Uniportal VATS right superior lobectomy: management of pulmonary vein variation: a case report

Clinical observation of three-dimensional reconstruction in thoracoscopic segmental pneumonectomy

BACKGROUND

Accurately identifying the branches of pulmonary segmental vessels and bronchi, as well as adjacent structures, and determining the spatial location of lesions within pulmonary segments, are major challenges for thoracic surgeons. The application of three-dimensional reconstruction technology holds promise in addressing this issue.

OBJECTIVE

To evaluate the clinical value of three-dimensional reconstruction in thoracoscopic segmental surgery.

METHODS

Seventy-seven patients who underwent thoracoscopic segmental surgery combined with three-dimensional reconstruction at our hospital from January 1, 2020, to August 31, 2023, were retrospectively analyzed. Preoperative chest enhanced CT scans were conducted, and MIMICS software aided in reconstructing DICOM format original data for patients with pulmonary nodules to facilitate intraoperative nodule localization. Accurate segmental pneumonectomy was performed by comparing preoperative anatomical identification of target segmental arteries, veins, and bronchi, with surgical details and postoperative outcomes recorded, including intraoperative pulmonary resection distribution, operation time, blood loss, chest tube drainage, extubation time, hospital stay, and complications.

RESULTS

Following preoperative three-dimensional reconstruction, successful segmental lung surgeries were performed, predominantly with single segmental resection (92.2%), and a minority with combined segmentectomy (7.8%). Median operation time was 130225 minutes, with intraoperative blood loss at 70100 mL and postoperative chest tube drainage at 347 mL (159690 mL). Median extubation time and hospital stay were 4 days and 7 days, respectively. Complications within the 3-month follow-up affected 11.7% of cases, including persistent pulmonary leakage (7.1%), pulmonary infection (4.3%), atelectasis (4.3%), and pleural effusion (1.4%), with no fatalities.

CONCLUSION

Preoperative 3D reconstruction can help the operator to perform safe, efficient and accurate thoracoscopic segmental pneumonectomy, which is worth popularizing in clinic.

En Bloc Right Upper Bilobectomy For a Patient With Incomplete Minor Fissure and Multiple Anomalies of the Right Superior Pulmonary Vein

Variations in the anomaly of the right superior pulmonary vein can lead to perioperative complications if misunderstood. Additionally, incomplete fissures increase the complexity of performing pulmonary anatomical resection. Therefore, accurate preoperative anatomical assessment using three-dimensional computed tomography is crucial for ensuring safe surgery. We herein report a case of en bloc right upper bilobectomy via uniportal video-assisted thoracic surgery in a patient with an incomplete minor fissure and a complex anomaly of the right superior pulmonary vein.

Robotic Right Lower Lobectomy in a Patient With V2 and V4+5 Pulmonary Vein Variation Merging Into the Lower Pulmonary Vein: A Case Report

Several variations of pulmonary vein (PV) branching patterns exist. Since robot-assisted thoracoscopic surgery (RATS) is performed with magnified vision, it is crucial to carefully identify the running pattern of blood vessels before and during surgery. We present a case of a 77-year-old male patient with right lower lobe lung cancer. Right lower lobectomy via RATS was scheduled. Chest CT before surgery confirmed that the middle lobe PV (V4+5) merged with the inferior PV. Three-dimensional multidetector CT (3D-MDCT) subsequently confirmed that not only V4+5 but also the posterior segmental vein of the upper lobe (V2) merged with the inferior PV. We should have taped the lower lobe PV only, but we also taped the V2 and the middle lobe vein. However, since the oblique fissure was separated before cutting the taped blood vessel, the cutting of the blood vessel to be preserved was avoided. Surgeons should have a detailed understanding of the running patterns of pulmonary blood vessels before surgery to perform the procedure safely. Preoperative 3D-MDCT is useful for identifying the running pattern of blood vessels. An abnormality involving V2 and V4+5 merging into the inferior PV can also occur; hence, during right lower lobe resection, by dividing the lower lobe PV after the oblique fissure division, the surgeon can avoid unexpected transection of anomalous PVs that should be preserved.

[Application Value of Artificial Intelligence-assisted Three-dimensional Reconstruction in Planning Thoracoscopic Segmentectomy]

BACKGROUND

The three-dimensional (3D) can assist in planning lung segmentectomy. 3D reconstruction software based on artificial intelligence algorithm is gradually applied in clinic. The aim of this study was to evaluate the accuracy and safety of 3D reconstruction assisted planning of thoracoscopic segmentectomy.

METHODS

A total of 90 patients admitted to Department of Thoracic Surgery of Lanzhou University Second Hospital were evaluated for thoracoscopic segmentectomy. Before operation, artificial intelligence 3D reconstruction software was used to make 3D lung images and conduct preoperative planning. Surgical videos were saved during the operation and perioperative data were recorded. Video recordings of 38 patients were selected to explore the effectiveness of artificial intelligence 3D reconstruction for surgical planning. The results of artificial intelligence 3D reconstruction and Mimics 21 software reconstruction were compared with the actual results in the operation, and the detection and classification ability of bronchus and blood vessels of the two reconstruction methods were compared.

RESULTS

All the 90 patients underwent artificial intelligence 3D reconstruction planning, including 57 patients (63.3%) with single lung segmentectomy and 33 patients (36.7%) with combined sub-segmentectomy. The accuracy of artificial intelligence 3D reconstruction for lesion localization was 100.0%, and the accuracy of computed tomography (CT) was 94.4% (85/90). The detection accuracy of artificial intelligence 3D reconstruction and Mimics 21 software was 92.1% (35/38) and 89.5% (34/38), and the anatomic typing accuracy was 89.5% (34/38) and 84.2% (32/38), and the total accuracy was 76.3% (29/38) and 71.1% (27/38). In the comparative observation of 38 surgical videos and reconstructed images, the consistent rates of target segment planning, surgical approach, artery dissection, vein dissection and bronchial dissection for preoperative planning using artificial intelligence 3D reconstruction were 92.1% (35/38), 92.1% (35/38), 89.5% (34/38), 86.8% (33/38) and 94.7% (36/38). The overall planning operational consistency rate was 68.4% (26/38).

CONCLUSIONS

It is accurate and safe to use artificial intelligence 3D reconstruction to assist planning thoracoscopic segmentectomy.

Application of three-dimensional reconstruction of left upper lung lobes in anatomical segmental resection

BACKGROUND

The lobar and segmental anatomy are the basis for anatomical pulmonary segmentectomy.

METHODS

From October 2017 to June 2021, 136 patients with small pulmonary nodules scheduled for anatomical pulmonary segmentectomy at our institution underwent three-dimensional (3D) lung reconstruction. The anatomy of the left upper lobe (LUL) was statistically analyzed and graphically mapped using the reconstructed models, and the role of this reconstruction method in performing pulmonary segmentectomy was explored.

RESULTS

Through the analysis of the reconstructed models, the upper stem (S1 + 2 + 3) bronchus was classified as having two (94/136 cases) or three branches (42/136 cases). The upper stem artery had two branches in 24/136 patients, three in 60/136 cases, four in 44/136 cases, and five in 8/136 cases. A total of 103/136 upper stem veins had two branches, 26/136 had three branches, and 7/136 had four branches. The lingual stem (S4 + 5) bronchus was two-branched in 116/136 cases and three-branched in 20/136 cases, while the lingual artery was single-branched in 61/136 cases, two-branched in 70/136 cases, and three-branched in rare cases (5/136 cases). The lingual stem vein was unbranched in 119/136 cases and two-branched in 17/136 cases. Additionally, six unusual variants (<5%) were identified: one in the bronchus, with four cases; three in the pulmonary artery, with six cases; and two in the pulmonary vein, with two cases.

CONCLUSIONS

3D reconstruction can yield results similar to specimens for lung segment studies. The reconstruction strategy and the data presented in this article will be valuable references for thoracic surgeons performing anatomic resections.