Sublobar resection of small (<2 cm) well-differentiated lung cancers is appropriate, especially in elderly patients, and it preserves useful lung parenchyma, thereby maximizing postoperative lung function [1]. Though minimally invasive anatomic segmental lung resection by video-assisted thoracoscopic surgery is relatively straightforward for resection of the lingular (S4+5), trisegment (S1+2+3), superior (S6), and basilar (S7+8+10) segments, resection of individual segments such as the anterior segment (S3) is rarely performed due to the complexity of the procedure. The dexterity inherent in the surgical robot, however, facilitates delicate dissection of the individual segmental vascular and bronchial structures and allows for the performance of “atypical” segmental resections [2]. Here, the author presents a completely portal robotic segmentectomy of the anterior (S3) segment of the left upper lobe in an 80-year-old man with a small peripheral well-differentiated adenocarcinoma.
Hardware:da Vinci Xi® surgical robot 0 degree scopenear-infrared imagingEndoWrist® 30 mm and 45 mm robotic staplerfenestrated bipolar (left port, non-dominant hand)curved bipolar dissector (dominant hand)robotic scissors (right port, dominant hand)tip-up fenestrated grasper (posterior port, retraction)flexible 14 Fr tracheal suction tubing attached to 5 mm endoscopic suction device for intermittent suctioning, if neededKey points in the conduct of the procedure include:Complete portal technique is used with four robotic ports, carbon dioxide insufflation, and no bedside assistant except for specimen extraction.Initial dissection of mediastinal N1 and N2 lymph nodes is performed, with frozen section pathologic analysis to confirm the absence of metastases.Dissection of the hilar lymph nodes (10L, 11L, and 12L) facilitates the dissection of the vascular and bronchial structures, and it enables correct identification of the segmental anatomy and the division of the appropriate structures.Intraoperatively, frequent correlation of the visualized anatomy with the preoperative computed tomography imaging is important to ensure that the correct structures are dissected and divided.Division of the small arteries to the involved segment is often best accomplished by dividing between ligatures. The bronchus may be either divided by stapler or transected with scissors and sutured closed. A posterior-to-anterior trajectory for...
Hardware:da Vinci Xi® surgical robot 0 degree scopenear-infrared imagingEndoWrist® 30 mm and 45 mm robotic staplerfenestrated bipolar (left port, non-dominant hand)curved bipolar dissector (dominant hand)robotic scissors (right port, dominant hand)tip-up fenestrated grasper (posterior port, retraction)flexible 14 Fr tracheal suction tubing attached to 5 mm endoscopic suction device for intermittent suctioning, if neededKey points in the conduct of the procedure include:Complete portal technique is used with four robotic ports, carbon dioxide insufflation, and no bedside assistant except for specimen extraction.Initial dissection of mediastinal N1 and N2 lymph nodes is performed, with frozen section pathologic analysis to confirm the absence of metastases.Dissection of the hilar lymph nodes (10L, 11L, and 12L) facilitates the dissection of the vascular and bronchial structures, and it enables correct identification of the segmental anatomy and the division of the appropriate structures.Intraoperatively, frequent correlation of the visualized anatomy with the preoperative computed tomography imaging is important to ensure that the correct structures are dissected and divided.Division of the small arteries to the involved segment is often best accomplished by dividing between ligatures. The bronchus may be either divided by stapler or transected with scissors and sutured closed. A posterior-to-anterior trajectory for...