Subxiphoid Left S3 Segmentectomy

This video demonstrates a subxiphoid left S3 segmentectomy, as a day surgery radical oncological treatment of an early stage lung cancer in an elderly patient. This is the case of an 82-year-old COPD patient with a 10 mm suspect nodule located in the middle of segment 3. 

An anatomical 3D reconstruction allowed us to plan this segmentectomy with sufficient margin. The patient was integrated in an ERAS program and a standardized triportal subxiphoid approach was considered as already described. We usually practice an exclusive subxiphoid approach on the right side, but an accessory intercostal port is clearly mandatory on the left, if you want to keep a precise dissection and to reach subcarinal area, due to cardiac obstruction. Here you can see an external view: we use energy dissection, 4K vision and camera-holder stabilization. The subxiphoid approach comes through a paramedian incision opening only the anterior aponeurosis of rectus abdominis, reaching the pleura via the M orgagni foramen. We complete with the subcostal port more laterally, through diaphragmatic insertions. It's an anterior approach, the intercostal port is placed through a 1cm incision in the third intercostal space with a 45° angle relative to hilar structures. We begin with station #11 lymph node, followed by venous dissection, V3C Ligasure, anterior #12 station and A3 dissection, which is stapled. Venous branches from S1+2 are further dissected, and also arterial and bronchial elements which are revealed when pushing far away the radical lymph node dissection of station #12 and #13. The distal dissection of V1+2 a is the key for an adequate superior intersegmental plane. Then B3 appears evident and is stapled after hyperinflation, which is very easy through the subxiphoid port. The demarcation line between S3 and the lingula is well defined and stapled. Stump traction is very important as it gives you the finally the posterior wall of S3. ICG is coming soon in our institution , but we find however for the moment that the association of both advanced venous dissection of adjacent segments and hyperinflation technique is very efficient for an accurate intersegmental plane delimitation. Then the piece is retrieved through the subxiphoid port and a complete mediastinal lympadenectomy is achieved. You can see the final anatomical view.

In conclusion, whatever the approach choosen, thoracic surgeons have to reach an accurate, oncological segmentectomy. Minimally-invasive Segmentectomy remains the best treatment even for such fragile patients, if we are able to offer them a complete lung-sparing resection with sufficient margin, radical lymphadenectomy, within an ERAS advanced program. Our standardized subxiphoid ERAS strategy appears quite efficient from this point of view. If you are interested, here are two recent papers from our institution and you can find others videos on Youtube. Thank you for your attention.

References

1. Pfeuty K, Lenot B. Early postoperative day 0 chest tube removal using a digital drainage device protocol after thoracoscopic major pulmonary re- section. Interact CardioVasc Thorac Surg 2020;31:657–63.
2. Pfeuty K, Lenot B. Multiportal subxiphoid thoracoscopic major pulmonary resections. J Thorac Dis 2019 http://dx.doi.org/10.21037/jtd.2019.07.21

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