Robotic left ventral segmentectomy

Abstract

Central MessageSegmentectomy is an increasing used surgical approach in thoracic surgery. We describe and discuss technical steps using a 4-arm completely portal approach with a Da Vinci Xi system. Segmentectomy is an increasing used surgical approach in thoracic surgery. We describe and discuss technical steps using a 4-arm completely portal approach with a Da Vinci Xi system. We present a video of an 84-year-old woman, a former smoker (30 packs per year) diagnosed with suspected stage I (cT2 N0 M0) primary lung cancer in the left segment 3 (S3). The patient's medical history included moderate chronic obstructive pulmonary disease, obstructive sleep apnea syndrome, and cerebral aneurysm. Considering the high surgical risk (eg, age, diffusing capacity for carbon monoxide, and pathological underlying lungs) she was scheduled for a robotic S3 segmentectomy with radical node harvest.1Durand M. Four arm robotic double right segmentectomies S3 & S7–10 with fluorescence lung mapping.J Vis Surg. 2020; 6: 40Google Scholar We describe and discuss technical steps using a 4-arm completely portal approach with a Da Vinci Xi system (Intuitive Surgical, Sunnyvale, Calif) using near-infrared fluorescence with indocyanine green (ICG) for intersegmental plan definition. As for any lung resection, patient's position and port setting were done as previously described2Durand M. Four-arm robotic sleeve right upper lobectomy.Ann Cardiothorac Surg. 2019; 8: 286-287Google Scholar,3Novellis P. Bottoni E. Alloisio M. Velez-Cubian F.O. Toloza E.M. Veronesi G. Robotic-assisted pulmonary segmentectomies.J Vis Surg. 2018; 4: 166Google Scholar (Figure 1). Firstly, inferior exposure was achieved to perform the triangular ligament dissection, visualization of the inferior pulmonary vein and zone 8 and 9 node harvest. Secondly, zone 7, 10, and 4L node harvest was completed through posterior exposure and caution was exercised to preserve the vagus nerve. Thirdly, through fissure exposure, spotting the artery and zone 11, 12 node harvest were performed. A recurrent lingula artery had to be ligated to avoid its tear during later fissure stapling. Subsequently, anterior exposure was conducted. This allowed the completion of node harvest (zone 5, 12, and 13) and S3 vein, artery, and bronchus control. In a sequence, vein 3 and artery 3 were controlled and manually ligated (silk 0 size, 10 cm length). Bronchus 3 was mechanically stapled through the port access (8.5 mm Echelon Powered35-mm white load, Ethicon, Somerville, NJ). S3 lung mapping was completed 20 seconds after ICG intravenous injection (20 mg; ie, 8 mL followed by 10 mL saline flush). Both intersegmental plans stapling required 5 60-mm green loads from the right-hand port (12 mm Echelon Powered Flex). Airtight patency was checked under water, specimen removed in a bag through the port access hole, and chest closed with a 24F chest tube through the anterior port. Postoperative course was uneventful. Chest tube was removed on postoperative day 1 and the patient was discharged on day 3. Final pathology confirmed pT2 N0 R0 squamous cell carcinoma. Institutional review board approval was not required for the publication of the study data, and the patient's informed consent was received. Segmentectomy is a increasingly used surgical approach in thoracic surgery because it combines en bloc resection with radical node harvest and lung sparing strategy.4Cao C. Chandrakumar D. Gupta S. Yan T.D. Tian D.H. Could less be more? A systematic review and meta-analysis of sublobar resections versus lobectomy for non–small cell lung cancer according to patient selection.Lung Cancer. 2015; 89: 121-132Google Scholar It is admitted for a <2 cm lesion but will also be considered for larger tumors in comorbid patients as a best-care strategy versus radiotherapy.4Cao C. Chandrakumar D. Gupta S. Yan T.D. Tian D.H. Could less be more? A systematic review and meta-analysis of sublobar resections versus lobectomy for non–small cell l