Commentary: Navigating the path rarely taken.

John F. Lazar, MD

The greater surgical question is not the feasibility of a S7 segmentectomy. Rather, it is finding a need for its application and possible role in cancer therapy. Once correctly applied, being able to navigate this tricky anatomy can be of tremendous benefit to patients.

See Article page 145.

The growing adoption of uniportal video-assisted thoracoscopic surgery (VATS) on pulmonary segment resection, especially in Europe and Asia, has been well documented., This trend follows the already established multiport approach to VATS segmentectomies that have proven feasibility and clinical/oncological outcomes.3, 4, 5, 6 The decision to perform a segment versus a lobectomy has yet to be fully determined, but the overall increase in the discovery of incidental nodules by diagnostic chest computed tomography scans looking for other pathology and lung cancer screening has led to an increased interest in lung-sparing techniques. This trend has resulted in a burden on surgeons to master a greater armamentarium of smaller and rarer anatomical resections.

Huang and colleagues present an article and video describing how to perform a uniportal segment 7 resection that is both thorough and easy to follow. The greater surgical question is not feasibility. Rather, it is finding a need for application and its possible role in cancer therapy. There seem to be 2 very clinically relevant applications: If the segmentectomy is part of any anatomical en bloc resection (eg, middle lobectomy with en bloc segment 7 instead of a bilobectomy) or if ground glass opacity highly suspicious for carcinoma with limited pulmonary reserve is determined.

The rarity of the procedure requires diligent preplanning as well as a fundamental comfort with performing segmentectomies on a regular basis. It goes without saying that segment 7 is a highly specialized segmental resection and should only be attempted after doing several more straightforward segmentectomies (eg, segment 1, segment 6, and left segment 4 + 5). Preplanning may require mapping out the vasculature with either segment mapping software or 3-dimensional printing and ordering specialized staplers for the smaller airways or vessels.

Complicating this approach is oncology-related considerations such as positive metastatic lymph nodes requiring further resection beyond segment 7 and a return to the operating room. In addition, very aggressive histopathology should also be a consideration for further resection beyond segmentectomy. Although both have been challenged in a more recent article by Martin-Uncar and colleagues, demonstrating that lobectomy does not confer significant survival benefit for cT1, pN1/2 cancer.

Regardless of the approach (open/uniport or multiport VATS/robotic) or the indication, all of which are debatable, being able to navigate this tricky anatomy can be of tremendous benefit to patients if surgeons are not only well prepared but understand how to navigate the path less taken.