Ruijin robotic thoracic surgery: S1+2+3 segmentectomy of the left upper lobe
Case Report

Ruijin robotic thoracic surgery: S1+2+3 segmentectomy of the left upper lobe

Han Wu, Su Yang, Wei Guo, Runsen Jin, Yajie Zhang, Xingshi Chen, Hailei Du, Dingpei Han, Kai Chen, Jie Xiang, Hecheng Li

Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, Shanghai 200025, China

Correspondence to: Hecheng Li, MD, PhD. Department of Thoracic Surgery, Ruijin Hospital, Shanghai Jiao Tong University, School of Medicine, 197 Ruijin Er Road, Shanghai 200025, China. Email:

Abstract: Robotic-assisted thoracic segmentectomy is a minimally invasive option for the treatment of the resectable lung cancer. Its advantages over conventional video-assisted thoracic surgery include a clear and magnified three-dimensional operative field and the flexible multi-joint arms. This technical article presents a case from our center to share some surgical techniques for this procedure.

Keywords: Segmentectomy; robotic-assisted thoracic surgery

Received: 02 December 2016; Accepted: 27 December 2016; Published: 17 January 2017.

doi: 10.21037/amj.2017.01.12

Clinical data

A 65-year-old woman was admitted because of pulmonary nodules for 1 month detected by computed tomography (CT). Chest CT (Figure 1) showed ground glass opacity (GGO) in the S1+2+3 segment of the left upper lobe. The patient’s complaints did not include chest tightness, shortness of breath, cough, expectoration, low fever, chills, night sweats or hoarseness. Cardiopulmonary function, blood gas analysis and laboratory tests were normal. There was no positive sign or supraclavicular lymph node enlargement in physical examination. She had no past medical history.

Figure 1 Preoperative CT showed GGO in the S1+2+3 segment of the left upper lobe. GGO, ground glass opacity.

Operation steps

Anesthesia and body position

The patient received general anesthesia by double-lumen endotracheal intubation and was placed in the lateral decubitus position and in a jackknife position with single-lung (right) ventilation (Figure 2).

Figure 2 Jackknife position.


A 1.5-cm camera port (for a 12-mm trocar) was created in the 8th intercostal space (ICS) at the left mid axillary line, and three separate 1.0-cm working ports (for 8-mm trocars) were made in the 6th ICS (#1 arm) at the left anterior axillary line, the 8th ICS (#2 arm) at the left posterior axillary line, and the left 7th ICS (#3 arm), 2 cm from the spine. An auxiliary port (for a 12-mm trocar) was made in the 8th ICS near the costal arch (Figure 3).

Figure 3 Ports in the 6th, 7th, and 8th ICS. ICS, intercostal space.

Installation of the surgical arms

The robot patient cart was positioned above the operating table and then connected. The #1 arm was connected to a unipolar cautery hook and the #2 arm was connected with bipolar cautery forceps. An incision protector was used in the auxiliary port.

Surgical procedure

See Figures 4-18.

Figure 4 The mediastinal pleura was opened.
Figure 5 Lymph nodes of the bronchus and pulmonary artery were dissected, and the pulmonary artery was exposed.
Figure 6 The pulmonary artery was dissected from the interlobar fissure, and a tunnel was formed to open the posterior interlobar fissure.
Figure 7 The posterior interlobar fissure was transected with the Echelon flex.
Figure 8 Pulmonary vein V1+2a-c was skeletonized and cut with Echelon flex.
Figure 9 Vein V3c was skeletonized and ligated to cut.
Figure 10 Pulmonary artery A1+2a+b was skeletonized and cut with Echelon flex.
Figure 11 Artery A3 was skeletonized and dissociated.
Figure 12 Artery A3 was cut with Echelon flex.
Figure 13 Bronchus B1+2+3 was dissected.
Figure 14 Bronchus B1+2+3 was clamped, and the lung was ventilated to expose the plane of the S1+2+3 segment.
Figure 15 Bronchus B1+2+3 was cut with Echelon flex.
Figure 16 Ventilating the lung to expose intersegment plane.
Figure 17 Segment S1+2+3 was cut along the intersegmental plane with the Echelon flex.
Figure 18 The lung was filled with water and checked for air leaks.

Postoperative condition

Postoperative treatments included anti-inflammatory and phlegm-resolving treatments. The thoracic drainage tube was withdrawn 2 days after surgery, and the patient was discharged 3 days after surgery. No complications were observed during hospitalization. Pathological diagnosis was atypical adenomatous hyperplasia (AAH) at local alveolar epithelium of the S1+2+3 segment of the left upper lobe.


The segmental dissection of the left upper lobe is a major challenge in robotic surgery because of the thin segmental vessels and bronchus. In addition, it is not easy to determine the segmental plane. The many arterial branches in the left upper lobe should be identified carefully when dissociating and pulling, especially the short branch A3. For that reason, the surgeon should be familiar with the fine anatomy of the vessels and bronchus. The robot has a clear and magnified field of view and flexible arms, which make dissection and use of Endo-GIA stapler easier compared with the thoracoscope. The #3 arm can help the surgeon to find the pulling location, which reduces the work of the assistant. In all surgeries, we dissect the hilum using a posterior approach and expose the pulmonary artery, which improves safety. We inject CO2 before removing the specimen of lung lobe to form a closed space, which keeps the operation field clear (1-5).




Conflicts of Interest: The authors have no conflicts of interest to declare.

Informed Consent: Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images.


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doi: 10.21037/amj.2017.01.12
Cite this article as: Wu H, Yang S, Guo W, Jin R, Zhang Y, Chen X, Du H, Han D, Chen K, Xiang J, Li H. Ruijin robotic thoracic surgery: S1+2+3 segmentectomy of the left upper lobe. AME Med J 2017;2:2.