Thoracoscopic subxiphoid right S9+10 segmentectomy: a case report

Thoracoscopic segmentectomy of posterior (S10) and lateral basal (S9) segments is highly challenging, because of the frequency of anatomical variations and the particularly complex intersegmental plane delimitation, due to the pyramidal shape of the lower lobe. We report here the case of a 77-year-old male presenting with a colorectal metastatic evolutive centimetric nodule deeply located between S9 and S10 segments, requiring a sub-lobar resection. A thoracoscopic right S9+10 segmentectomy was performed through an original subxiphoid approach, combining interlobar fissure and inferior pulmonary ligament approaches and assisted by both three-dimensional computed tomography (3D-CT) anatomical reconstruction and fluorescence imaging. Pathological examination confirmed metastatic nature and complete resection of the nodule with sufficient margin. The patient was integrated in an enhanced recovery after surgery (ERAS) programme and discharge on postoperative day 1 with an uneventful follow-up. Subxiphoid approach appears quite efficient for such complex right S9+10 segmentectomy, particularly when designed in a personalized way, based on an accurate anatomical planning strategy for an optimal oncological lung sparing resection.