Thoracoscopic anatomic segmentectomies for lung cancer: technical aspects

3D printing in anatomical lung segmentectomies: A randomized pilot trial

Objective

This pilot study evaluated the impact of using a 3D printed model of the patient's bronchovascular lung anatomy on the mental workload and fatigue of surgeons during full thoracoscopic segmentectomy.

Design

We performed a feasibility pilot study of a prospective randomized controlled trial with 2 parallel arms. All included patients underwent digital 3D visual reconstruction of their bronchovascular anatomy and were randomized into the following two groups: Digital arm (only a virtual 3D model was available) and Digital + Object arm (both virtual and printed 3D models were available). The primary end-point was the surgeons' mental workload measured using the National Aeronautics and Space Administration-Task Load Index (NASA-TLX) score.

Setting

Between October 28, 2020 and October 05, 2021, we successively investigated all anatomic segmentectomies performed via thoracoscopy in the Thoracic Department of the Montsouris Mutualiste Institute, except for S6 segmentectomies and S4+5 left bi-segmentectomies.

Participants

We assessed 102 patients for anatomical segmentectomy. Among the, 40 were randomly assigned, and 34 were deemed analysable, with 17 patients included in each arm.

Results

Comparison of the two groups, each comprising 17 patients, revealed no statistically significant difference in primary or secondary end-points. The consultation of the visual digital model was significantly less frequent when a 3D printed model was available (6 versus 54 consultations, p = 0.001). Notably, both arms exhibited high NASA-TLX scores, particularly in terms of mental demand, temporal demand, and effort scores.

Conclusion

In our pilot study, 3D printed models and digital 3D reconstructions for pre-operative planning had an equivalent effect on thoracoscopic anatomic segmentectomy for experienced surgeons. The originality of this study lies in its focus on the impact of 3D printing of bronchovascular anatomy on surgeons, rather than solely on the surgical procedure.

Thoracoscopic segmentectomy versus lobectomy: A propensity score–matched analysis

Objectives

The aim of this study is to compare the postoperative complications, perioperative course, and survival among patients from the multicentric Spanish Video-assisted Thoracic Surgery Group database who received video-assisted thoracic surgery lobectomy or video-assisted thoracic surgery anatomic segmentectomy.

Methods

From December 2016 to March 2018, a total of 2250 patients were collected from 33 centers. Overall analysis (video-assisted thoracic surgery lobectomy = 2070; video-assisted thoracic surgery anatomic segmentectomy = 180) and propensity score–matched adjusted analysis (video-assisted thoracic surgery lobectomy = 97; video-assisted thoracic surgery anatomic segmentectomy = 97) were performed to compare postoperative results. Kaplan–Meier and competing risks method were used to compare survival.

Results

In the overall analysis, video-assisted thoracic surgery anatomic segmentectomy showed a lower incidence of respiratory complications (relative risk, 0.56; confidence interval, 0.37-0.83; P = .002), lower postoperative prolonged air leak (relative risk, 0.42; 95% confidence interval, 0.23-0.78; P = .003), and shorter median postoperative stay (4.8 vs 6.2 days; P = .004) than video-assisted thoracic surgery lobectomy. After propensity score–matched analysis, prolonged air leak remained significantly lower in video-assisted thoracic surgery anatomic segmentectomy (relative risk, 0.33; 95% confidence interval, 0.12-0.89; P = .02). Kaplan–Meier and competing risk curves showed no differences during the 3-year follow-up (median follow-up in months: 24.4; interquartile range, 20.8-28.3) in terms of overall survival (hazard ratio, 0.73; 95% confidence interval, 0.45-1.7; P = .2), tumor progression–related mortality (subdistribution hazard ratio, 0.41; 95% confidence interval, 0.11-1.57; P = .2), and disease-free survival (subdistribution hazard ratio, 0.73; 95% confidence interval, 0.35-1.51; P = .4) between groups.

Conclusions

Video-assisted thoracic surgery segmentectomy showed results similar to lobectomy in terms of postoperative outcomes and midterm survival. In addition, a lower incidence of prolonged air leak was found in patients who underwent video-assisted thoracic surgery anatomic segmentectomy.

Surgeon Knowledge of the Pulmonary Arterial System and Surgical Plan Confidence Is Improved by Interactive Virtual 3D-CT Models of Lung Cancer Patient Anatomies

Objective: Interactive three-dimensional virtual models of pulmonary structures (3D-CT) may improve the safety and accuracy of robotic-assisted thoracic surgery (RATS). The aim of this study was to evaluate the impact of 3D-CT models as an imaging adjunct on surgical confidence and anatomical assessment for lobectomy planning. Methods: We retrospectively analyzed the response of 10 specialist thoracic surgeons who each reviewed 10 pre-operative images of patients undergoing robotic-assisted lobectomy lung cancer cases from June to November 2018 in our institute, resulting in 100 data points. The number of arteries, veins, and bronchi entering the resected lobes were determined from the operation video recording by the operating surgeon. 3D-CT models were generated for each case and made available for online visualization and manipulation. Thoracic surgeons were invited to participate in the survey which consisted of evaluation of CT (control) and 3D-CT (intervention) models. A questionnaire regarding anatomical structures, surgical approach, and confidence was administered. Results: Ten participants were recruited. 3D-CT models led to a significant (p < 0.003) increase in the surgeons' ability to correctly identifying pulmonary arteries entering the resection lobes in 35% (CT) and 57% (3D-CT) of cases. A significant (p < 1e-13) improvement in anatomy assessment and surgical plan confidence was observed for the 3D-CT arm, with median Likert scale scores of "2-Slightly easy" (CT) and "4-Very easy" (3D-CT). Conclusion: The use of 3D-CT models for thoracic surgery planning increases the surgeon confidence in recognizing anatomical structures, largely by enhanced appreciation of anatomical variations in the segmental pulmonary arterial system. Further studies are needed to investigate if 3D-CT models can be used in providing precise information about segmental artery distribution and therefore surgical planning of sub-lobar resections.

Robotic segmentectomy: indication and technique

Use of low-dose CT scan allows detection of lung cancer at early stages, enabling a more conservative surgery and a better long-term survival in those patients. In this scenario, intentional anatomical segmentectomy is gaining consent over standard lobectomy among surgeons. A minimally invasive approach such as VATS reduced invasiveness and complication rate compared to open surgery, but this technique comes also with some disadvantages in terms of dexterity and intuitiveness. Robotic surgery allows to overcome those limitations, making segmentectomies easier and safer to perform. In addition, it offers the possibility to utilize intravenous indocyanine green to define the intersegmental plane, allowing a more precise surgery. We reviewed the literature and describe the technique of the robot assisted segmentectomy with a focus on the new technologies available nowadays.

Towards Virtual VATS, Face, and Construct Evaluation for Peg Transfer Training of Box, VR, AR, and MR Trainer

The aim of this study is to develop and assess the peg transfer training module face, content and construct validation use of the box, virtual reality (VR), cognitive virtual reality (CVR), augmented reality (AR), and mixed reality (MR) trainer, thereby to compare advantages and disadvantages of these simulators. Training system (VatsSim-XR) design includes customized haptic-enabled thoracoscopic instruments, virtual reality helmet set, endoscope kit with navigation, and the patient-specific corresponding training environment. A cohort of 32 trainees comprising 24 novices and 8 experts underwent the real and virtual simulators that were conducted in the department of thoracic surgery of Yunnan First People's Hospital. Both subjective and objective evaluations have been developed to explore the visual and haptic potential promotions in peg transfer education. Experiments and evaluation results conducted by both professional and novice thoracic surgeons show that the surgery skills from experts are better than novices overall, AR trainer is able to provide a more balanced training environments on visuohaptic fidelity and accuracy, box trainer and MR trainer demonstrated the best realism 3D perception and surgical immersive performance, respectively, and CVR trainer shows a better clinic effect that the traditional VR trainer. Combining these in a systematic approach, tuned with specific fidelity requirements, medical simulation systems would be able to provide a more immersive and effective training environment.

Preoperative 3-dimensional computed tomography lung simulation before video-assisted thoracoscopic anatomic segmentectomy for ground glass opacity in lung

Background

Three-dimensional (3D) simulation of pulmonary vessels and the space between the lesion and adjacent tissues may improve the safety and accuracy of video-assisted thoracoscopic surgery (VATS) for lung. The aim of this study was to evaluate the effect of 3D simulation on the outcome of VATS segmentectomy for ground glass opacity (GGO) in lung.

Methods

We retrospectively analyzed 68 cases of small (≤2 cm) GGO, which were diagnosed as cT1aN0M0 lung cancer, from May 1, 2016 to February 28, 2017 in our institute. All the patients underwent VATS segmentectomy. The patients were divided into "3D" group, 3D preoperative reconstruction simulation in 36 patients and "non-3D" group, 32 patients with only computed tomography (CT). Operation plans were firstly made by CT in all patients, then by 3D simulation only in 3D group. The clinical outcomes, including operation time, blood loss, resection margin distance, length of postoperative stay and postoperative complications were compared between the two groups.

Results

There were 21 male and 47 female analyzed, aging from 34 to 72 years (median 57). In 3D group, pathological result showed 8 cases of adenocarcinoma, 23 cases of microinvasive adenocarcinoma (MIA), 5 cases of adenocarcinoma in situ (AIS). In non-3D group, 18 cases of MIA, 9 cases of adenocarcinoma and 5 cases of AIS were diagnosed pathologically. The blood loss, postoperative hospital stay and the incidence of the postoperative complications were similar in both of the groups. There was no 30-day postoperative mortality in either group. The median operation time for the 3D group (111 minute) was shorter than non-3D group (139 minute) (P=0.03). Seven cases (19%) in 3D group changed the original operation plan according to the simulation result with the consideration of adequate resection margin distance. All cases in 3D group had adequate resection margin distance. Four cases (13%) in non-3D group got inadequate resection margin distance, and more lung tissues than the original plan were then resected in these patients (P=0.04).

Conclusions

3D preoperative simulation may be more precise in operation plan than CT scan and can significantly shorten the operation time in VATS segmentectomy for GGO in lung.

Thoracoscopic segmentectomy: hybrid approach for clinical stage I non-small cell lung cancer

Background

Recently, minimally invasive surgical approaches have been developed, typified by video-assisted thoracic surgery (VATS). A meticulous surgical procedure to prevent local recurrence is required during segmentectomy for clinical stage I non-small-cell primary lung cancer. In this article, we demonstrated the validity of hybrid VATS segmentectomy.

Methods

Of these 125 patients, 62 (49.6%) underwent intensively radical segmentectomy (RS). The remaining 63 (50.4%) patients underwent palliative segmentectomy (PS). We used two 2-cm ports and performed a muscle-sparing mini-thoracotomy in which a partially open metal retractor allowed direct, thoracoscopic visualization as hybrid VATS segmentectomy in 63.2% of our cases.

Results

The consolidation/tumor ratio obtained with thin-sliced computed tomography was significantly lower in RS cases than in PS cases (P=0.001). The proportion of pathological stage IA cases was significantly higher in RS cases (95.2%) than in PS cases (66.7%; P<0.01). Five-year overall survival (OS) for clinical stage I was 100.0% in RS cases and 73.5% in PS cases (log-rank P<0.001). Five-year disease-free survival (DFS) was 95.5% and 55.7%, respectively (log-rank P<0.001).

Conclusions

During segmentectomy, the most critical consideration is establishment of sufficient surgical margins around the cancer. Our hybrid approach that includes meticulous surgical manipulations may produce sufficient surgical margins.

Planning and marking for thoracoscopic anatomical segmentectomies

Although sublobar resection (SLR) for treating non-small cell lung carcinoma (NSCLC) is still controversial, thoracoscopic segmentectomy is rising. Performing it by closed chest surgery is complex as it means confirming the location of the lesion, identifying vascular and bronchial structures, preserving venous drainage of adjacent segments, severing the intersegmental plane and ensuring an oncological safety margin with no manual palpation and different landmarks. Accurate planning is mandatory. We discuss in this article the interest of 3D reconstruction and mapping technics to enhance safety and reliability of these procedures.

Development of a precision multimodal surgical navigation system for lung robotic segmentectomy

Minimally invasive sublobar anatomical resection is becoming more and more popular to manage early lung lesions. Robotic-assisted thoracic surgery (RATS) is unique in comparison with other minimally invasive techniques. Indeed, RATS is able to better integrate multiple streams of information including advanced imaging techniques, in an immersive experience at the level of the robotic console. Our aim was to describe three-dimensional (3D) imaging throughout the surgical procedure from preoperative planning to intraoperative assistance and complementary investigations such as radial endobronchial ultrasound (R-EBUS) and virtual bronchoscopy for pleural dye marking. All cases were operated using the DaVinci System^TM. Modelisation was provided by Visible Patient™ (Strasbourg, France). Image integration in the operative field was achieved using the Tile Pro multi display input of the DaVinci console. Our experience was based on 114 robotic segmentectomies performed between January 2012 and October 2017. The clinical value of 3D imaging integration was evaluated in 2014 in a pilot study. Progressively, we have reached the conclusion that the use of such an anatomic model improves the safety and reliability of procedures. The multimodal system including 3D imaging has been used in more than 40 patients so far and demonstrated a perfect operative anatomic accuracy. Currently, we are developing an original virtual reality experience by exploring 3D imaging models at the robotic console level. The act of operating is being transformed and the surgeon now oversees a complex system that improves decision making.

Division of the intersegmental plane using electrocautery for segmentectomy in clinical stage I non-small cell lung cancer

Background

Division of intersegmental planes is one of the important practical issues for segmentectomy to obtain feasible outcomes without relapse for clinical stage I non-small cell lung cancer. Almost all surgeons perform this procedure using a stapler. However, division of intersegmental planes for segmentectomy can also be performed by electrocautery. In this article, we demonstrate the merits and drawbacks of division of the intersegmental plane by electrocautery for segmentectomy.

Methods

Of those 125 patients who underwent segmentectomy with clinical stage I primary lung cancer, we compared cautery cases (n=50) with stapler cases (n=75). The cautery group included 29 cases (58.0%) with partial use of a staple at the end of division.

Results

Operative time was significantly longer in cautery cases (281±72 min) than stapler in cases (235±86 min; P=0.003). No difference in the duration of chest tube placement was evident between cautery (3.0±3.0 days) and stapler groups (2.8±1.7 days; P=0.613). However, delayed air leakage occurred significantly more frequently in cautery cases (14.0%) than in stapler cases (4.0%; P=0.048). Five-year overall survival (OS) in clinical stage I was 94.7% in cautery cases and 80.5% in stapler cases (log-rank P=0.047). Five-year disease-free survival (DFS) was 80.0% and 71.3%, respectively (log-rank P=0.075).

Conclusions

The merits of cautery division include the ability to achieve meticulous division of the intersegmental plane and good preservation of the shape of residual segments. Conversely, the drawbacks include prolonged air leakage. Pleural suture or closure of residual segments may be useful to prevent delayed air leakage.