Patient positioning and trocar placement
The patient is placed in a lateral decubitus position with the table generously flexed to move the patient’s hip out of the way and widen the intercostal spaces, which improves range of motion.
We use a posterior approach when performing a superior segmentectomy: the surgeon stands behind the patient and dissection proceeds from the back. This provides the most direct path to the anatomic structures at the base of the segment and simplifies the procedure.
We introduce the trocars in the following sequence:
First, a port inserted inferiorly is used for the camera throughout. It is placed somewhat posteriorly to the tip of the scapula, which improves visualization of the posterior aspect of the hilum. A 5-mm scope in optimal working condition provides excellent visualization. However, available 5-mm scopes are fragile and in our hospital setting deteriorate quickly with routine maintenance. For this reason, we prefer using a 10-mm scope.
Next, a 10-mm port is placed anteriorly and inferiorly. This is used for retraction and stapling of the bronchus and vessels. This port is also used for specimen extraction.
A 10-mm port is placed posteriorly and inferiorly and is used for dissection and parenchymal division.
A 5-mm port behind the scapula is used mainly for retraction.
Although endoscopic trocars may be used, we have found that they limit range of motion and we generally avoid them, except for the camera. Likewise, we have not found CO2 insufflation to be necessary.
Mediastinal lymph node dissection is generic to all oncologic pulmonary resections. However, as it is not specific to segmentectomy, it is not included in this tutorial.