Uniportal video-assisted thoracoscopic combined subsegmentectomy: a case report of left S³b + S⁴b

Anatomical complex segmentectomy has become increasingly important in oncological lung resection, particularly for small ground-glass nodules of primary lung cancers. Resection of a lung nodule located between the left upper division and the lingual segment is technically challenging. Delicate surgical planning is crucial to ensure adequate surgical margin while preserving maximum pulmonary function. A combined subsegmentectomy can be a feasible choice but is challenging to perform under uniportal approach due to limited working space and insufficient exposure of target segmental bronchi and pulmonary arteries. The purpose of this article is to introduce the technique we use to overcome these challenges. Herein, we report a case with two ground-glass nodules in the left upper lobe, one 0.6-cm adjacent to the V³ b and one 0.4-cm beneath the S⁴ b surface. Instead of extended upper division trisegmentectomy or extended lingulectomy, a uniportal video-assisted thoracoscopic S³b + S⁴ b combined subsegmentectomy was planned and performed. Three-dimensional computed tomography reconstruction was performed preoperatively to reveal the branching pattern of the associated sub-segmental bronchi and pulmonary vessels. Inflation-deflation method was applied to identify intersegmental planes, and both lesions were removed successfully. We describe our “open the side door” technique for performing subsegmentectomy in this patient. This technique is helpful when performing a complex subsegmentectomy.