Thoracoscopic S2 segmentectomy by a posterior approach for a central metastasis: a case report

Abstract

: Central metastases are an ideal indication for anatomic sublobar resection. This allows adequate, safe resection, with preservation of lung function and decreased morbidity. This paper illustrates a case of S2 segmentectomy for a central metastasis and highlights key technical considerations. The author finds that a direct posterior approach to S2 facilitates the operation, minimizing dissection and allowing sparing of the horizontal fissure which may reduce the potential for prolonged air leak. Sparing tissue planes may also facilitate redo-surgery and increase therapeutic options in the event of future metastatic disease. Anatomic sublobar resection requires attention to detail. Planning is very important, and advanced imaging including 3D reconstruction and 3D printing is increasingly being considered for this purpose. Intraoperatively, correct positioning of trocars and deliberate, purposeful retraction are key. Finally, a challenge specific to the resection of central S2 segment lesions is the requirement for sufficient space at the base of the segment to allow parenchymal division with negative margins. Methodical identification, dissection, and division of the segmental venous drainage is an important step that allows the space at the base of the segment to open up. This space can then be dissected widely in order to position the stapler and complete the resection, even for lesions at the very root of the segment.