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Page 2 of 22 Gharagozloo et al. Mini-invasive Surg 2020;4:66 I http://dx.doi.org/10.20517/2574-1225.2020.53

structures. It is important to differentiate segmentectomy from “wedge resection”, which is a form of
sublobar resection. A wedge resection is defined as removal of a portion of the lung along non-anatomic
planes usually with the aid of a stapling device.

Controversy about sublobar lung resection is largely attributed to The Lung Cancer Study Group’s
prospectively randomized study in 1995 which showed that sublobar resections (a combined cohort of
anatomic segmentectomies and wedge resections) had 75% increased recurrence, 30% increased overall
[1,2]
death, and 50% increased cancer-related death compared to lobectomy . This study did not differentiate
between anatomic segmentectomy and wedge resection. Subsequently, multiple retrospective studies
have shown that in general segmentectomies have lower recurrence rates and better survival than wedge
[8]
[3-7]
resections . On the other hand, in a retrospective study of patients with T1N0 disease, Altorki et al.
showed that anatomic segmentectomy and wedge resection are comparable oncologic procedures. In
addition, although anatomic segmentectomy was associated with a more thorough lymph node dissection,
it did not offer a survival advantage in this group of patients with early disease. Although prospective
studies comparing wedge resection and anatomic segmentectomy for T1N0 disease are in progress,
anatomic segmentectomy may be a better oncologic procedure in patients with more advanced disease.
Furthermore, multiple retrospective studies have demonstrated no significant difference in oncologic
outcomes with anatomic segmentectomy versus lobectomy [9-12] .

As the result of these findings, recently, there has been renewed interest in segmentectomy for small
[13]
primary lung cancer tumors, as well as in patients with marginal pulmonary reserve .

Robotic surgical systems have the advantage of high definition three-dimensional visualization, precise
instrument maneuverability in a confined space, and decreased surgeon fatigue. The surgical robot is
ideally suited for performing minimally invasive anatomic segmentectomy. It allows for precise dissection
of the segmental bronchopulmonary structures while minimizing trauma to surrounding tissue and allows
for thorough complete dissection of the mediastinal nodes. Dylewski reported the first experience with
robotic anatomic segmentectomy . In this study, robotic segmentectomy had a lower complication rate
[14]
than robotic lobectomy (11.4% vs. 31%). Pardolesi and Cerfolio reported a similar experience [15-17] . Demir
reported that VATS and robotic segmentectomy have similar morbidity and mortality . Nguyen et al.
[19]
[18]
used the Standard da Vinci and Si da Vinci platforms and replicated the anatomic segmentectomy
technique as performed by a thoracotomy. In their experience, the robotic approach was used for the apical,
anterior, and posterior segments of the upper lobe; the superior segment of the lower lobe on the right;
the apical, anterior, and posterior segments of the upper lobe; and the lingual and superior segment of the
lower lobe on the left.

This paper outlines a step by step approach to robotic anatomic segmentectomy to the segments of the right
lung. The segmental anatomy of the right lung is illustrated in Figure 1.

RIGHT SIDED SEGMENTECTOMY
Port placement
Port placement for anatomic segmentectomy is the same as with pulmonary lobectomy.

The operating room table is reversed such that the pedestal does not interfere with the docking of the robot
over the head of the patient.

A double lumen endotracheal tube is placed, and the patient is positioned in a full lateral decubitus
position. The double lumen endotracheal tube is preferable to a bronchial blocker. The manipulation of
the lung and the hilum can dislodge the bronchial blocker and result in loss of exposure during robotic