Robotic segmentectomy using a lung base-flip approach

Abstract

Central MessageWe developed a novel lung base-flip approach for robotic basilar segmentectomies using 3D-computed tomography images to overcome the difficulty in accessing the intersegmental planes. The use of robotic lung segmentectomies for early-stage lung cancer has been increasing.1Kumar A. Deng J.Z. Raman V. Okusanya O.T. Baiu I. Berry M.F. et al.A national analysis of minimally invasive vs open segmentectomy for stage IA non-small-cell lung cancer.Semin Thorac Cardiovasc Surg. 2021; 33: 535-544Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Single segmentectomies of the lung base (single or combined basilar segments [or subsegments] such as S9, S10, S8-9, S9-10, S9b, etc) are often more technically challenging than other lung segmentectomies because of anatomic complexity and difficulty in identifying the intersegmental planes.2Eguchi T. Sato T. Shimizu K. Technical advances in segmentectomy for lung cancer: a minimally invasive strategy for deep, small, and impalpable tumors.Cancers (Basel). 2021; 13: 3137Crossref PubMed Scopus (11) Google Scholar Herein, we demonstrate a newly developed lung base-flip approach with 3D computed tomography (CT) image-based navigation for safe and secure robotic basilar segmentectomies. This single-center study was approved by the institutional review board of the Shinshu University Hospital (Project ID 5541). The patient provided written informed consent for the video presentation. For all patients who undergo lung segmentectomies at Shinshu University Hospital, thoracic surgeons routinely use a novel 3D-CT processing software (Revoras, Ziosoft) for segmentectomy planning.2Eguchi T. Sato T. Shimizu K. Technical advances in segmentectomy for lung cancer: a minimally invasive strategy for deep, small, and impalpable tumors.Cancers (Basel). 2021; 13: 3137Crossref PubMed Scopus (11) Google Scholar Segmentectomy planning provides surgery-specific images, including the vascular/bronchial stumps and the intersegmental planes with corresponding intersegmental veins. These images are easily modified on the basis of the margin distance and target vessels/bronchi to be divided. The images can be generated and modified in multiple terminal computers in our hospital including computers in the operating rooms, outpatient clinic, surgical ward, and meeting rooms. The planning process can be performed by thoracic surgeons or trainees without help from radiologists or radiation technicians. In addition, the planning process is “semiautomated,” meaning that the 3D-CT software can create 3D-CT images automatically except for simple intervening actions by surgeons such as selecting a series of CT scans being used for 3D reconstruction, pointing out a tumor to be resected, and selecting a segmental branch to be divided during segmentectomy. During the lung base-flip approach, 3D-CT images of the “flipped view” (180° rotation around the horizontal axis) are used for intraoperative navigation (Figure 1). At Shinshu University Hospital, we use the daVinci Si system for robotic lung resection. For segmentectomies at the middle and lower lobes on the right side and at the lingular segment and lower lobe on the left side, we use the sixth to eighth intercostal spaces. Port placement in the present case is shown in Figure 2. We use Maryland bipolar forceps in the right arm (first arm), fenestrated bipolar forceps in the left arm (second arm), and Cadiere forceps in the assist arm (third arm). Using the lowest assistant port, a bedside surgeon manipulates a surgical stapler and energy device. To obtain better access to the basilar segmental anatomy, particularly the intersegmental veins, we developed a lung base-flip approach in which the lung base is retracted cephalad or toward the “ceiling” (chest wall) using the third arm in the Si system after dividing the lung ligament (Figure 1, Video 1). In general, we subsequently complete a basilar segmentectomy using the following steps: (1) dissection