Uniportal video-assisted thoracoscopic surgery segmentectomy for early-stage non-small cell lung cancer: indications and surgical technique

This article describes a standardized uniportal video-assisted thoracoscopic surgery (VATS) anatomical segmentectomy technique for early-stage non-small cell lung cancer (NSCLC) within evidence-based oncologic indications. Candidates are peripheral clinical stage I tumors (≤2 cm) with clinical N0 status after appropriate hilar/mediastinal evaluation, and a planned parenchymal margin at least equal to tumor diameter (margin/tumor ≥1.0); centrally located or clearly hypermetabolic lesions are directed to lobectomy. The workflow integrates mandatory preoperative three-dimensional computed tomography (3D-CT) planning, a vein-oriented hilar strategy when venous anatomy reliably outlines the intersegmental plane, and complementary methods to delineate the plane intraoperatively—intravenous indocyanine green (ICG) fluorescence or the classical inflation-deflation technique. To reduce bronchial misidentification, endobronchial ICG marking is used selectively, recognizing contraindications and the acceptability of intraoperative bronchoscopy and non-ICG methods. Step-by-step maneuvers, troubleshooting, and segment-specific caveats are detailed for a coaxial uniportal view, including when artery or bronchus first sequencing is preferable. Systematic nodal evaluation is performed to confirm pathologic N0, consistent with trial protocols supporting sublobar resection. Perioperative outcomes from a consecutive institutional cohort (n=38) are summarized to document feasibility and safety under these indications. This technique aims to preserve parenchyma without compromising oncologic principles by pairing indication-first decision-making with a reproducible uniportal approach.