the chief complaints were intermittent cough and mild fever ongoing for one month . computed tomography ( ct ) revealed a mass ( 3.32.2 cm ) in the lingula of the left upper lobe ( lul ) and a second lesion ( 2.21.6 cm ) in the superior segment of the left lower lobe ( lll ) , which were most likely malignant ( fig .
preoperative assessments included magnetic resonance imaging of the brain , bone scan , whole - body positron emission tomography - ct , echocardiography , and bronchoscopy .
clinically , an abscess of lul and a cancer of lll ( stage ct1bn0m0 ) were suspected .
preoperative forced expiratory volume in one second ( fev1 ) was 1.37 l. echocardiography revealed normal ejection fraction ( 60% ) , but akinesia on the basal posterior wall and a ventricular premature complex were observed in the electrocardiography . for the complete resection , lingular segmentectomy and lll lobectomy should be carried out .
postoperative fev1 was estimated to be 0.9 l. due to advanced age and poor respiratory function , the surgical plan was wedge resection for the lul lesion first . if the lesion was not malignant on the frozen report , the next step was the superior segmentectomy of lll . under general anesthesia ,
a double - lumen endotracheal tube was placed , and the patient was transitioned to the right lateral decubitus position .
once selective lung ventilation was achieved , a 4-cm incision was made in the fifth intercostal space at the anterior axillary line with a wound protector ( applied medical , rancho santa margarita , ca , usa ) .
the two distinct masses were digitally palpable , with a visible retraction of the lower lobe visceral pleura .
first , the anterior portion of the fissure was dissected and divided , exposing the interlobar artery ( fig .
the lingular segmental artery was then identified and divided , followed by the elevation and resection of the upper lobe mass .
then , complete resection was achieved , and the distance between the mass and the resection margin was 0.6 cm . after there was no evidence of malignancy on the frozen section report , the superior segmental artery ( encircled by a drain catheter )
was identified and divided using an endostapler ( tristapler ; covidien , norwalk , ct , usa ) ( fig .
eventually , the superior segmental vein was divided using a hem - o - lok ( teleflex medical inc . , research triangle park , nc , usa ) . after identifying the superior segmental bronchus , the peribronchial tissue and lymph nodes were dissected .
3a ) , enabling the visualization of the segmental plane and stapler division ( fig .
mediastinal lymph node dissection ( para - aortic , subcarinal , inferior pulmonary ligament , and paraesophageal lymph nodes ) was performed ( fig .
4a , b ) . a chest tube ( 24 fr . ) was placed in the pleural cavity through the utility incision , and the wound was closed ( fig .
histopathology confirmed an abscess of lul and an adenocarcinoma ( 1.61.4 cm ) of lll with the invasion of the visceral pleura ( stage t2an0m0 ) , and a distance of 3 cm was obtained between the tumor and the divided segmental plane .
since its introduction in the 1990s , video - assisted thoracoscopic surgery ( vats ) has been an attractive treatment modality for thoracic surgery , resulting in shorter recovery periods and less postoperative pain than open procedures .
although , generally , three or four incisions are used for vats lobectomy or the segmentectomy of lung cancers , a report by rocco et al .   on uniportal vats wedge resection , citing the potential to reduce postoperative pain and paresthesia ,
has caught the interest of thoracic surgeons . since 2010 , gonzalez - rivas et al .   have adopted this technique for lung cancer surgery , confirming its feasibility in a recent publication .
although lobectomy is the standard surgical management for early lung cancer , lobectomy is not suitable for all patients .
segmentectomy is a reasonable alternative procedure . in a comparison of segmentectomy with lobectomy for non - small cell lung cancer < 2 cm , okada et al
in particular , in the older patients , segmentectomy leads to less complications and low comparable oncologic impact than lobectomy .
we extended our experience with vats for lung cancer to include a single - incision approach using a 4-cm utility incision of the 5th intercostal space ( at the anterior axillary line ) .
a wound protector is employed to protect the camera lens from oozing by the intercostal muscle .
the required instrumentation does not otherwise differ from that of conventional vats ( endograsper , 10-mm camera with 30 angle , right - angle clamp , and ultrasonic device ) .
a harmonic scalpel is very useful and suitable for the dissection and coagulation of microvessels because of its blunt tip and scissors - like action .
we preferred a long right - angle clamp with a blunt tip during the tunneling and encircling of the vessels and the bronchus .
single - incision vats does have some limitations . clearly , when the multiple views of conventional vats are forfeited , obstruction of view and impingement of instruments commonly occur . however , the surgical technique is not different , including the identification and division of the vessels and the bronchus , and lymph node dissection .
we generally center the camera on the incision , inserting instruments on either side of it ; further , for better visualization , the stapler is placed in the thoracic cavity beneath the camera . conducting extensive surgery through a single , small incision is often ergonomically problematic for surgeons and assistants . during an operation ,
the operator and the assistant are sometimes superimposed ; therefore , it is important to prevent contamination .
the procedure through the 6th intercostal space allows the division of the inferior pulmonary ligament and the inferior pulmonary vein more easily .
however , our first step is the dissection of the interlobar space ; this approach is easier through the 5th intercostal space .
if a conversion to conventional vats is required , a utility incision in the 5th intercostal space is more convenient because a utility incision in the 5th intercostal space is always used during conventional vats . in our experience
although segmentectomy is generally expected to be more difficult than lobectomy , superior , basal , and lingula segmentectomies are more easily executed , owing to the readily defined segmental planes . however , without multiple views through a single incision , the division of segmental planes has to be performed in one direction .
division of segmental planes is slightly difficult during the division of segmental planes in single - incision segmentectomy . in conclusion ,
single - incision vats superior segmentectomy of lll for early - stage lung cancer was both feasible and safe in this instance .
 lobectomy with mediastinal node dissection has been standard treatment for non - small cell lung cancer ( nsclc ) . 
 nowadays , video - assisted thoracoscopic surgery ( vats ) is gaining acceptance as an alternative treatment option , given the quality - of - life benefits that it confers . 
 for the vats procedure , most surgeons create two or three ports with a utility incision of 3 to 5 cm . 
 however , with acquired skill and instrumentation advances , single - incision thoracoscopic surgery has emerged over time . here , 
 we report the case of an 86-year - old female with nsclc treated by single - incision segmentectomy . 
CASE REPORT
DISCUSSION