Anatomic pulmonary segmentectomy and mediastinal nodal dissection has been advocated in patients with smaller tumors or patients with limited pulmonary reserve. The overall 5-year survival and the lung cancer-specific 5-year survival following anatomic segmentectomy have been shown to be equivalent to that of lobectomy. Robotic surgical systems have the advantage of magnified, high-definition three-dimensional visualization and greater instrument maneuverability in a minimally invasive platform. These robotic systems can facilitate the dissection of the bronchovascular structures and replicate the technique of segmentectomy by thoracotomy. Greater experience with the robotic platform has resulted in a reproducible anatomic segmentectomy technique. This is a companion paper to The Technique of Robotic Anatomic Segmentectomy I: Right Sided Segments. This paper outlines the technique of anatomic pulmonary segmentectomy for the left lung: Left Upper Lobe (LUL) Anterior Segment (S3), LUL Apicoposterior Segment (S1 + S2), LUL Lingulectomy (S4, S5), Left Lower Lobe (LLL) Superior Segmentectomy (S6), and LLL Basal Segmentectomy (S7-S10).
Historically, anatomic pulmonary segmentectomy was used for the surgical treatment of lung abscesses and other lung infections. Chevalier Jackson and John Hubert first proposed a system of nomenclature for the bronchopulmonary segments[
In the latter half of the twentieth century, the advent of antibiotic therapy led to a decrease in segmentectomies performed for infectious lung processes and an increase in their use for primary malignancies of the lung. In the 1960’s and 1970’s, Rasmussen and Clagett published reports of segmentectomy for lung cancer with low mortality[
Recently, anatomic pulmonary segmentectomy has been shown to be a viable oncologic procedure for early lung cancer, including patients who are elderly or have limited pulmonary reserve[
This is a companion paper to The Technique of Robotic Anatomic Segmentectomy I: Right Sided Segments. This paper outlines the technique of anatomic pulmonary segmentectomy for the left lung: Left Upper Lobe (LUL) Anterior Segment (S3), LUL Apicoposterior Segment (S1 + S2), LUL Lingulectomy (S4, S5), Left Lower Lobe (LLL) Superior Segmentectomy (S6), and LLL Basal Segmentectomy (S7-S10).
The bronchopulmonary segments of the left lower lobe are similar to the right lower lobe. Although there are only two lobes in the left lung, there is some symmetry among the bronchopulmonary segments bilaterally. However, some segments of the left lung merge, resulting in fewer bronchopulmonary segments on the left than there are on the right lung
Bronchopulmonary segments of the left lung
The apicoposterior segment (S1 + S2) of the left upper lobe represents the fusion of the apical and posterior segments. Although the Lingula is divided into two bronchopulmonary segments, the superior (S4) and inferior (S5) Lingular segments, from a practical standpoint, S4 + S5 segmentectomy or lingulectomy is typically performed. In the left lower lobe, there are four segments unlike the right lower lobe which has five segments. The anteromedial basal segment (S7 + S8) represents the fusion of the anterior basal and medial basal segments. The other segments (superior S6, posterior basal S10, and lateral basal S9) maintain the same relative positions as observed in the right lung.
From a surgical standpoint, sublobar resection is usually performed for LUL anterior segment (S3), LUL apicoposterior segment (S1 + S2), LUL lingulectomy (S4, S5), LLL superior segmentectomy (S6), and LLL basal segmentectomy (S7-S10). It is possible to perform individual anatomic segmentectomy of the basal segments S7 + S8, S9, or S10. We have no experience with robotic segmentectomy of these individual basal segments and therefore have not included them in this report.
The operating room table is reversed such that the pedestal does not interfere with the docking of the robot over the head of the patient.
A double lumen endotracheal tube is placed, and the patient is positioned in a full lateral decubitus position. The left arm is placed over pillows and positioned high enough such that access to the 4th intercostal space in the anterior axillary line is readily attained. The table is flexed in order to move the hip down and to open the intercostal spaces. The lung is deflated and placed on suction. The position of the double lumen tube is rechecked after the patient is prepped and draped. We prefer the use of a double lumen tube as opposed to a bronchial blocker. During robotic dissection, manipulation of the hilum and the bronchus can result in dislodgement of the blocker and loss of lung isolation. Every effort should be made to ensure lung isolation for the entire procedure. The position of the robot over the head of the patient makes manipulation of the endotracheal tube difficult. Untimely inflation of the lung can result in loss of exposure and its associated complications.
Proper port positioning is crucial and a fundamental prerequisite to the conduct of the procedure.
Port placement for robotic segmentectomy in the left chest (please see description in the text)
Port placement for robotic segmentectomy in the left chest. Dotted line: Scapular line; Red: Ports; Yellow: Si arm numbering; Green: Xi arm numbering; AP: assistant port
For the da Vinci Si robot, the bed is angled posteriorly away from the anesthesia machine and the robot is brought in over the head of the patient. For the Xi system, the robot is brought in from the back and perpendicular to the patient and the boom is rotated to the proper position.
One of the advantages of the Xi robot is that the surgeon can control the stapling device. We prefer a 30 mm stapler with a white load for the vascular structures, and a blue or green load for the bronchus and the lung tissue as judged by the size and thickness of the structure.
Instruments: 0° and/or 30° down viewing endoscope, 5 mm Thoracic Grasper, Cadiere Forceps, and Curved Bipolar Dissector.
For all segmentectomies, begin by dividing the inferior pulmonary ligament and remove station #9, and station #8 [
Left sided Segmentectomy: begin by dividing the IPL. IPL: inferior pulmonary ligament
Left sided Segmentectomy: dissection and removal of station #9 and station #8 lymph nodes. IPL: inferior pulmonary ligament
Left sided Segmentectomy: the station #7 nodal bundle is accessed between the IPV and the LB. IPV: inferior pulmonary vein; LB: left mainstem bronchus
Left sided Segmentectomy: station #5L nodes are removed from the aorto-pulmonary window. AO: aorta; PA: pulmonary artery; LN: lymph node
The left main pulmonary artery is identified above the left main bronchus. The space between the pulmonary artery and the bronchus is opened and station #10L nodal bundle is identified overlying the superior border of the bronchus
Left sided Segmentectomy: the space between the PA and the LB is opened and the station #10L nodal bundle is identified overlying the superior border of the bronchus. PA: pulmonary artery; LB: left mainstem bronchus
Left sided Segmentectomy: clear the nodal bundle which encases the apicoposterior trunk (TRPA) of the left PA. TRPA: truncus branch of pulmonary artery; PA: pulmonary artery
Next the upper and lower lobe are retracted in opposite directions and the fissure is identified. Dissection of nodal bundle in station #11 allows for the identification of the pulmonary artery in the fissure
Left sided Segmentectomy: dissection of nodal bundle in station #11 allows for the identification of the PA in the fissure. PA: pulmonary artery
Left sided Segmentectomy: pass a vessel loop under the pulmonary parenchyma in the posterior aspect of the fissure
Following the dissection of mediastinal nodes, the lung is retracted posteriorly and the anterior hilum is approached. The nodes in station #5 are removed and the proximal left pulmonary artery is exposed just posterior to the left phrenic nerve
LS3 Segmentectomy: the nodes in station #5 (LN) are removed and the proximal left PA is exposed just posterior to the left PN. PA: pulmonary artery; PN: phrenic nerve; LN: lymph node
LS3 Segmentectomy: the nodes between the SPV and the PA are dissected and removed. PA: pulmonary artery; SPV: superior pulmonary vein
LS3 Segmentectomy: the anatomic relationship between S3 segmental veins (V3), S3 segmental artery (A3), and S3 segmental bronchus (B3)
V3 is encircled, elevated with a vessel loop, and divided with a stapler with a white cartridge. Care is taken to preserve the V1 branch to the S1 segment of the upper lobe. The B3 bronchus is encircled, elevated off the pulmonary artery, and divided with a stapler using a purple cartridge. Division of the B3 facilitates division of the A3 PA branch(es). The A3 PA branch is encircled with a vessel loop and divided with a stapling device. The A3 PA branches can be divided before dividing B3; however, this usually requires suture ligation and division of the A3. Next the intersegmental fissures between S1 + S2 and S3 and between S4 + S5 and S3 are delineated either using indocyanine green if using the Xi robot or inflation technique and divided using a stapler carrying a green cartridge
LS3 Segmentectomy: the intersegmental fissure between S3, and S4, 5 is delineated either by using Indocyanine Green if using the Xi robot or by inflation if using the Si robot
The approach to these left sided segments is similar. Although individual posterior (S2) segmentectomy is possible, instead of an individual apical segmentectomy, many times an apicoposterior (S1 + S2) segmentectomy is performed on the left side.
As with all segmentectomies, the procedure begins with mediastinal nodal dissection as has been described previously.
For a posterior S2 or apicoposterior S1 + S2 segmentectomy, the pulmonary artery branches to the respective segments as identified in
LS1, S2 Segmentectomy: the pulmonary artery branch to the posterior segment (A2) are identified. PA: pulmonary artery
LS1, S2 Segmentectomy: the segmental bronchus (B) is isolated and divided
LS1, S2 Segmentectomy: the intersegmental fissure between S1 + S2 and S4 + S5 segments is divided in a stepwise progressive manner using a stapling device with a Green load
Lingulectomy can be performed with either a vein first or artery first technique. The advantage of the artery first technique is that the fissure is approached first, station #11 nodes are removed first, and if they are positive, a left upper lobectomy is performed.
After a complete mediastinal nodal dissection as with the other left sided segmentectomies, the oblique fissure is opened and the subadventitial plane above the descending pulmonary artery is entered
Lingulectomy (LS4, LS5): the oblique fissure is opened and the subadventitial plane above the descending pulmonary artery is entered. MPA: main pulmonary artery; LPA: lingular pulmonary artery
Next, the lung is retracted posteriorly, and the anterior hilum is approached. The space between the superior and inferior pulmonary veins is developed and the nodes are removed. The superior pulmonary vein is dissected away from the underlying pulmonary artery, encircled with a vessel loop, and elevated. After the entire superior pulmonary vein is dissected, the Lingular vein(s) are identified, encircled, elevated with a vessel loop, and divided with a vascular stapler. Then, the anterior aspect of the oblique fissure is divided by passing a stapler with a blue cartridge from an anterior to posterior direction, heading toward the space between the Lingular artery and the inferior pulmonary artery. This enables easy access to the Lingular pulmonary artery which is encircled, elevated with a vessel loop, and divided with a stapler carrying a white cartridge
Lingulectomy (LS4, LS5): LPA is encircled and elevated with a vessel loop and divided with a stapler carrying a white cartridge. LPA: lingular pulmonary artery
Lingulectomy (LS4, LS5): the stump of the Lingular bronchus is seen (B4, B5). PA: main pulmonary artery
Lingulectomy (LS4, LS5): the intersegmental fissure between S2 and the Lingula is identified using ICG dye. ICG: indocyanine green
Port placement and instruments are similar to the left upper lobe segmentectomy procedures.
Following the complete mediastinal dissection which has been outlined previously, the pulmonary artery is identified in the oblique fissure. The subadventitial plane overlying the pulmonary artery is entered, and dissection is carried posteriorly under the pulmonary parenchyma in the posterior aspect of the fissure toward the main pulmonary artery
LS6 Segmentectomy: the subadventitial plane is entered, and dissection is carried posteriorly under the pulmonary parenchyma in the posterior aspect of the fissure toward the main pulmonary artery. LA: lingular artery; PA: descending main pulmonary artery
LS6 Segmentectomy: a vessel loop is passed underneath SSPA and used to encircle and elevate the vessel. SSPA: superior segmental pulmonary artery
The lung is elevated and retracted medially. The Cadiere forceps is passed from a medial to lateral direction under the inferior pulmonary vein and a vessel loop is used to encircle and elevate the vein
LS7-LS10 Segmentectomy: the IPV is isolated. LMB: left mainstem bronchus; IPV: inferior pulmonary vein
LS7-LS10 Segmentectomy: isolation of the left lower lobe basal vein (V7-10) from superior segmental vein (V6). AO: aorta
LS6 Segmentectomy: B6 bronchus is identified, encircled, and divided. LLLB: left lower lobe bronchus; B7-10: bronchus to basal segment of left lower lobe
The approach to this segmentectomy is similar to superior segmentectomy (S6). Following the complete mediastinal nodal dissection, the inferior pulmonary vein is encircled with a vessel loop and elevated. Then the superior segmental vein is identified, thereby allowing for identification of the basal branch of the inferior pulmonary vein. The basal vein (V7-10) is then divided with a stapling device with a white cartridge. Next, the pulmonary artery is isolated in the fissure as has been described previously. The left lower lobe pulmonary artery is identified
LS7-LS10 Segmentectomy: the basal branch of the left pulmonary (A7-10) is encircled and divided. A6: pulmonary to superior segment of left lower lobe (S6)
LS7-LS10 Segmentectomy: the bronchus to the basal segment (B7-10) is encircled and divided. A7-10: stump pf the divided pulmonary artery branch to basal segment; A6: pulmonary artery branch to superior segment of left lower lobe (S6); S6: superior segment of left lower lobe
LS7-LS10 Segmentectomy: the intersegmental fissure is identified and divided using a stapler with a green cartridge
Anatomic pulmonary segmentectomy in patients with early stage lung cancer is an oncologically efficacious procedure. The surgical robot allows for precise dissection of the segmental bronchopulmonary structures while minimizing trauma to surrounding tissues, and it allows for thorough and complete dissection of the mediastinal nodes. Robotic segmentectomy should be considered when planning a lung sparing operation in patients with small tumors, in elderly patients or patients with borderline lung function.
Contributed equally to the performance of the surgeries, collection of data and writing the manuscript: Gharagozloo F, Meyer M
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Both authors declared that there are no conflicts of interest.
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© The Author(s) 2020.