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Address reprint requests to Joshua R. Sonett, MD, FACS, Section of Thoracic Surgery, Columbia University, NewYork-Presbyterian Hospital, PH Room 104, 14th Floor, 622 West 168th Street, New York, NY 10032
Minimally invasive lobectomy and thoracic lymph node dissection is now widely established as a safe, anatomic, and oncologically sound procedure that may now be considered the standard of care for early-stage lung cancer. Technical familiarity and advances in equipment have now enabled many thoracic surgeons to apply these techniques to anatomic segmentectomy. Anatomic sublobar resection, segmentectomy, involves separate ligation of the segmental arteries, veins, and bronchial anatomy with concomitant hilar lymph node dissection. Although definitive indications for sublobar resection in early lung cancer are still debated in evolution, a clear distinction should be understood of the differences in anatomic sublobar resection as described in this text and stapled nonanatomic sublobar resections (wedge).
Clear indications for anatomic lung-sparing resections in malignant and benign disease exist (Table 1), and continued debate is evolving as to the routine use of segmentectomy in early-stage lung cancer as a routine lung preservation technique (Table 2).
Table 1Indications for Anatomic Segmentectomy
Patient with insufficient cardiopulmonary reserve to tolerate lobectomy
Multiple synchronous lesions requiring resection
Centrally located metastatic disease requiring metastasectomy
Resection of undiagnosed lesion for tissue assessment
When deciding on anatomic segmentectomy vs formal lobectomy in a patient with nonsmall-cell lung cancer, great care must be taken not to try to preserve lung at the cost of oncological failures. This is especially important as we await more definitive proof of the sublobar study. Patient selection must weigh the benefit of sublobar resection in that patient vs the potential for suboptimal cancer care. Given the propensity of tumors not to have necessarily chosen to live in the center of a common segment, that supports resection, the decision can be greatly blurred.
Additionally, one must ask how much lung preservation is really benefiting the patient in regards to improved pulmonary function that is relevant. Thus, only lesions that are situated centrally in anatomic location that afford excellent margins should be considered.
The most common and anatomically apparent segmentectomies performed are as follows:
Superior segments of the lower lobes
Composite basilar segments of the lower lobes
Lingular-sparing left upper lobectomy (trisegmentectomy)
Lingula of the left lobe
Posterior segment of the right upper lobe
Apical segment of the right upper lobe
General Surgical Approach
Video-assisted thoracic surgery (VATS) segmentectomy is performed via the same access and port positions that one usually uses for an anatomic lobe resection. Initial exploration of all lobes and the pleural space is performed to rule out additional lesions, metastatic disease, or gross anatomic abnormalities. The fissures are assessed for ease of procedure, but fissureless techniques are applicable in segmentectomy.
Final confirmation of the correct bronchial segment can be facilitated with insufflations of the lung after isolation of the bronchus, and final confirmation may be performed using a bronchoscope. The bronchoscopic confirmation may be quite comforting given the common cross-segmental ventilation that may occur even with proper bronchial isolation. I find marking the segmental delineation with an indelible operative marking pen during ventilation testing helps with stapling the segment once atelectasis returns. Segmental bronchial dissection is facilitated with a peanut. I also find placing a silk suture around the bronchus for retraction helps facilitate stapling and confirmation of the segmental anatomy.
Initial dissection of the mediastinal and progressive hilar lymph nodes is important to assure safe sublobar resection and facilitate resection. All nodes are sent for frozen section analysis, and sublobar resection is abandoned if positive nodes are identified.
All specimens are removed from the chest in a protected fashion; I use a bag for the segment and a wound protector for the lymph nodes.
Posterior Segment Right Upper Lobe
Lingular-Sparing Left Upper Lobectomy
Left Lower Lobe Segmentectomy
Left Lower Lobe Basilar Segmentectomy
Anatomic segmentectomy can be safely and reproducibly performed as a minimally invasive procedure. The techniques and dissection are a natural evolution of lessons learned from minimally invasive lobectomy. Because the Lung Cancer Study Group seminal prospective series on lobectomy vs less than lobectomy defined lobectomy as the standard of care, multiple single-institution studies have produced compelling data that show anatomic segmentectomy may be performed with identical lung cancer survival in select patients. This debate has been accelerated with the advent of lung cancer screening protocols as well as alternatives to resection such as radiofrequency ablation and “radiosurgery.” However, the safe oncological use of sublobar resections is currently undergoing rigorous prospective study in a Cancer and Leukemia Group B and intergroup study (Cancer and Leukemia Group B trial 140503): Conventional lobectomy vs wedge or segmentectomy for small peripheral tumors <2 cm.
The author would like to acknowledge the assistance of Cole Sonett in the preparation of the initial sketches of artwork that were sent to Mr. Gordon for the final illustrations.