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Address reprint requests to Robert J. Cerfolio, MD, FACS, FCCP, Chief of Section of Thoracic Surgery, Department of Surgery, University of Alabama at Birmingham, 1900 University Blvd., THT 712, Birmingham, AL 35294
Pulmonary segmentectomy is defined as the removal of an anatomic subdivision or segment of the pulmonary parenchyma in a lobe of the lung. Pulmonary segmentectomy has been most commonly used by general thoracic surgeons for the resection of tumors in patients with poor pulmonary function who could not tolerate lobectomy. However, recently the concept of segmentectomy over lobectomy has been increasingly applied and used for patients with normal lung function for lesions less than 2 cm, especially those who do not have visceral pleural invasion. Although the benefits of this practice compared with the risk of not removing the entire lobe are not known, several current ongoing prospective multi-institutional studies will help answer this question. One such example is the National Cancer Institute Cancer and Leukemia Group B 140503 study,
where patients, who have biopsy-proven non-small-cell lung cancer but do not have a recent history of another solid organ cancer and whose lung lesions are 2 cm or less, are randomized to either a lobectomy or a segmentectomy. The randomization process occurs in the operating room after several specific N2 and N1 lymph nodes are biopsied and proven to be benign. In addition to this North American study, there is also an ongoing study in Asia sponsored by the Japan Clinical Oncology Group and the West Japan Oncology Group.
Importantly, not all lesions are positioned perfectly in the lobe for a segmentectomy and thus do no setup well for a formal anatomic segmentectomy. A formal segmentectomy, as opposed to a “large wedge resection,” refers to one in which the artery to that segment, the vein (sometimes), and the bronchus are all dissected free from the surrounding tissue, individually identified, and then ligated. In addition, all of the appropriate draining N1 lymph nodes are removed. Some types of segments avail themselves to this type of resection better than others. These include, on the right side, in the right upper lobe, an apical, an anterior, and a posterior segment. In the right middle lobe, both the superior and the inferior segments can be performed but are rarely done because the right middle lobe is so small. The segmentectomies of the right lower lobe that can be performed are mainly the right lower superior segment and sometimes the basilar segments.
On the left side, the lingula presents itself as an ideal segment as well as the left upper apical, anterior, and posterior segment. In addition, a trisegmentectomy of the left upper lobe can be performed, which spares the lingula but removes the rest of the left upper lobe. In the left lower lobe, the superior segment is an anatomically well-defined area where all 3 structures, the artery, vein, and bronchus, are easily identified and individually ligated or stapled. Although basilar segmentectomy can be performed for lesions in either the right or the left lower lobes, they often do not afford ideal anatomy. Segmentectomy can be performed via many surgical approaches including thoracotomy, video-assisted thoracoscopy, and robotic surgery. The example illustrated in this article is a robotic posterior segment of the left upper lobe.
Once both the parenchyma and the bronchial margins are confirmed as negative, the chest should be irrigated. The lack of a bronchopleural fistula and air leaks from the lung parenchyma should be ensured. One small chest tube should be placed. We currently favor a 20-French soft chest tube placed through one of the more anterior ports when performing a minimally invasive segmentectomy.
Prospective randomized studies will tell us the oncologic effectiveness of segment versus lobectomy. In the future, it is likely that the true comparison group will be stereotactic radiosurgery compared with minimally invasive segmentectomy.
Phase III randomized study of lobectomy versus sublobar resection in patients with small peripheral IA non-small cell lung cancer, 2010.