Uniportal VATS Anatomic Right Basal Segmentectomy (S7-10)

Anatomic sublobar resections have been used primarily for benign pulmonary lesions, lung metastases, and early stage lung cancer. There are many recent studies that support the oncological results of anatomic sublobar resections compared to lobectomy in terms of recurrence and overall survival [1-8]. In addition, the procedure’s performance through minimally invasive procedures is possible by experienced teams [9, 10]. The authors present a sublobar resection performed for a 50-year-old woman who was diagnosed with a 2.5 cm diffuse ground glass opacity adenocarcinoma in the right basal segments (Figure 1) that was identified during chronic asthma follow-up.<br>Preoperative studies ruled out nodal or distant involvement. A lung function test presented significant limitation, with an estimated postoperative DLCO near 30% after right lower lobectomy. Given the tumor characteristics, the absence of lymph node involvement, and the functional limitation, the authors decided to perform an anatomic segmentectomy of the basal segments (S7 + S8 + S9 + S10) through a uniportal video-assisted thoracoscopic (VATS) approach.<br><br>The authors began the procedure by making a 3.5 cm incision in the sixth intercostal space. A lymphadenectomy was performed in stations 12, 11, 10, 9, 8, 7, and 4R for intraoperative analysis. After confirmation of no nodal involvement, the major fissure was dissected, identifying the pulmonary artery and its branches to the basal segments and for segment 6 (S6). The common arterial branch for the basal segments was dissected and then divided using an endostapler. The inferior pulmonary vein was dissected, progressing distally until the vein of S6 was identified and the authors clearly found the division with the basal venous trunk. Then, the authors divided the basal venous trunk using an endostapler. The posterior fissure was completed with a stapler, identifying the venous branch for S6 from anterior and posterior in order to ensure its preservation.<br>The inferior lobar bronchus was dissected to the distal sublobar divisions, and the bronchus for the basal segments (B7-10) was dissected and divided with an endostapler after adequate ventilation of S6 was assured. Before this step, the authors also performed bronchoscopic evaluation of distal bronchial divisions. No intraoperative or postoperative complications were recorded. The chest tube was removed, and the patient was discharged home on postoperative day two. The final diagnosis was lepidic adenocarcinoma without nodal involvement (T2bN0M0).<br><strong>Conclusion</strong><br>The performance of anatomic segmentectomies through minimally invasive approaches as uniportal VATS is safe and feasible.<br><strong>References</strong>Traibi A, Grigoroiu M, Boulitrop C, et al. Predictive factors for complications in anatomical pulmonary segmentectomies. <em>Interact Cardiovasc Thorac Surg</em>. 2013;17(5):838-844.Martin-Ucar AE, Nakas A, Pilling JE, West KJ, Waller DA. A case-matched study of anatomical segmentectomy versus lobectomy for stage I lung cancer in high-risk patients. <em>Eur J Cardiothorac Surg</em>. 2005;27(4):675-679.Date H, Andou A, Shimizu N. The value of limited resection for “clinical” stage I peripheral non-small cell lung cancer in poor-risk patients: comparison of limited resection and lobectomy by a computer-assisted matched study. <em>Tumori</em>. 1994;80(6):422-426.Okada M, Yoshikawa K, Hatta T, Tsubota N. Is segmentectomy with lymph node assessment an alternative to lobectomy for non-small cell lung cancer of 2 cm or smaller? <em>Ann Thorac Surg</em>. 2001;71(3):956-961.Watanabe T, Okada A, Imakiire T, Koike T, Hirono T. Intentional limited resection for small peripheral lung cancer based on intraoperative pathologic exploration. <em>Jpn J Thorac Cardiovasc Surg</em>. 2005;53(1):29-35.Campione A, Ligabue T, Luzzi L, et al. Comparison between segmentectomy and larger resection of stage IA non-small cell lung carcinoma. <em>J Cardiovasc Surg (Torino)</em>. 2004;45(1):67-70.Keenan RJ, Landreneau RJ, Maley RH, et al. Segmental resection spares pulmonary function in patients with stage I lung cancer. <em>Ann Thorac Surg</em>. 2004;78(1):228-233.Dziedzic R, Zurek W, Marjanski T, et al. Stage I non-small-cell lung cancer: long-term results of lobectomy versus sublobar resection from the Polish National Lung Cancer Registry. <em>Eur J Cardiothorac Surg</em>. 2017;52(2):363-369.Galvez C, Lirio F, Sesma J, Baschwitz B, Bolufer S. Single-incision video-assisted thoracoscopic surgery left-lower lobe anterior segmentectomy (S8). <em>J Vis Surg</em>. 2017;3:114.Gonzalez Rivas, Lirio F, Sesma J. Uniportal anatomic combined unusual segmentectomies. <em>J Vis Surg</em>. 2017;3:91.解剖性肺亚段切除术（anatomic sublobar resection）最初主要应用于良性肺部病变、肺转移瘤及早期肺癌。近年来多项研究[1-8]证实，相较于肺叶切除术，解剖性肺亚段切除术在肿瘤复发率与总生存期层面的肿瘤学疗效相当。此外，经验丰富的手术团队可通过微创手术路径完成该术式[9,10]。本文报告1例接受亚段切除术的50岁女性患者：该患者因慢性哮喘随访期间检出右基底段（图1）2.5cm弥漫性磨玻璃影腺癌而收治手术。 术前检查已排除淋巴结及远处转移。肺功能检查提示存在显著通气受限，预计行右下肺叶切除术后的肺一氧化碳弥散量（DLCO）仅约为30%。结合肿瘤特征、无淋巴结受累及肺功能受限情况，术者决定采用单孔胸腔镜手术（uniportal video-assisted thoracoscopic surgery, VATS）术式，为患者实施基底段（S7+S8+S9+S10）解剖性肺段切除术。 术者首先于第6肋间做3.5cm切口。术中对第12、11、10、9、8、7及4R组淋巴结进行清扫并送检术中冰冻病理。确认无淋巴结转移后，术者解剖叶间裂，暴露肺动脉及其至基底段与第6段（S6）的分支。解剖并使用内镜吻合器（endostapler）离断基底段总动脉干。随后解剖下肺静脉，向远端分离直至识别出S6静脉，并明确其与基底静脉干的汇合处，再以内镜吻合器离断基底静脉干。使用吻合器完成后叶裂分离，同时辨识S6的前、后侧静脉分支以确保其得以保留。 术者随后解剖下叶支气管至远端亚段分支，在确认S6通气良好后，解剖并离断基底段支气管（B7-10），使用内镜吻合器完成离断。该操作前，术者还通过支气管镜对远端支气管分支进行了评估。术中及术后均未出现并发症。术后第2日拔除胸腔引流管，患者顺利出院。最终病理诊断为鳞屑样腺癌（lepidic adenocarcinoma），无淋巴结受累（T2bN0M0）。 **结论** 通过单孔胸腔镜手术等微创手术路径实施解剖性肺段切除术，安全性与可行性俱佳。 **参考文献** 1. 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