Complete thoracoscopic S9 and/or S10 segmentectomy through a pulmonary ligament approach: a retrospective study

BACKGROUND

The high resolution of computed tomography has found the pulmonary ligaments that consists of a double serous layer of visceral pleura, forms the intersegmental septum, and enters the lung parenchyma. This study aimed to investigate the clinical feasibility of thoracoscopic segmentectomy (TS) of the lateral basal segment (S9), posterior basal segment (S10), and both through the pulmonary ligament (PL).

METHODS

Between February 2009 and November 2021, 542 patients underwent segmentectomy for malignant lung tumors at Tokyo Women's Medical University Hospital (Tokyo, Japan). This study included 51 patients. Among them, 40 underwent a complete TS of the S9, S10, or both by the PL approach (PL group), and the remaining 11 by the interlobar fissure approach (IF group).

RESULTS

Patients' characteristics did not significantly differ between the two groups. In the PL group, 34 underwent video-assisted thoracoscopic surgery (VATS), and 6 underwent robot-assisted thoracoscopic surgery. In the IF group, all 11 underwent VATS. Operation duration, estimated blood loss, and postoperative complication frequency were not significantly different between these groups, but the maximum tumor diameter showed a significant difference.

CONCLUSIONS

Complete TS of the S9, S10, and both through the PL is a reasonable option for tumors located in such segments. This approach is a feasible option for performing TS.

Computer-assisted image-based risk analysis and planning in lung surgery - a review

In this paper, we give an overview on current trends in computer-assisted image-based methods for risk analysis and planning in lung surgery and present our own developments with a focus on computed tomography (CT) based algorithms and applications. The methods combine heuristic, knowledge based image processing algorithms for segmentation, quantification and visualization based on CT images of the lung. Impact for lung surgery is discussed regarding risk assessment, quantitative assessment of resection strategies, and surgical guiding. In perspective, we discuss the role of deep-learning based AI methods for further improvements.

The intersegmental pulmonary vein is not always located on the intersegmental plane of the lung: Evaluation with 3-dimensional volume-rendering image reconstruction

Objective

To clarify whether intersegmental pulmonary veins are always located on the intersegmental plane and determine the division from which blood flows into them.

Methods

We analyzed representative intersegmental veins located between the upper/lingular and superior/basal division of the lungs using preoperative chest computed tomography (CT) DICOM data from 22 patients who underwent lobectomy or segmentectomy during 2020. The location and blood flow of V³a+b and V⁶b+c were assessed using REVORAS (Ziosoft), a novel volume-rendering 3-dimensional (3D) image reconstruction software dedicated to lung segmentectomy.

Results

The V³a+b was in the upper division and on the intersegmental plane between the upper and lingular divisions of the left lung in 11 patients (50%) each. A main root of V³a+b was not found in the lingular division, but some peripheral flow in the V³a+b was derived from it in 14 patients (64%). The V⁶b+c was found in the superior division of the right lower lobe in 13 patients (59%) and the left lower lobe in 10 patients (45%), and on the intersegmental plane between the superior and basal division of the right lower lobe in 6 patients (27%) and the left lower lobe in 10 patients (45%). A main root of V⁶b+c was imperceptible in the basal division. Some peripheral blood flow was derived from the basal division in 6 patients (27%) with V⁶b+c veins located in the right lower lobe and in 8 patients (36%) with V⁶b+c veins located in the left lower lobe.

Conclusions

Precise evaluation of intersegmental veins using preoperative volume-rendering 3D reconstructed CT images provides useful anatomic information for separating intersegmental pulmonary parenchyma.

Adoption of Robotic Core Technology in Minimally Invasive Lung Segmentectomy: Review

A recent randomized trial demonstrated the survival superiority of lung segmentectomy over lobectomy in patients with early stage, small-sized lung cancer. Hence, there is a pressing need for thoracic surgeons to gain familiarity with lung segmentectomy. However, lung segmentectomy, especially via minimally invasive surgery, is a technically challenging thoracic surgical procedure. The robotic surgery platform helps surgeons to improve their operative performance based on its core technological features: improved dexterity, precision, and visualization. Herein, we have discussed the key issues related to robotic lung segmentectomy, explicitly focusing on the technical features of complex segmentectomy under difficult conditions. We have also introduced our preferred surgical strategy for robotic lung segmentectomy with specific maneuvers.

A fully automated noncontrast CT 3-D reconstruction algorithm enabled accurate anatomical demonstration for lung segmentectomy

Background

Three‐dimensional reconstruction of chest computerized tomography (CT) excels in intuitively demonstrating anatomical patterns for pulmonary segmentectomy. However, current methods are labor‐intensive and rely on contrast CT. We hereby present a novel fully automated reconstruction algorithm based on noncontrast CT and assess its performance both independently and in combination with surgeons.

Methods

A retrospective pilot study was performed. Patients between May 2020 to August 2020 who underwent segmentectomy in our single institution were enrolled. Noncontrast CTs were used for reconstruction. In the first part of the study, the accuracy of the demonstration of anatomical variants by either automated or manual reconstruction algorithm were compared to surgical observation, respectively. In the second part of the study, we tested the accuracy of the identification of anatomical variants by four independent attendees who reviewed 3‐D reconstruction in combination with CT scans.

Results

A total of 20 cases were enrolled in this study. All segments were represented in this study with two left S1‐3, two left S4 + 5, one left S6, five left basal segmentectomies, one right S1, three right S2, 1 right S2b + 3a, one right S3, two right S6 and two right basal segmentectomies. The median time consumption for the automated reconstruction was 280 (205–324) s. Accurate vessel and bronchial detection were achieved in 85% by the AI approach and 80% by Mimics, p = 1.00. The accuracy of vessel classification was 80 and 95% by AI and manual approaches, respectively, p = 0.34. In real‐world application, the accuracy of the identification of anatomical variant by thoracic surgeons was 85% by AI+CT, and the median time consumption was 2 (1–3) min.

Conclusions

The AI reconstruction algorithm overcame defects of traditional methods and is valuable in surgical planning for segmentectomy. With the AI reconstruction, surgeons may achieve high identification accuracy of anatomical patterns in a short time frame.

Application of Mimics Medical 21.0 software in thoracoscopic anatomical sublobectomy

BACKGROUND

The anatomical structure of pulmonary segments is complex, and there are many anatomical variations, making the operation more difficult, so we used Mimics Medical 21.0 software for three-dimensional computed tomography bronchography and angiography (3D-CTBA), carefully formulated the surgical plan and on this basis completed the video-assisted thoracoscopic anatomical sublobectomy.

METHODS

A total of 38 patients with pulmonary nodules were selected and received video-assisted thoracoscopic anatomical sublobectomy after using Mimics Medica 21.0 software for 3D-CTBA.

RESULTS

The mean operative duration was 158.42±20.21 minutes, and the operative hemorrhage was 97.66±22.37 mL. In pathological diagnoses, there were 5 benign cases (13.2%), 9 cases with atypical adenomatous hyperplasia (23.7%), 12 cases with adenocarcinoma in situ (31.6%), 11 cases with minimally invasive adenocarcinoma (28.9%) and 1 case with invasive adenocarcinoma (2.6%); 8.29±0.98 lymph nodes sampled had no metastasis. The chest tube drainage duration and postoperative hospitalstay were 2.47±0.73 days and 5.47±0.73 days, respectively.

CONCLUSIONS

Using Mimics Medical 21.0 software can quickly and accurately complete 3D-CTBA, which is beneficial to formulate a personalized anatomical sublobectomy surgical plan.

Technical Advances in Segmentectomy for Lung Cancer: A Minimally Invasive Strategy for Deep, Small, and Impalpable Tumors

With the increased detection of early-stage lung cancer and the technical advancement of minimally invasive surgery (MIS) in the field of thoracic surgery, lung segmentectomy using MIS, including video- and robot-assisted thoracic surgery, has been widely adopted. However, lung segmentectomy can be technically challenging for thoracic surgeons due to (1) complex segmental and subsegmental anatomy with frequent anomalies, and (2) difficulty in localizing deep, small, and impalpable tumors, leading to difficulty in obtaining adequate margins. In this review, we summarize the published evidence and discuss key issues related to MIS segmentectomy, focusing on preoperative planning/simulation and intraoperative tumor localization. We also demonstrate two of our techniques: (1) three-dimensional computed tomography (3DCT)-based resection planning using a novel 3DCT processing software, and (2) tumor localization using a novel radiofrequency identification technology.

Anatomical analysis of the left upper lobe of lung on three-dimensional images with focusing the branching pattern of the subsegmental veins

Background

A clear understanding of the anatomical characteristics of the pulmonary veins (PVs) is essential for the successful performance of segmentectomy and important to avoid intraoperative pulmonary vessels injury. However, there is no report showing the relations between the branching patterns of PVs and pulmonary arteries (PAs). Moreover, internationally accepted symbols for describing PVs remain unavailable. For anatomically assessing the branches and courses of the subsegmental veins in the left upper lobe (LUL), the diverse branching patterns of blood vessels and bronchi should be investigated.

Methods

The branching patterns and intersegmental courses of PVs were assessed by performing three-dimensional image analysis of the bronchi, and PAs and PVs in the LUL in 103 patients who were scheduled to receive segmentectomy in LUL from January 2008 through August 2012.

Results

Branching types of the bronchi and pulmonary vessels failed to be independent each other. Although the combinations of anterior extension type of bronchus with the inter-lobar type (IL-type) of arterial branching pattern were often observed, but those with the mediastinal type (M-type) were rarely observed. The combinations of apical vein dominant type with the IL-type of arteries, and intermediate and central vein types with the M-type were often observed. Since LUL was adjoined by various subsegments, and the intersegmental pulmonary veins showed diverse patterns.

Conclusions

This study found the relationship among PA, PV, and bronchus patterns, in the subsegment where the branching patterns were fixed in 103 cases. This study discovered PVs that was difficult to be named by the conventional naming systems because of the diversity of the locations in the subsegment.

Three-dimensional computed tomography reconstruction for operative planning in robotic segmentectomy: a pilot study

Background

The objective of our pilot study was to assess if three-dimensional (3D) reconstruction performed by Visible Patient™ could be helpful for the operative planning, efficiency and safety of robot-assisted segmentectomy.

Methods

Between 2014 and 2015, 3D reconstructions were provided by the Visible Patient™ online service and used for the operative planning of robotic segmentectomy. To obtain 3D reconstruction, the surgeon uploaded the anonymized computed tomography (CT) image of the patient to the secured Visible Patient™ server and then downloaded the model after completion.

Results

Nine segmentectomies were performed between 2014 and 2015 using a pre-operative 3D model. All 3D reconstructions met our expectations: anatomical accuracy (bronchi, arteries, veins, tumor, and the thoracic wall with intercostal spaces), accurate delimitation of each segment in the lobe of interest, margin resection, free space rotation, portability (smartphone, tablet) and time saving technique.

Conclusions

We have shown that operative planning by 3D CT using Visible Patient™ reconstruction is useful in our practice of robot-assisted segmentectomy. The main disadvantage is the high cost. Its impact on reducing complications and improving surgical efficiency is the object of an ongoing study.

Three-dimensional image reconstruction with free open-source OsiriX software in video-assisted thoracoscopic lobectomy and segmentectomy

OBJECTIVE

The aim of this retrospective study was to evaluate the practice and the feasibility of Osirix, a free and open-source medical imaging software, in performing accurate video-assisted thoracoscopic lobectomy and segmentectomy.

METHODS

From July 2014 to April 2016, 63 patients received anatomical video-assisted thoracoscopic surgery (VATS), either lobectomy or segmentectomy, in our department. Three-dimensional (3D) reconstruction images of 61 (96.8%) patients were preoperatively obtained with contrast-enhanced computed tomography (CT). Preoperative resection simulations were accomplished with patient-individual reconstructed 3D images. For lobectomy, pulmonary lobar veins, arteries and bronchi were identified meticulously by carefully reviewing the 3D images on the display. For segmentectomy, the intrasegmental veins in the affected segment for division and the intersegmental veins to be preserved were identified on the 3D images. Patient preoperative characteristics, surgical outcomes and postoperative data were reviewed from a prospective database.

RESULTS

The study cohort of 63 patients included 33 (52.4%) men and 30 (47.6%) women, of whom 46 (73.0%) underwent VATS lobectomy and 17 (27.0%) underwent VATS segmentectomy. There was 1 conversion from VATS lobectomy to open thoracotomy because of fibrocalcified lymph nodes. A VATS lobectomy was performed in 1 case after completing the segmentectomy because invasive adenocarcinoma was detected by intraoperative frozen-section analysis. There were no 30-day or 90-day operative mortalities CONCLUSIONS: The free, simple, and user-friendly software program Osirix can provide a 3D anatomic structure of pulmonary vessels and a clear vision into the space between the lesion and adjacent tissues, which allows surgeons to make preoperative simulations and improve the accuracy and safety of actual surgery.

Do the lung segments exist continuously from the early stage of the embryonic period as units?

OBJECTIVES

Although various types of segmentectomy are frequently performed for resecting lung tumours at present, there is no clear answer to the question what kind of segmentectomy would be more efficient for performing lymphadenectomy. Learning the embryological mechanism of the segment formation could be one of the methods for selecting the surgical procedure. To investigate the developmental mechanism of the lung, this study focused on 'sharing structure', a unique 3D structure consisting of the bronchi and pulmonary arteries. In the structure, two arteries from different directions, after straddling the bronchus in the central part, share one bronchial tree at the peripheral part.

METHODS

Using computed tomography data obtained before segmentectomy, this study observed the 'sharing structure' in 193 left and right upper lobe cases. This study investigated the relationship between the segmental arterial types and the straddled bronchi, which were straddled by the pulmonary arteries found in the centre of the sharing structure.

RESULTS

In the right upper lobes, the straddled bronchi were anterior segmental bronchi. In the left upper lobes, however, the straddled bronchi of the lingular interlobar pulmonary artery type contained no anterior segmental bronchi. But, the straddled bronchi of lingular mediastinal pulmonary artery type contained anterior segmental bronchi in all cases.

CONCLUSIONS

Although pulmonary arteries in almost all sharing structures in the right upper lobes straddled anterior bronchi, those in mediastinal type and interlobar type in the left upper lobe were found to straddle the anterior and apicoposterior bronchi, respectively. These findings indicated that the interlobar type was speculated to be rotating mediastinal type backward in the embryonic period. This study strongly suggested a new concept that 'the lung segments never continuously exist from the early stage of the embryonic period as units, but they are only simple units artificially named by their prevailing bronchial branching patterns'. Therefore, during segmentectomy including lymphadenectomy for pulmonary tumours, the retrieval of the branching patters of pulmonary arteries could allow the segmentectomy to become more efficient with considering the formations of lung lobes.

Navigating the mesentery: a comparative pre- and per-operative visualization of the vascular anatomy

AIM

Awareness of anatomy is critical for performing safe surgery within the root of the mesentery. Our aim was to investigate the anatomical relationship between the superior mesenteric artery (SMA) and vein (SMV) and their branches within a predefined D3 area of the right colon and to compare preoperatively established three-dimensional (3D) mesenteric vessel anatomy from CT with that found at surgery.

METHOD

Prospective data were collected on 139 patients included in the 'Safe Radical D3 Right Hemicolectomy for Cancer Through Preoperative Biphasic Multi-detector Computed Tomography (MDCT) Angiography' trial. CT data sets were 3D reconstructed before surgery and compared with photographs taken during the operation.

RESULTS

The ileocolic artery was present and correctly identified in all patients and crossed the SMV anteriorly in 58 (41.7%). Seventeen patients had a right colic artery at surgery and there were three false-negative and one false-positive CT findings, yielding a diagnostic accuracy of 97.1%, sensitivity of 85.7% and specificity of 95.2%. Positive and negative predictive values were 94.7% and 97.5%, respectively. The middle colic artery was absent in one (0.7%) patient and multiple (nine double and one triple) in 10 (7.2%) patients. A mean of 3.8 ± 1.2 jejunal arteries and 2.0 ± 0.8 jejunal veins arose from the SMA and SMV. Jejunal veins crossed the SMA in the D3 area anteriorly in 30.9% of patients. In 26 (18.7%) patients, additional veins drained into the SMV, including pancreaticoduodenal in 16, right colic in six and both in two. The inferior mesenteric vein entered the SMV in 58 (41.7%) patients and crossed the D3 area in three (2.2%).

CONCLUSION

CT-reconstructed anatomy has high specificity, sensitivity, accuracy and reliability.

Preoperative Prediction of Ki-67 Labeling Index By Three-dimensional CT Image Parameters for Differential Diagnosis Of Ground-Glass Opacity (GGO)

The aim of this study was to predict Ki-67 labeling index (LI) preoperatively by three-dimensional (3D) CT image parameters for pathologic assessment of GGO nodules. Diameter, total volume (TV), the maximum CT number (MAX), average CT number (AVG) and standard deviation of CT number within the whole GGO nodule (STD) were measured by 3D CT workstation. By detection of immunohistochemistry and Image Software Pro Plus 6.0, different Ki-67 LI were measured and statistically analyzed among preinvasive adenocarcinoma (PIA), minimally invasive adenocarcinoma (MIA) and invasive adenocarcinoma (IAC). Receiver operating characteristic (ROC) curve, Spearman correlation analysis and multiple linear regression analysis with cross-validation were performed to further research a quantitative correlation between Ki-67 labeling index and radiological parameters. Diameter, TV, MAX, AVG and STD increased along with PIA, MIA and IAC significantly and consecutively. In the multiple linear regression model by a stepwise way, we obtained an equation: prediction of Ki-67 LI=0.022*STD+0.001* TV+2.137 (R=0.595, R’s square=0.354, p<0.001), which can predict Ki-67 LI as a proliferative marker preoperatively. Diameter, TV, MAX, AVG and STD could discriminate pathologic categories of GGO nodules significantly. Ki-67 LI of early lung adenocarcinoma presenting GGO can be predicted by radiologic parameters based on 3D CT for differential diagnosis.

Binocular stereo-navigation for three-dimensional thoracoscopic lung resection

Background

This study investigated the efficacy of binocular stereo-navigation during three-dimensional (3-D) thoracoscopic sublobar resection (TSLR).

Methods

From July 2001, the authors’ department began to use a virtual 3-D pulmonary model on a personal computer (PC) for preoperative simulation before thoracoscopic lung resection and for intraoperative navigation during operation. From 120 of 1-mm thin-sliced high-resolution computed tomography (HRCT)-scan images of tumor and hilum, homemade software CTTRY allowed sugeons to mark pulmonary arteries, veins, bronchi, and tumor on the HRCT images manually. The location and thickness of pulmonary vessels and bronchi were rendered as diverse size cylinders. With the resulting numerical data, a 3-D image was reconstructed by Metasequoia shareware. Subsequently, the data of reconstructed 3-D images were converted to Autodesk data, which appeared on a stereoscopic-vision display. Surgeons wearing 3-D polarized glasses performed 3-D TSLR.

Results

The patients consisted of 5 men and 5 women, ranging in age from 65 to 84 years. The clinical diagnoses were a primary lung cancer in 6 cases and a solitary metastatic lung tumor in 4 cases. Eight single segmentectomies, one bi-segmentectomy, and one bi-subsegmentectomy were performed. Hilar lymphadenectomy with mediastinal lymph node sampling has been performed in 6 primary lung cancers, but four patients with metastatic lung tumors were performed without lymphadenectomy. The operation time and estimated blood loss ranged from 125 to 333 min and from 5 to 187 g, respectively. There were no intraoperative complications and no conversion to open thoracotomy and lobectomy. Postoperative courses of eight patients were uneventful, and another two patients had a prolonged lung air leak. The drainage duration and hospital stay ranged from 2 to 13 days and from 8 to 19 days, respectively. The tumor histology of primary lung cancer showed 5 adenocarcinoma and 1 squamous cell carcinoma. All primary lung cancers were at stage IA. The organs having metastatic pulmonary tumors were kidney, bladder, breast, and rectum. No patients had macroscopically positive surgical margins.

Conclusions

Binocular stereo-navigation was able to identify the bronchovascular structures accurately and suitable to perform TSLR with a sufficient margin for small pulmonary tumors.

Lung cancer in situs inversus totalis (SIT)--literature review

We present 21 studies of cases of lung cancer in patients with situs inversus totalis (SIT) published worldwide. The first case was described in 1952. Thirteen patients were from Japan, 4 from Eastern Europe, including 2 Polish cases from the authors` center (Department of Thoracic Surgery, Pomeranian Medical University in Szczecin, Poland), 2 from Western Asia, 1 from the U.S. and 1 from Australia. Male patients (20/21) as well as left-sided lung cancer cases (14/21) and squamous cell carcinoma cases (8/21) dominated in the entire group. Thirteen patients underwent surgical treatment. There were 10 left-sided and 3 right-sided surgical interventions with uneventful intra- and postoperative course. Explorative thoracotomy was performed in one case only on the right side. Upper lobectomy was performed in 5 cases, pneumonectomy in 3 cases, lower bilobectomy and middle lobectomy in one case and lower lobectomy in two cases. Surgery was performed through thoracotomy in 10 cases, VATS-assisted approach in two cases and sternotomy in one case. Descriptions of the surgical anatomy confirmed mirror image of the anatomy in all cases and were consistent with the preoperative CT images. Preoperative diagnosis was discussed including the role of 3-D reconstruction of CT for improving perioperative safety in this group of patients. In conclusion, lung cancer/SIT cases despite inversed but regular anatomy can be operated on radically as cases with normal anatomy with preservation of intraoperative security level.

Comparison of 3D reconstructive technologies used for morphometric research and the translation of knowledge using a decision matrix

The use of three-dimensional (3D) models for education, pre-operative assessment, presurgical planning, and measurement have become more prevalent. With the increase in prevalence of 3D models there has also been an increase in 3D reconstructive software programs that are used to create these models. These software programs differ in reconstruction concepts, operating system requirements, user features, cost, and no one program has emerged as the standard. The purpose of this study was to conduct a systematic comparison of three widely available 3D reconstructive software programs, Amira(®), OsiriX, and Mimics(®) , with respect to the software's ability to be used in two broad themes: morphometric research and education to translate morphological knowledge. Cost, system requirements, and inherent features of each program were compared. A novel concept selection tool, a decision matrix, was used to objectify comparisons of usability of the interface, quality of the output, and efficiency of the tools. Findings indicate that Mimics was the best-suited program for construction of 3D anatomical models and morphometric analysis, but for creating a learning tool the results were less clear. OsiriX was very user-friendly; however, it had limited capabilities. Conversely, although Amira had endless potential and could create complex dynamic videos, it had a challenging interface. These results provide a resource for morphometric researchers and educators to assist the selection of appropriate reconstruction programs when starting a new 3D modeling project.

Complete video-assisted thoracoscopic multi-subsegmentectomy based on patients' specific virtual 3-D pulmonary models

INTRODUCTION

Video-assisted thoracoscopic surgery is widely used for resecting early-stage non-small cell lung cancer. Segmentectomy and subsegmentectomy require a thorough knowledge of the 3-D bronchovascular anatomy of the lung. Previously, our department reported using a 3-D pulmonary model of a patient for thoracoscopic surgical treatment of non-small cell lung cancer. This study investigates multi-segmentectomy for patients with non-small cell lung cancer.

METHODS

Between July 2001 and January 2012, 943 patients underwent surgical resection of primary lung cancer. Of these, 11 patients had video-assisted thoracoscopic multi-subsegmentectomy. For preoperative simulation, virtual 3-D pulmonary models have been constructed since July 2001.

RESULTS

The mean age of patients was 69.2 ± 11.6 years (range, 43.0-86.0 years). Histological diagnoses included adenocarcinoma in eight patients, squamous cell carcinoma in two, and large cell carcinoma (neuroendocrine tumor) in one. Tumor size was ≤ 10 mm in one patient, 11-15 mm in four, 16-20 mm in four, and 21-25 mm in two. One patient was treated without lymphadenectomy, nine patients underwent additional hilar lymphadenectomy, and one patient underwent additional hilar and mediastinal lymphadenectomy. No patients were converted to thoracotomy. All patients had a macroscopically negative surgical margin. The pathological stage of patients was IA in nine patients, IB in one, and IIA in one. No pulmonary vessel injuries were found. Three patients had a prolonged lung air leak (> 6 days).

CONCLUSION

Using a reconstructed 3-D pulmonary model, this study demonstrates that video-assisted thoracoscopic multiple subsegmentectomy is feasible with adequate margins in selected patients.

Three-dimensional simulation, surgical navigation and thoracoscopic lung resection

This report describes a 3-dimensional (3-D) video-assisted thoracoscopic lung resection guided by a 3-D video navigation system having a patient-specific 3-D reconstructed pulmonary model obtained by preoperative simulation. A 78-year-old man was found to have a small solitary pulmonary nodule in the left upper lobe in chest computed tomography. By a virtual 3-D pulmonary model the tumor was found to be involved in two subsegments (S1 + 2c and S3a). Complete video-assisted thoracoscopic surgery bi-subsegmentectomy was selected in simulation and was performed with lymph node dissection. A 3-D digital vision system was used for 3-D thoracoscopic performance. Wearing 3-D glasses, the patient's actual reconstructed 3-D model on 3-D liquid-crystal displays was observed, and the 3-D intraoperative field and the picture of 3-D reconstructed pulmonary model were compared.

Three dimensional computed tomography lung modeling is useful in simulation and navigation of lung cancer surgery

The number of minimally invasive operations, such as video-assisted thoracoscopic surgery (VATS) lobectomy or segmentectomy, has enormously increased in recent years. These operations require extreme knowledge of the anatomy of pulmonary vessels and bronchi in each patient, and surgeons must carefully dissect the branches of pulmonary vessels during operation. Thus, foreknowledge of the anatomy of each patient would greatly contribute to the safety and accuracy of the operation. The development of multi-detector computed tomography (MDCT) has promoted three dimensional (3D) images of lung structures. It is possible to see the vascular and bronchial structures from the view of the operator; therefore, it is employed for preoperative simulation as well as navigation during operation. Due to advances in software, even small vessels can be accurately imaged, which is useful in performing segmentectomy. Surgical simulation and navigation systems based on high quality 3D lung modeling, including vascular and bronchial structures, can be used routinely to enhance the safety operation, education of junior staff, as well as providing a greater sense of security to the operators.