How to manage tumor located between upper division and lingular segment “S3+S4 segmentectomy and S3b+S4 segmentectomy”

Segmentectomy is one of the treatment of choice for small-sized non-small cell lung cancer (NSCLC). Although simple segmentectomy is feasible even if under thoracoscopy, complicated segmentectomy which contains more than two segmental plane divisions is difficult especially thoracoscopic surgery. We here present the case of totally thoracoscopic segmentectomy between upper division and lingular segment. In the first case, the 64-year-old female patient admitted for further examination and treatment of left lung ground glass nodule. Tumor located between upper division (S3) and lingular (S4) segment was operated by bi-segmentectomy and intraoperative frozen section pathology showed minimally invasive adenocarcinoma. Systematic nodal dissection was followed after retrieval of specimens. A3b A3a+c, and A4 was individually divided and followed by division of B3 and B4. Finally, intersegmental veins V1+2a and V1+2d was identified between segments and V3a+b was divided. In the second case, the 76-year-old female patient with left lung nodule between upper division (S3b) and lingular (S4) segment was operated by bi-segmentectomy. Since sealing test revealed air leakage from resected segmental planes, fibrin glue was applied to stop air leakage and direct suturing by 4-0 prolene between S3a+S3c and S5 was performed. Target lesion between upper division and lingular segments may be resected safely if appropriate demarcation lines are identified regardless of without highly sophisticated imaging systems.