CONSERVATION OF LUNG TISSUE BY PARTIAL LOBECTOMY

Comparison of stapler and electrocautery for division of the intersegmental plane in lung segmentectomy

Background

We retrospectively compared the use of a stapler and electrocautery for division of the intersegmental plane during pulmonary segmentectomy.

Methods

We enrolled 156 patients who underwent pulmonary segmentectomy in our department between March 2006 and August 2020. The patients were divided into electrocautery (n=62) and stapler (n=94) groups based on the device used to divide the intersegmental plane. Patient characteristics, perioperative outcomes, and ratios of actual (calculated using software) to predicted (calculated by counting the resected segments) lung volumes were compared between the two groups. Additionally, we used multivariate analysis to identify the factors that contributed to the incidence of postoperative air leakage after cut-off value was set by receiver operating characteristic (ROC) curve analysis. Moreover, a subset analysis was performed based on the type of segmentectomy (common or uncommon). Common segmentectomies included resection of the basilar or superior segment of the lower lobe, or lingular or upper division of the left upper lobe; all other segmentectomies were classified as uncommon.

Results

Compared to the electrocautery group, the stapler group had shorter operative times (P=0.0027), duration of postoperative drainage (P=0.00037), and duration of postoperative hospitalization (P=0.0021). Moreover, incidence of postoperative ≥3 days drainage was significantly reduced in the stapler group (P=0.003). There were no significant differences between the stapler and electrocautery groups in the actual:predicted lung volumes at 6 months (1.01 and 1.04, respectively; P=0.28) or 12 months (1.06 and 1.07, respectively; P=0.68) after surgery. Preoperative lung volume was significantly correlated with preoperative vital capacity (VC) (γ=0.69; P<0.001) and forced expiratory volume in 1 second (FEV₁) (γ=0.48; P<0.001). The multivariate analysis indicated that the use of stapler for division of intersegmental plane was the only factor that contributed to reducing the incidence of postoperative ≥3 days drainage (P=0.0027, odds ratio: 0.23, 95% CI: 0.086–0.597). In a subset analysis of uncommon segmentectomy, there were no significant differences among the groups in most perioperative results.

Conclusions

Compared to electrocautery, the use of a stapler for division of the intersegmental plane was associated with better perioperative outcomes, especially reduction of postoperative drainage time, and similar postoperative remnant lung volumes and function.

Identification of the intersegmental plane during thoracoscopic segmentectomy: state of the art

During thoracoscopic segmentectomy, where direct palpation of the tumour is not always possible, achieving adequate margins from the cancer is of crucial importance. It is thus mandatory to accurately identify the intersegmental plane (ISP). Indeed, inadequate determination and division of the ISP can lead to unsatisfactory oncological results. Our systematic review focused on the effectiveness of the different techniques for identifying the ISP, highlighting the fact that a 1-size-fits-all method is not feasible. Based on the published evidence, 6 main methods were reported, each with its pros and cons: inflation-deflation technique, selective resected segmental inflation, systemic injection of indocyanine green, injection of endobronchial dye, 3-dimensional simulation using multidetector computed tomography and virtual-assisted lung mapping. In conclusion, ISP demarcation is mandatory to achieve a high rate of success of thoracoscopic segmentectomy, and it is very helpful in surgical planning, especially when preoperative multidetector computed tomography and 3-dimensional reconstructions are routinely performed.

Thoracoscopic segmentectomy for small-sized peripheral lung cancer

Background

Lung segmentectomy is a therapeutic option in containing pathological diagnosis and radical cure for small-sized peripheral lung cancer. We retrospectively investigated the results of thoracoscopic segmentectomy (TS-S).

Methods

From April 2008 to December 2016, 191 patients who underwent TS-S for small-sized peripheral lung cancer were reviewed retrospectively. Intentional indication of TS-S is peripheral radiologically noninvasive lung cancer whose tumor size is less than 2 cm in size with consolidation to tumor (C/T) ratio less than 0.5. Compromised indication is radiologically invasive lung cancer (C/T ration more than 0.5) which we can keep sufficient surgical margin.

Results

We performed TS-S in 191 patients (81 males and 110 females, median age 66 years). The mean diameter of the nodules was 15 mm (range, 6-46 mm), and clinical IA/IB was 184/7, respectively. Intentional indication was 145 (76%) and compromised one was 46 (24%). The mean operation time was 169 min (range, 73-319 min) and the mean blood loss was 42 g (range, 0-2,900 g). One procedure was converted to open thoracotomy due to bleeding of pulmonary artery (conversion rate, 0.5%). The median chest drainage duration was 1 day (range, 1-9 days), and the median postoperative hospital stay was 7 days (range, 3-30 days). Postoperative complications occurred in 19 patients (10%), including air leak lasting more than 7 days in 3 patients, and late phase air leak in 1 patient. There was no 30-day mortality. Median follow-up was 52 months. The 5-year overall survival (OS) rates and relapse free survival rates, including deaths from all causes, were 93.4% and 90.8%, respectively. During this period, there were 4 distal recurrences after TS-S. However, there was no local recurrence.

Conclusions

Our result of TS-S was an acceptable. Appropriate selection of patient and surgical procedure in TS-S is important issue.

Novel techniques for video-assisted thoracoscopic surgery segmentectomy

Small lung cancers are being increasing diagnosed because of advances in computed tomography (CT) and low-dose CT screening. Sublobar resection of peripheral, small lung nodules, such as ground-glass nodules, is a useful therapeutic option that obtains both a pathological diagnosis and radical cure. Lung segmentectomy is a better option than wedge resection for securing a sufficient surgical margin and can also be used to assess hilar nodes. Anatomical segmentectomy, however, is a technically more complicated operative procedure than standard lobectomy. We describe the issues and novel techniques of video-assisted thoracoscopic segmentectomy.

Determination of the intersegmental plane using the slip-knot method

Background

Visualization of intersegmental planes in the lung is desirable for precise anatomical lung segmentectomy. We developed the slip-knot method for creating inflation-deflation lines. This study aimed to assess relevant data for thoracoscopic segmentectomy performed using this method.

Methods

In the slip-knot method, the objective segmental bronchus is looped with a monofilament thread. One end of the thread is then pulled during temporary bilateral ventilation, causing the knot to slip toward the bronchus. Thereafter, bronchial ligation is tightened to block the outflow of segmental air, ensuring that the segment remains expanded while the other reserved segments collapse on resumption of unilateral ventilation. Data from 221 patients who underwent thoracoscopic pulmonary segmentectomy between 2010 and 2016 were analyzed.

Results

A total of 147 patients (67%) were indicated for the slip-knot method, and 74 cases (33%) were non-adaptive cases. Ninety six percent of 147 cases were well adapted to the slip-knot method, which allowed us to obtain good inflation-deflation line images to determine the intersegmental plane. The mean operative time was 171±51 min (range, 71-367 min). The mean duration of chest tube insertion was 1.5±1.2 days (range, 1-7 days). Three cases (2.0%) had prolonged air-leakage and one (0.7%) case had readmission for late air-leakage.

Conclusions

Our method enables determination of anatomical intersegmental planes using only one monofilament thread, thus facilitating thoracoscopic pulmonary anatomical segmentectomy.

How to demarcate intersegmental plane with resected-segments inflation method using the slip knot technique in thoracoscopic anatomic segmentectomy

Intersegmental demarcation line on the surface of the visceral pleura could not be found at thoracoscopic findings. The resected segments inflation (RSI) method has been reported as a useful technique for visualizing the intersegmental demarcation line during segmentectomy. Thoracoscopic anatomic segmentectomy is performed as follows: firstly, the pulmonary vein and artery of the segment planned for resection are dissected from the hilum in order to isolate the segmental bronchus located behind the pulmonary artery. Secondly, a monofilament non-absorbable suture is passed through the segmental bronchus, and a slip-knot is made outside the thorax. Thirdly, bilateral lung ventilation with pure oxygen is conducted. When the affected segment has inflated sufficiently, the slip knot suture is pulled and the segmental bronchus is ligated and collapse of the lung is made on reserved segments. Fourthly, as inflation of the affected segment and collapse of the reserved segments could be found, resection of intersegmental plane could be easily performed with the inflation-deflation line and the intersegmental pulmonary vein. If resected segmental bronchus could be identified, thoracoscopic segmentectomy with the slip-knot technique would be applicable. This slip-knot procedure is economical and is not need special instrument.

Left lower lobectomy and systematic lymph node dissection by complete video-assisted thoracic surgery

A 50-year-old female was administered with left lower lobe lesion for 10 days. A preoperative chest computed tomography (CT) revealed a mass in the left basilar segment of the lung, about 2.1 cm × 1.7 cm in size. Therefore, video-assisted thoracic surgery (VATS) left lower lobectomy was performed. The operation takes 60 minutes. During the operation, the estimated blood loss was 15 mL. The patient was discharged on postoperative day (POD) 6 with no complications. And the pathological results confirmed the diagnosis of adenocarcinoma with no lymph nodes metastasis.

Anatomic segmental resection of the lung by thoracoscopy: an experimental study

In patients who are unable to undergo a lobectomy for a small peripheral lung cancer, a partial thoracoscopic resection appears to be one viable alternative. However, since the regional lymphatics are disrupted in an anatomical fashion with a segmentectomy, it appears superior to a wedge resection. This experimental study was conducted to determine whether or not an anatomical segmental resection is feasible by thoracoscopy. A segmental resection of porcine lungs was performed using thoracoscopy. The segmental vessels were divided between ligatures. The segmental bronchus was divided by an endoscopic stapler. The intersegmental lung parenchyma was divided using a cotton dissector and a contact neodymium-yttrium aluminum garnet laser. Forty-three pigs were divided into seven groups as follows. Group 1: S1 + 2; group 2: S3; group 3: upper division; group 4: lower division; group 5: S6; group 6:S8; and group 7: S9 + 10. The operating times ranged from 145 +/- 15 min to 191 +/- 47 min. Blood loss ranged from 36 +/- 35 ml to 151 +/- 48 ml in all groups. The blood loss in the group with a resection of S6 and S9 + 10 was significantly greater than that of the other five groups. Most of the blood loss occurred during the division between the intersegmental planes. In conclusion, a thoracoscopic segmentectomy is considered to be technically feasible; however, further refinements in this technique are warranted before beginning clinical trials.

Naming the bronchopulmonary segments and the development of pulmonary surgery

An international agreement on bronchial nomenclature and anatomy was not reached until well after operations for bronchopulmonary segmental disease were well developed. R. C. Brock, in 1950, was the reporter of the efforts of The Thoracic Society of Great Britain to bring some order to this confused state. This Society delayed its action until an ad hoc committee made up of members from other countries and specialties met at the International Congress of Otorhinolaryngology in 1949. The anatomy and nomenclature of the bronchopulmonary segments was agreed upon. The Thoracic Society then accepted the report of the ad hoc committee. The system was followed closely by the first Nomina Anatomica in 1955. This report did not open new surgical vistas but was the marker indicating that pulmonary surgery was now mature.

Practical correlative anatomy of the bronchial tree and lungs

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