Robotic Right Apicoposterior S1 and S2 Anatomic Segmentectomy

Much is being discussed about how far surgeons need to go with lung resection among ground glass opacities (GGO) and part-solid lesions. However, one thing that is becoming well accepted is the improved quality of anatomical lung resections with new technological perspectives. This video presents a case of a forty-five-year-old woman, nonsmoker, with no medical records. She underwent a CT scan because of COVID-19 suspicions and ground-glass opacity on the right upper lobe measuring 15 mm was found, without any other relevant finding. It was decided to a follow-up in six months, which showed an increase in size to 20 mm with a small excavated area and consolidation tumor ratio (CTR) < 0.5. Therefore, regarding the high probability of primary lung adenocarcinoma, and after discussing the possibilities with the patient, the medical team opted to perform an upfront surgery. PET scan and brain MRI showed no distant metastasis and no lymph node uptake. The Surgery Given the localization of the lesion on the transition to S1 and S2, to guarantee oncology margin the surgeons performed a robotic-assisted thoracoscopic (RATS) right S1 + S2 apicoposterior segmentectomy using a Da Vinci Xi® surgical platform with four ports of 8 mm for the robotic arms and one 15 mm port for the assistant on a right-side approach. The surgery began with the dissection of the pulmonary ligament, opening the posterior mediastinal pleura to the azygous vein and contiguous lymphadenectomy with all nodes negative in frozen section. The meticulous dissection of the sump node is important since it is the ending of the tunnel for the posterior fissure. The dissection of the hilum showed a V1 and a central vein with early bifurcation on V3b. The hilar artery branches segmentated on A1 and Rec. A2 was dissected and immediately stapled and the V1. On the fissure, the surgeons aimed to find the pulmonary artery and started on the adventitia plane toward the posterior plane to join the sump node dissection. It was also made sure to safely open the posterior fissure. Next, the ascending A2 was dissected and stapled, and an unusual accessory V6 draining to the interlobar central vein was found. This was preserved (1), and the dissection of V2a+b and V2c began. Then, bronchial dissection and stapling of B1 + B2 was performed, followed by the injection of 10 mg of Indocyanine green with the Firefly™ Fluorescence Imaging Scope to determinate the intersegmental plane of the robotic platform and finish t