Chapter 72: Minimally Invasive Segmentectomy for Malignancy

INTRODUCTION

Sublobar resection refers to any pulmonary resection in which only part of the pulmonary lobe is removed. Nonanatomic sublobar resection is commonly called wedge resection (see Chapter 79). It implies removal of the target lesion and associated surrounding lung parenchyma without paying attention to the boundaries of the bronchopulmonary segment and without separate division of the segmental vessels and bronchi. Anatomic sublobar resection, in contrast, involves identification and ligation of those structures and complete removal of one or more bronchopulmonary segments. Although segmentectomy was first described for the treatment of pulmonary infection, more common indications include lung cancers in patients who are unable to undergo lobectomy because of physiologic constraints, lung metastases not amenable to simple wedge excision, and pulmonary lesions that require resection and cannot be easily localized intraoperatively by palpation or other means (Table 72-1). Such nodules may be amenable to segmentectomy by virtue of their known location in a specific lung segment on preoperative CT imaging. The latter is frequently the case with minimally invasive resection of nodules located deep within the lung parenchyma, where the ability to palpate the lung may be limited. The use of segmentectomy for small lung cancers in healthy patients who could tolerate lobectomy is an area of ongoing controversy.

HISTORIC PERSPECTIVE

Although the bronchial and vascular anatomy of the lungs was already well described by the late 1800s,¹ the concept of the bronchopulmonary segment was not described until 1932, by Kramer and Glass.² The technique of segmentectomy was described a few years later by Churchill and Belsey, who performed the operation for regions of bronchiectasis and destroyed lung resulting from infectious etiologies such as tuberculosis.³ Throughout the subsequent three decades, segmentectomy was rarely used for the treatment of lung cancer, with most surgeons initially adopting pneumonectomy and then lobectomy as the preferred treatment. In the early 1970s, however, several centers published reports of patients with lung cancer who could apparently be successfully treated by segmentectomy alone. In 1972, Le Roux showed equivalent survival and recurrence patterns in 17 patients with lung cancer resected by segmentectomy.⁴ In 1973, Jensik and colleagues reported 5-year survival of 56% in 69 patients with stage IC lung cancer who underwent segmentectomy, and 39% of the deaths were unrelated to the primary tumor.⁵ Local recurrence occurred in 10%. In 1990, Read et al. reported similar 5-year overall survival (OS) of 51% in 113 patients who underwent sublobar resection; however, 5-year cancer-specific survival was 78% and not significantly different ...