Tutorial
Thoracoscopic S1 segmentectomy, right upper lobe: alternative posterior approach
Minimally invasive pulmonary segmentectomy allows adequate oncological treatment in selected cases while preserving lung parenchyma and minimizing perioperative morbidity and length of hospital stay. Although several variations of minimally invasive pulmonary segmentectomy have been described, a fully thoracoscopic multiport approach that allows direct access to the segmental structures, is straightforward and is versatile enough to allow adaptation in case of unexpected intraoperative findings (such as conversion to lobectomy in the case of positive margins) is preferable.
The S1 (apical) segment of the right upper lobe has some unique features that may make a conventional anterior approach challenging. The presence of multiple vascular structures bearing complex anatomical relationships and the requirement for preserving these structures may make identification of and access to the apical artery, and subsequent access to the segmental bronchus, challenging.
In contradistinction, a posterior approach may obviate some of these challenges by allowing direct access to the segmental bronchus. Once the bronchus is divided, the apical artery is in direct alignment with the operating instruments, without encroachment from other troublesome vascular structures. This situation, however, remains contingent on individual anatomy, which may vary.
Segmentectomy offers the possibility of an adequate oncological treatment in selected patients, of preserving pulmonary parenchyma and function and of minimizing perioperative morbidity and length of hospital stay, particularly when performed thoracoscopically [1–3]. Most segments may be resected individually or as part of bisegmentectomies (e.g. lingulectomy), although the resection of individual basal segments may be particularly challenging.
The requirement to preserve complex vascular structures in an S1 (apical) segmentectomy of the right upper lobe may make a conventional anterior approach challenging [3, 4]. In contradistinction, a posterior approach may obviate some of these challenges.
1 - Patient presentation (0:12)
A posterior approach to the S1 segment of the right upper lobe in a 73-year-old male patient with a 9-mm nodule highly suspicious for non-small cell lung cancer but without a preoperative diagnosis, is illustrated. The patient also had a history of diabetes, hypertension and coronary artery disease. Lung function testing showed a forced expiratory volume in 1 second of 2.27 L (75%) and a carbon dioxide diffusion capacity of 106%. Sublobar resection is always undertaken after a comprehensive discussion with the patient covering risks, benefits, oncological results and treatment alternatives.
An anterior approach was used previously for performing a right S1 (apical) segmentectomy [3]. However, identification of arterial branches may not be straightforward, because complex vascular structures and relationships often encroach upon the operative field, hinder exposure and identification of the apical artery and impede subsequent access to the segmental bronchus [3, 4].
In contradistinction, a posterior approach obviates these challenges in many cases. It allows direct access to the segmental bronchus, and once the segmental bronchus is divided, the segmental artery is in direct view of the scope and in line with the operating instruments, making identification and dissection fairly straightforward.
2 - Patient positioning and trocar placement (1:04)
The patient is placed in a lateral decubitus position with the table generously flexed to move the patient’s hip out of the way and to widen the intercostal spaces, which improves range of motion.
The trocars are introduced in the following sequence: First, a port inserted inferiorly is used for the camera throughout. This port is placed somewhat behind the border of the latissimus dorsi, which improves visualization of the posterior portion of the hilum. Next, a 10-mm port is placed anteriorly and inferiorly. It is used for retraction and for stapling of the bronchus. A 10-mm port is placed posteriorly and inferiorly and is used for dissection, stapling the artery and dividing the intersegmental plane. A 5-mm port behind the scapula is used for retraction.
Although endoscopic trocars may be used, they limit the range of motion and generally should be avoided, except for the camera and the 5-mm port. Likewise, CO2 insufflation is usually not necessary.
Mediastinal lymph node dissection is generic to all oncological pulmonary resections. However, because it is not specific to segmentectomy, it is not included in this video tutorial.
3 - Dissection of the hilum (2:15)
Dividing the inferior pulmonary ligament is important to give the lung full mobility. Purposeful retraction is key to exposing the posterior bronchial bifurcation and the apex of the hilum. This step requires anterior retraction as well as counterclockwise rotation of the lung by the assistant.
The operation begins with dissection of the posterior aspect of the hilum. As one dissects upward and around the apex of the hilum towards the front, one must be wary of the phrenic nerve, which should be positively identified at the beginning of every case.
4 - Dissection of the bronchus (3:22)
Dissection proceeds distally along the upper border and posterior aspect of the bronchus, until the bifurcation between B1 and B2 is identified. Preoperative imaging is an invaluable guide, because individual anatomy may vary. As the bronchus is encircled, one must be wary of the artery that courses directly behind.
5 - Division of the bronchus (4:40)
A suture passed around the bronchus is useful for retraction, and a small-calibre red rubber catheter helps guide the anvil of the stapler safely across the bronchus. As the bronchus is divided, traction must be minimized to avoid undue tension on the artery when the bronchus is released.
6 - Dissection of the artery (5:37)
Upward traction on the parenchyma clearly exposes the S1 segmental artery. However, traction must be applied sparsely to avoid vascular injury. A circumflex artery to S2 is frequently present; it is easily identified from this vantage point and should be preserved.
It is important to note that the posterior approach does not involve visualizing the truncus anterior. Rather, it relies on anatomical relationships as reviewed on preoperative imaging and intraoperative anatomical landmarks to correctly identify A1. In the author’s opinion, a posterior approach is therefore appropriate in cases where such a relationship can be established on imaging. This approach is consistent with the author’s philosophy of targeted dissection and minimal disruption of tissue planes.
7 - Division of the intersegmental plane (6:54)
Once B1 and A1 are divided, retracting the parenchyma upward can expose the apical segmental vein. In the author’s opinion, individual dissection is not absolutely necessary, and the vein here is divided en bloc with the intersegmental plane.
The intersegmental plane is divided with an endoscopic stapler from the back to the front. The apical vein is included in the parenchymal staple line. In this case, the plane is highlighted using differential insufflation, although indocyanine green may be ideal for this purpose [5]. One should be careful to incorporate the bronchovascular stumps in the specimen. Because the stumps are not in direct view of the scope, this step may take some patience and camera work. A suture through the bronchial stump may facilitate retraction and exposure during this portion of the operation.
Outcome
The chest tube was removed on postoperative day 2, and the patient was discharged on postoperative day 3. There were no adverse events. The final pathological analysis revealed a 9-mm adenocarcinoma with 3.5-cm parenchymal margins and negative lymph nodes.
Discussion
Thoracoscopic segmentectomy requires familiarity with segmental anatomy and operative approaches to the different segments.
The optimal minimally invasive approach (VATS, uniportal VATS, completely thoracoscopic, robotic) remains the subject of debate. This author favours a completely thoracoscopic approach, which is straightforward and versatile.
The S1 (apical) segment of the right upper lobe has some unique features that may make a conventional anterior approach challenging. The presence of multiple vascular structures bearing complex anatomical relationships and the requirement for preserving these structures may make identification of and access to the apical artery, and subsequent access to the segmental bronchus, challenging [1].
In contradistinction, the author has found that a posterior approach may obviate some of these challenges by allowing direct access to the segmental bronchus. Once the bronchus is divided, the apical artery is in direct alignment with the operating instruments, without encroachment from other troublesome vascular structures. This outcome, however, remains contingent on individual anatomy, which may vary. Once again, it is important to note that the posterior approach does not involve visualizing the truncus anterior. Rather, it relies on the anatomical relationships as reviewed on preoperative images and intraoperative anatomical landmarks for correct arterial identification [6]. In the author’s opinion, a posterior approach would seem most appropriate in cases where such a relationship can be established on preoperative images (ideally 3D reconstructions), which remain essential for operative planning. This approach is consistent with the author’s philosophy of targeted dissection and minimal disruption of tissue planes.
The author does not dissect or divide the V1 vein individually, even when using an anterior approach [3]. In the author’s opinion, this is not necessary. As other examples of segmental vessels being safely included in parenchymal staple lines, the author suggests the circumflex artery in S2 resections, A2 in right upper lobectomies and V2 in posterior segmentectomies [7].
In summary, thoracoscopic segmentectomy may allow the optimization of perioperative outcomes. Familiarity with anatomy and the pros and cons of different approaches expand the surgeon’s armamentarium and allow the effective individualization of treatment.
1. Yang CF, D'Amico TA. Open, thoracoscopic and robotic segmentectomy for lung cancer. Ann Cardiothorac Surg 2014;3:142–52.
PubMed Abstract | NA
2. Schuchert MJ, Pettiford BL, Pennathur A, Abbas G, Awais O, Close J, et al. Anatomic segmentectomy for stage I non-small-cell lung cancer: comparison of video-assisted thoracic surgery versus open approach. J Thorac Cardiovasc Surg 2009;138:1318–25.
PubMed Abstract | Publisher Full Text
3. Rakovich G, Hubert J. Thoracoscopic apical segmentectomy, right upper lobe. Multimed Man Cardiothorac Surg 2019;2019.
PubMed Abstract | Publisher Full Text
4. Nomori H, Okada M. Illustrated Anatomical Segmentectomy for Lung Cancer. 1st ed. Springer, 2011.
NA | Publisher Full Text
5. Tarumi S, Misaki N, Kasai Y, Chang SS, Go T, Yokomise H. Clinical trial of video-assisted thoracoscopic segmentectomy using infrared thoracoscopy with indocyanine green. Eur J Cardiothorac Surg 2014;46:112–5.
PubMed Abstract | Publisher Full Text
6. Rakovich, G. Commentary: Right Upper Lobe Segmentectomies: A Game of Details. Oper Tech Thorac Cardiovasc Surg 2024;29:129–31.
NA | Publisher Full Text
7. Rakovich, G. Thoracoscopic S2 segmentectomy by a posterior approach for a central metastasis: a case report. Journal of Visualized Surgery, 2022;8.
NA | Publisher Full Text
Original artwork: Kathy Hernandez, Technicienne en arts graphiques, DERI, Service des techniques audiovisuelles, CIUSSS de l'Est-de-l'Île-de-Montréal.
Video editing: Christopher Desalliers, Technicien informatique, DERI, Service des techniques audiovisuelles, CIUSSS de l'Est-de-l'Île-de-Montréal.
Author
George Rakovich
Affiliation
Hôpital Maisonneuve-Rosemont, University of Montreal School of Medicine, Montreal, Quebec, Canada
Corresponding Author
Hôpital Maisonneuve-Rosemont
University of Montreal School of Medicine
Montreal
Quebec
Canada
Email: george.rakovich@umontreal.ca
© The Author 2024. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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