Indocyanine green fluorescence-navigated robotic segmentectomy

Abstract

Background: Pulmonary segmentectomy with radical lymphadenopathy has been considered effective to manage small primary lung cancers [1, 2]. This procedure provides the advantages of minimal invasive surgery and is reported sufficient for safe margin. However, segmentectomy is more difficult to be performed than lobectomy because intersegmental plane cannot be detected easily. Several methods have been reported for identifying the actual intersegmental plane [3-7], but the sensitivity of these methods is limited to the lung conditions like patients with emphysematous lung and needed skilled surgeon to perform. We demonstrated the technique of visualizing the intersegmental plane via fluorescence navigated with indocyanine green (ICG) injection intravenously during robotic S6 segmentectomy.

Methods: This video presents a case that 70-year-old male who has past history of rectal cancer status post-LAR in 1991, HCC status post-RFA, and hepatitis C was found a lung nodule over superior segment of left lower lobe during regular examination. The nodule was considered metastatic tumor preoperatively. The segmental pulmonary artery and pulmonary bronchus to superior segment of left lower lobe were ligated firstly, and the intersegmental plane was seen clearly after ICG injection intravenously under fluorescence navigated. Intersegmental plane was marked by electrocautery, and then, the target segment was resected by endostapler.

Results: Patient tolerated the procedure well. Chest tube was removed by postoperative day 3, and he was discharged smoothly by postoperative day 5. There were no complications. Postoperative chest X-ray revealed good lung expansion. Not as preoperative expectation, the final pathology was consistent with caseating granulomatous inflammation.

Conclusion: It is difficult to identify intersegmental plane during segmentectomy. ICG fluorescence-navigated segmentectomy provides immediate visualization of the intersegmental plane and makes the procedure easy and fast.

Keywords: Indocyanine green; Robotic surgery; Segmentectomy.