Limited resections for early stage lung cancer have recently aroused increasing interests. Theoretical advantages of limited resections for early stage lung cancer include preservation of pulmonary function and potentially similar oncologic results supported by quite a few studies recently published (1-6). Several retrospective reports have demonstrated that video-assisted thoracoscopic surgery (VATS) segmentectomy for stage IA lung cancer may have survival and local recurrence rate comparable to VATS lobectomy (4,5). But it is still unclear to what extent a limited resection could preserve the pulmonary function comparing to a standard lobectomy, especially in the context of the minimally invasive surgery (7-9).
Although segmentectomy helps to spare more lung parenchyma than lobectomy, it is not necessarily associated with more pulmonary function preserved. As recently reported by Gu et al. (10), pulmonary function loss per segment resected would be almost doubled after segmentectomy than after lobectomy. And combined segmentectomy would certainly cost more functional loss than single segmentectomy. It seems that postoperative functional benefit could be expected only if at least more than half of the lung parenchyma in the corresponding lobe is preserved. Therefore, for small peripheral lung cancers located in the apico-dorsal segment of the left upper lobe, it is less likely for lingual-sparing left upper lobectomy to have significantly more functional preservation comparing to a standard left upper lobectomy. In this context, the role of S1+2 segmentectomy could be more beneficial comparing to a typical tri-segmentectomy, in order to preserve the pulmonary function of the patient. Here, we present a case of a patient with a minimally invasive adenocarcinoma (MIA) in the S1+2 segment of the left upper lobe treated with a S1+2 segmentectomy.
A 55-year-old female patient, non-smoker, with no significative past clinical history, came to us for a chest CT scan finding of a 9.8 mm subsolid nodule in the S1+2 segment of the left upper lobe. PET scan showed a slight FDG uptake of the pulmonary nodule. Considering it highly suspicious for neoplastic lesion, a surgical excision of the pulmonary nodule by a S1+2 segmentectomy was proposed. The patient was in good clinical condition, with a good cardio-pulmonary function. Patient’s informed consent was acquired before surgery. Two hours before the operation, a hook wire was inserted into the lesion under CT guidance. After intubation, the patient was placed in a right lateral decubitus position. The left arm was suspended on a frame above her head. A three-port VATS approach was selected. In the Figure 1, we show the surgical procedure. First, a camera port was created in the 7th intercostal space on the mid-axillary line and a 10-mm 30-degree thoracoscope was introduced through a 12-mm trocar for exploration. Under the guide of the camera, a 4 cm utility port in the 4th intercostal space, on the mid-anterior axillary line and a 20 mm assistant port in the 8th intercostal space, on the posterior axillary line were created. On exploration, the lesion was confirmed to be located in the S1+2 segment according to the position of the hook wire. Thus, we proceeded with the S1+2 segmentectomy. First, the incomplete fissure was divided. On the distal part of the fissure, between the S1+2 and S6 segments, the artery for the S2 segment (A2) was identified and divided. Sometimes, it is not so easy to differentiate A2 from A4+5. In this case, this artery clearly ran towards the S1+2 segment. Then, the anterior hilum of the left upper lobe was exposed to reveal the superior pulmonary vein and the left pulmonary artery; the pulmonary vein for the apical segment of the LUL (V1) was then exposed and divided. This helped revealing the pulmonary artery branches to the apical (A1) and the anterior (A3) segments. The subsequent step was to divide the A1 from the posterior hilum. After cutting the A1 and A2, No. 12 lymph nodes could be readily dissected, and this helped identifying the bronchus for the apico-dorsal segment of the LUL (B1+2). Before cutting the B1+2, it is always helpful to first localize B3 nearby, and to clamp the B1+2 bronchus while asking the anaesthesiologist to re-expand the lung. This helps verifying the correct bronchial branch to be cut and creating a marked parenchymal inflation-deflation line to identify the S1+2 parenchyma. After dividing the B1+2, the bronchial stump was lifted up from the hilum. This permitted elevating the lung parenchyma of the S1+2 away from the remaining left upper lobe and allowed dissecting it as peripherally as possible. Finally, the S1+2 was cut by endo staplers along the lung inflation-deflation line between the deflated S1+2 and the inflated remaining lung. The resected specimen was then removed in a retrieving bag through the utility port. And stations 4, 5, and 7 lymph nodes were sampled.
The post-operative course was uneventful, and the patient was discharged on the 4th post-operative day. Final histopathological examination revealed a MIA of the lung, staged as pT1miN0M0. Currently, the patient is in good condition and under routine follow-up.
In the treatment of early stage lung cancer located in apico-dorsal segment of the left upper lobe, S1+2 segmentectomy is a safe and useful procedure that permits to spare more remaining segments than a typical lingual-sparing tri-segmentectomy. The combination of limited anatomical resection and minimally invasive surgical approach is beneficial for the functional preservation of the patients as long as the oncological efficacy could be maintained.
Conflicts of Interest: The authors have no conflicts of interest to declare.
Informed Consent: Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images.
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Cite this article as: Ventura L, Gu Z, Zhao W, Zhang X, Fang W. S1+2 Segmentectomy of the left upper lobe: a good solution to preserve the pulmonary function of patients with stage I NSCLC. J Vis Surg 2018;4:179.