Uniportal VATS S9 segmentectomy: The ligamentum-based approach

A 62-year-old woman who was a current smoker was recently diagnosed with breast cancer. She was referred to our center because of the incidental radiological finding of 2 synchronous pulmonary lesions located on the right middle lobe and the lateral segment of the right lower lobe. The PET-CT scan showed moderate uptake of FDG by the 2 lesions with no evidence of intrathoracic lymph node involvement or distant metastases. The pulmonary function tests demonstrated a decreased predicted FEV1 (70%) and DLCO (70%). The bronchoscopy revealed a pulmonary adenocarcinoma in the middle lobe. After a multidisciplinary meeting, a middle lobectomy combined with a lateral basal segmentectomy was proposed.

During the procedure, general anesthesia is managed with a left double-lumen tube. The patient is positioned on her left side; the table was flexed to increase the distance between the ribs. A 4-cm incision is performed in the 5th intercostal space between the tip of the scapula and the breast in the anterior axillary line. The wound is protected by a plastic soft tissue retractor (Alexis Ò retractor, Applied Medical, Rancho Santa Margarita, CA, USA).

The surgeon and the assistant are positioned on the anterior side of the patient; the scrub nurse stands at the back. A 10-mm 30º Endoeye thoracoscope (Olympus, Tokyo, Japan) is used to optimize the visualization of the pleural cavity and all mediastinal structures. A dissector (Scanlan International, St. Paul, MN, USA) and a hook monopolar cautery are used for dissection and coagulation, respectively. All vessels are divided by endoscopic staplers (Endo GIA, Medtronic, Minneapolis, MN, USA).

Because mediastinal lymph node dissection is generic to all oncological pulmonary resections, it is not described in this video tutorial.

The procedure was started with a standard right middle lobectomy. We do not show the entire procedure because we perform a standard anterior approach with progressive dissection of the middle vein, bronchus, and arteries. We finish with division of the minor fissure. All interlobar lymph nodes were removed.

First, the pulmonary ligament is incised up to the lower vein using both hook monopolar and gentle traction of the lower lobe anteriorly.

The inferior pulmonary vein is thoroughly dissected to expose its segmental branches. Care is taken to properly identify the posterior basal vein V10. The intersegmental plane between S7 and S10 should be gradually opened with endoscopic staplers. This maneuver facilitates further dissection of the bronchovascular structures for segment 9. The bronchus B7 should be properly identified to follow the intersegmental plane.

After division of the intersegmental plane, the structure to segment becomes apparent. It is important to identify the bronchus to segment 10, which should be preserved. The recognition of the B10 may facilitate the dissection of the B9. We observed a small vein draining segment 9. We tried to preserve the intersegmental vein. The vein is tied with resorbable thread and clips.

After further division of the intersegmental plane between S7 and S10, the bronchial division between B10 and B9 is recognized. Then, the lateral segmental bronchus (B9) may be encircled and cut. Care is taken to avoid injury to segmental arteries that lie dorsal to the segmental bronchus

The A9 branch is identified; it is situated just above the segmental bronchus. Then, the A9 is dissected and stapled using an endoscopic curved-tip vascular stapler.

This step of the operation is the most difficult because the intersegmental plane is tridimensional. It is identified by using the systemic injection of indocyanine green with the near-infrared imaging system (Novadaq, Stryker, Kalamazoo,MI, USA) after transection of the segmental arteries. The demarcation line (between the green enhanced parenchyma and the normal parenchyma) is marked by electrocautery, and the intersegmental plane is divided by the successive application of endoscopic staplers. During this maneuver, it is important to include bronchovascular stumps in the specimen and to follow the division of the parenchyma in the direction of the segmental hilum.

The specimen is retrieved in a bag. Thereafter, a systematic lymph node dissection is performed. Finally, an intercostal block with local anesthesia (bupivacaine 0.5%) is applied between the 2nd and 8th intercostal spaces. A 28-Fr chest tube is placed, and the lung is reexpanded under direct vision.

The overall surgical time was 150 minutes. The postoperative course was uneventful. The patient was discharged on the 4th postoperative day. The histopathological analysis revealed an adenocarcinoma of 2.2 cm, pT1c pN0R0 in the middle lobe and an adenocarcinoma of 12 mm in the S9 pT1b pN0 R0. The CT scan of the chest at 3 months showed complete reexpansion of the remnant right lower lobe.