Single-Port Thoracoscopic RS3 Segmentectomy Via the Periareolar Approach

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A 37-year-old female patient was found to have a 7 mm pure ground-glass opacity (GGO) in the anterior segment of the right upper lobe. After one year of follow-up, the nodule had increased to 1 cm in diameter without any solid components. Positron emission tomography showed an apparently malignant pulmonary lesion in the anterior segment of the right upper lobe, but no other pathologic findings. The surgeons decided to proceed with diagnostic therapeutic surgery. Given the patient's high aesthetic requirements for the surgical incision, they chose to perform a single-port thoracoscopic RS3 segmentectomy via the periareolar approach. 

 The surgeons began by making a 1.5 cm incision along the right periareolar region, dissected through the subcutaneous fat, and entered the thoracic cavity at the fourth intercostal space after passing around the breast. 

The pleural tissue was opened along the anterior hilum of the lung. Due to the limited working space, the surgeons minimized the use of the electrocautery to reduce interference from the thoracoscope and suction, thereby enhancing the stability and safety of the operation. V3 was freed, and the lung tissue was retracted toward the foot side to free A3. A stapler was then used to close and cut V3 and A3. Next, the 12 station lymph nodes adjacent to B3 were sampled, and B3 was freed. A stapler was used to close and cut B3. The horizontal fissure was processed with the stapler, the intersegmental plane between S3 and S4+5 was opened and retracted along the central vein to the distal end at the junction of S3 with S1 and S2. Using the central vein and the residual B3 as landmarks, the boundary between S3 and S2 was identified, and the intersegmental plane between S3 and S2 was processed with the stapler. The intersegmental line between S1 and S3 was identified by using the concave portion of the apical construction. The stapler was used to handle the intersegmental plane between S3 and S1. The specimen was in good condition, and the frozen section pathology results showed minimally invasive adenocarcinoma. There were no air leaks. The operation took approximately 30 minutes, with an estimated blood loss of 30L. Only one 18F chest drain was inserted through the incision. The patient had the chest tube removed two days after surgery and was discharged on the third day. 

References

1. Cerezo Madueño, Francisco., Arango Tomás, Elisabet., Algar Algar, Francisco Javier., & Salvatierra Velázquez, Angel.. (2014). Periareolar approach for thoracoscopic lobectomy. The Annals of thoracic surgery, 97(4).

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