging was pT1c pN0.

Conclusions

A huge increase in robotic surgeries is well-known, and with them the number of anatomic segmentectomies has increased by 100 or 200 hundred percent in the first few years after robotic implement at some institutions (2,3). The Endowrist and more democratic learning curve of the platforms provide feasible and safe alternatives for difficult procedures, including an increase in complex segmentectomies, allowing more surgeons to ensure oncological purposes safely (4, 5). 

References

1. Amore D, Muto E, Caterino U, Casazza D, Saglia A, Imitazione P, et al. Anomalous segmental pulmonary vein: additional V6 behind the bronchus intermedius draining into the superior pulmonary vein. Monaldi Arch Chest Dis [Internet]. 2022 Mar 29 [cited 2022 Nov 4]; Available from: https://www.monaldi-archives.org/index.php/macd/article/view/2196
2. Veronesi G. Robotic lobectomy and segmentectomy for lung cancer: results and operating technique. J Thorac Dis. 2015;7:9.
3. Gergen AK, White AM, Mitchell JD, Meguid RA, Fullerton DA, Scott CD, et al. Introduction of robotic surgery leads to increased rate of segmentectomy in patients with lung cancer. J Thorac Dis. 2021 Feb;13(2):762–7.
4. Terra RM, Lauricella LL, Haddad R, de-Campos JRM, Nabuco-de-Araujo PHX, Lima CET, et al. Segmentectomia pulmonar anatômica robótica: aspectos técnicos e desfechos. Rev Colégio Bras Cir. 2019;46(4):e20192210.
5. Zhou N, Corsini EM, Antonoff MB, Hofstetter WL, Mehran RJ, Rajaram R, et al. Robotic Surgery and Anatomic Segmentectomy: An Analysis of Trends, Patient Selection, and Outcomes. Ann Thorac Surg. 2022 Mar;113(3):975–83.

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