Uniportal video-assisted thoracoscopic left superior segmentectomy

Obtaining adequate margins when performing lung cancer resection is crucially important. Therefore, during thoracoscopic segmentectomy, where the direct palpation of the tumor is not always possible, it is mandatory to accurately identify the intersegmental plane in order to achieve a satisfactory oncological and surgical result. In this video tutorial, we demonstrate a uniportal video-assisted thoracoscopic (VATS) superior segmentectomy of the left lower lobe, adopting two different techniques for identifying the intersegmental plane: the inflation-deflation method and selective resected segmental inflation, and we present the pros and cons of each. With the inflation/deflation technique, which is the most common maneuver used, we inflated the whole lung after occlusion of the target segmental bronchus, inducing collapse of the superior segment and inflation of the remaining lobe. However, this inexpensive and easy method often makes identification of the intersegmental plane unreliable because of the collateral ventilation. Moreover, because of the expansion of inflated segments, it limits thoracic working space during the VATS procedure. In contrast, selective resected segmental inflation guarantees an optimal surgical space even during a VATS procedure. In this case, we directly inflated the segmental bronchus of the superior segment through a butterfly needle in order to selectively expand only the selected segment. The careful demarcation of the intersegmental plane is mandatory in order to obtain adequate margins and achieve a high success rate for thoracoscopic segmentectomy. Although a one-size-fits-all method is not feasible, we strongly recommend  making every effort for identifying it as best as possible; indeed, its inadequate demarcation may be the main cause of unsatisfactory surgical and oncological results in terms of locoregional recurrence and long-term survival.