Uniportal S-10 segmentectomy by transfissural intersegmental tunneling

Pulmonary segmentectomy is a parenchyma-sparing technique that is currently proposed for diagnosis of centrally located nodules or definitive treatment of metastases or early stage non-small cell lung cancer. However, pulmonary segmentectomy is a technically more challenging procedure than lobectomy that requires individual dissection of segmental broncho-vascular structures and identification of the intersegmental plane to prevent incomplete resection and post-operative complications. Segmentectomy is now performed through the use of video-assisted thoracic surgery (VATS). Segmentectomies can be classified into simple and complex based on the difficulty to separate several intersegmental planes. Segmentectomies of the lower lobes are technically feasible by VATS but remain challenging, especially since standardization reports are still lacking. However, this procedure is interesting because the greatest part of pulmonary perfusion and function is located in the lower lobe. Although the posterior basal (S-10) is recognized as one the most challenging anatomical segmentectomy, it could be safely performed by uniportal VATS. Our approach consists in opening first the intersegmental between S-6 and S-10 by using an intersegmental tunneling technique. This technique permits the accurate identification of the bronchovascular structures of the segment S-10. Intra-operative assistance with indocyanine green (ICG) near-infrared angiography may help surgeons identify the intersegmental plane during these complex segmentectomies.