Buttonhole LASER pulmonary metastasectomy: an innovative parenchyma preserving technique

With advances in systemic anticancer therapies, pulmonary metastasectomy is being increasingly employed for local disease control while aiming to preserve lung parenchyma, anatomy, and function with complete (R0) resection. We introduce an innovative neodymium-doped yttrium aluminum garnet (Nd-YAG) light amplification by stimulated emission of radiation (LASER) approach for peripherally located, deep-seated, and fissural lesions, utilizing the lung's natural tongue-like configuration at the edges. This method involves cylindrical excision around the nodule, creating a buttonhole from one surface to the other. This approach minimizes parenchymal loss and maintains anatomical integrity, ensuring adequate lung expansion. We refer to this as the Nd-YAG LASER buttonhole pulmonary metastasectomy. Ten patients who underwent Nd-YAG LASER buttonhole pulmonary metastasectomy for synchronous and metachronous lesions at a tertiary oncology center in India between October 2023 and December 2024 were identified from a prospective database. Data was collected retrospectively from patient records from PARAS software, operative recordings, and clinical imaging systems. Between October 2023 and December 2024, 62 patients underwent Nd-YAG LASER-assisted pulmonary metastasectomy, with 10 patients undergoing buttonhole metastasectomy based on specific criteria. The procedure demonstrated efficacy in managing multiple and bilateral metastases, with 83.3% of bilateral cases completed in a single stage. In this cohort of 10 cases, 43 metastatic lesions were resected, out of which 27 were excised using LASER, including 14 via the buttonhole approach. This technique achieved precise excision with minimal parenchymal loss, maintaining a mean clear margin of 2.78 mm. Postoperative recovery was uneventful, and all patients remained disease-free at follow-up. For deep-seated peripheral lung lesions in the outer third of the lung, especially near the mediastinal pleura, diaphragm, or fissures, Nd-YAG LASER-assisted buttonhole pulmonary metastasectomy serves as a safe and effective alternative to LASER coring, stapled wide wedge resection, or segmentectomy. This technique enhances lung parenchymal preservation while allowing for potential future redo metastasectomies.

The online version contains supplementary material available at 10.1007/s12055-025-01988-7.