Three-dimensional computed tomography angiography and bronchography combined with three-dimensional printing for thoracoscopic pulmonary segmentectomy in stage IA non-small cell lung cancer

The advantages of preoperative 3D reconstruction over 2D-CT in thoracoscopic segmentectomy

Performing a pulmonary segmentectomy is a complex process, with precise localization of pulmonary nodules and recognition of intraoperative anatomical variations posing significant challenges. This study aims to assess the advantages of preoperative three-dimensional reconstruction (3D-RE) in thoracoscopic segmentectomy. The study, at Fujian Medical University Cancer Hospital, analyzed data from segmentectomy patients from January 2016 to February 2022. It compared 3D-RE and two-dimensional computed tomography (2D-CT) preoperative scans, focusing on perioperative complications within30 days to identify any differences. This investigation encompassed a total of 265 instances, with 148 belonging to the 3D-RE group and 117 aligned with the 2D-CT group. The 3D-RE group showed reduced intraoperative blood loss and shorter postoperative hospital stays (P < 0.001). They also had higher rates of lymph node sampling and combined subsegmentectomy and segmentectomy procedures (P < 0.01). Postoperative complications, particularly pneumonia and lung fistula, were lower in the 3D-RE group (P = 0.041). The rates of minimally invasive adenocarcinoma (MIA) and invasive adenocarcinoma (IAC) were significantly higher in the 3D-RE group, while adenocarcinoma in situ (AIS) and benign cases were less common (P = 0.006). Surgical duration, chest tube duration, chest drainage volume, surgery complexity, and pathological diagnoses showed no significant differences between the groups. Utilization of preoperative 3D-RE holds potential to minimize both intraoperative and postoperative complications, thereby enhancing the safety and feasibility of undertaking segmentectomy procedures.

Evolution of Three-Dimensional Computed Tomography Imaging in Thoracic Surgery

Radiologic reconstruction technology allows the wide use of three-dimensional (3D) computed tomography (CT) images in thoracic surgery. A minimally invasive surgery has become one of the standard therapies in thoracic surgery, and therefore, the need for preoperative and intraoperative simulations has increased. Three-dimensional CT images have been extensively used, and various types of software have been developed to reconstruct 3D-CT images for surgical simulation worldwide. Several software types have been commercialized and widely used by not only radiologists and technicians, but also thoracic surgeons. Three-dimensional CT images are helpful surgical guides; however, in almost all cases, they provide only static images, different from the intraoperative views. Lungs are soft and variable organs that can easily change shape by intraoperative inflation/deflation and surgical procedures. To address this issue, we have developed a novel software called the Resection Process Map (RPM), which creates variable virtual 3D images. Herein, we introduce the RPM and its development by tracking the history of 3D CT imaging in thoracic surgery. The RPM could help develop a real-time and accurate surgical navigation system for thoracic surgery.

Application of uniportal video-assisted thoracoscopic surgery for segmentectomy in early-stage non-small cell lung cancer: A narrative review

Uniportal video-assisted thoracoscopic surgery (UVATS) segmentectomy has emerged as an effective approach for managing early-stage non-small-cell lung cancer (NSCLC). Compared to conventional open and thoracoscopic surgeries, this minimally invasive surgical technique offers multiple benefits, including reduced postoperative discomfort, shorter hospital stays, expedited recovery, fewer complications, and superior cosmetic outcomes. Particularly advantageous in preserving lung function, UVATS segmentectomy is a compelling option for patients with compromised lung capabilities or limited pulmonary reserve. Notably, it demonstrates promising oncological results in early-stage NSCLC, with long-term survival rates comparable to those of lobectomies. Skilled thoracic surgeons can ensure a safe and effective execution of UVATS despite the potential technical challenges posed by complex tumor locations that may hinder visibility and maneuverability within the thoracic cavity. This study provided a comprehensive review of the literature and existing studies on UVATS segmentectomies. It delves into the evolution of the technique, its current applications, and the balance between its benefits and limitations. This discussion extends the technical considerations, challenges, and prospects of UVATS segmentectomy. Furthermore, it aimed to update advancements in segmentectomy for treating early-stage NSCLC, offering in-depth insights to thoracic surgeons to inform more scientifically grounded and patient-specific surgical decisions.

Harnessing 3D-CT Simulation and Planning for Enhanced Precision Surgery: A Review of Applications and Advancements in Lung Cancer Treatment

The clinical application of three-dimensional computed tomography (3D-CT) technology has rapidly expanded in the last decade and has been applied to lung cancer surgery. Two consecutive reports of large-scale prospective clinical trials from Japan and the United States have brought a paradigm shift in lung cancer surgery and may have led to a rapid increase in sublobar lung resections. Sublobar resection, especially segmentectomy, requires a more precise understanding of the anatomy than lobectomy, and preoperative 3D simulation and intraoperative navigation support it. The latest 3D simulation software packages are user-friendly. Therefore, in this narrative review, we focus on recent attempts to apply 3D imaging technologies, particularly in the sublobar resection of the lung, and review respective research and outcomes. Improvements in CT accuracy and the use of 3D technology have advanced lung segmental anatomy. Clinical applications have enabled the safe execution of complex sublobar resection through a minimally invasive approach, such as video-assisted thoracoscopic surgery and robotic surgery. However, currently, many facilities still render 3D images on two-dimensional monitors for usage. In the future, it will be challenging to further spread and advance intraoperative navigation through the application of 3D output technologies such as extended reality.

Three Dimensional Printing as a Tool For Anatomical Training in Lung Surgery

Objective

Pulmonary anatomy is challenging, due to the high variability and its three-dimensional (3D) shape. While demands in thoracic oncologic surgery are increasing, the transition from open to thoracoscopic surgery is hampering anatomical understanding. This study analyzed the value of a 3D printed lung model in understanding and teaching anatomy.

Methods

A 3D pulmonary model was created and tested among different levels of proficiency: 10 experienced surgeons, 10 fellow surgeons and 10 junior residents. They were tested in interpretation of anatomy based on thoracic CT-scans, either using the 3D model or a 2D anatomical atlas. Accuracy of the given answers, time to complete the task and the self-reported level of certainty were scored in each group.

Results

In the experienced surgeons group there was no difference in between the 2D-model or 3D-model with a high rate of correct answers in both groups, and no differences in time or certainty. Fellow surgeons highly benefitted from the 3D-model with an improved accuracy from 26.6% to 70.0% (p = 0.001). Time to complete the task was shorter (207 versus 122 s, p < 0.0001) and participants were more secure (median of 4 versus 3, p = 0.007). For junior residents time to complete the task was shorter, the level of certainty was higher, but there was no improvement in accuracy.

Conclusions

3D printing may benefit in understanding anatomical relations in the complex anatomy of the bronchiopulmonary tree, especially for surgeons in training and could benefit in teaching anatomy.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40670-023-01807-x.

Clinical application of VATS combined with 3D-CTBA in anatomical basal segmentectomy

Objective

This study aimed to summarize the clinical application experience of video-assisted thoracic surgery (VATS) combined with three-dimensional computed tomography-bronchography and angiography (3D-CTBA) in anatomical basal segmentectomy.

Methods

Clinical data of 42 patients who underwent bilateral lower sub-basal segmentectomy by VATS combined with 3D-CTBA in our hospital from January 2020 to June 2022 were retrospectively analyzed; the patients included 20 males and 22 females, with a median age of 48 (30-65) years. Combined with the preoperative enhanced CT and 3D-CTBA techniques to identify the altered bronchi, arteries, and veins during the operation, the anatomical resection of each basal segment of both lower lungs was completed through the fissure approach or inferior pulmonary vein approach.

Results

All operations were successfully completed without conversion to thoracotomy or lobectomy. The median operation time was 125 (90-176) min, the median intraoperative blood loss was 15 (10-50) mL, the median postoperative thoracic drainage time was 3 (2-17) days, and the median postoperative hospital stay was 5 (3-20) days. The median number of resected lymph nodes was 6 (5-8). There was no in-hospital death. Postoperative pulmonary infection occurred in 1 case, lower extremity deep vein thrombosis (DVT) in 3 cases, pulmonary embolism in 1 case, and persistent air leakage in the chest in 5 cases, all of which were improved by conservative treatment. Two cases of pleural effusion after discharge were improved after ultrasound guided drainage. Postoperative pathology showed 31 cases of minimally invasive adenocarcinoma, 6 cases of adenocarcinoma in situ (AIS), 3 cases of severe atypical adenomatous hyperplasia (AAH), and 2 cases of other benign nodules. All cases were lymph node-negative.

Conclusion

VATS combined with 3D-CTBA is safe and feasible in anatomical basal segmentectomy; consequently, this approach should be promoted and applied in clinical work.

[Port-only 4-Arms Robotic Segmentectomy Under Artificial Pneumothorax]

BACKGROUND

At present, robotic surgery is widely used in thoracic surgery, which has higher maneuverability, precision, and stability, especially for small space complex operations and reconstructive surgery. The advantages of robotic lung segment resection under full orifice artificial pneumothorax are obvious.

METHODS

Based on a large number of clinical practices, we established a set of surgical methods for 4-arm robotic lung segment resection under a port-only artificial pneumothorax. 98 cases of robotic lung segment resection were performed with this method from January 2019 to August 2022. The clinical experience was summarized.

RESULTS

Robotic lung segment resection under port-only artificial pneumothorax has obvious advantages in the anatomy of lung segment vessels and bronchi. It is characterized by less bleeding, shorter operation time, adequate exposure, and flexible operation.

CONCLUSIONS

This surgical model we propose optimizes the operation mode and technique of lung segment resection, makes each step procedural, reduces collateral damage, and is easy to learn and master, which is believed to cure more lung cancer patients with less trauma.

Application of three-dimensional (3D) reconstruction in the treatment of video-assisted thoracoscopic complex segmentectomy of the lower lung lobe: A retrospective study

Background

An increasing number of lung ground-glass nodules (GGNs) have been detected ever since low-dose computer tomography started growing in popularity. Three-dimensional (3D) reconstruction technology plays a critical role in lung resection, especially in segmentectomy. In this study, we explore the role of 3D reconstruction in thoracoscopic complex segmentectomy of lower lung lobe.

Methods

A total of 97 patients who underwent complex segmentectomy of lower lung lobe from January 2021 to March 2022 were retrospectively analyzed. We divided these patients into a 3D group (n = 42) and a routine group (n = 55) based on preoperative 3D reconstruction or without this procedure. The demographics of patients and GGNs were collected and perioperative outcomes were compared between the two groups.

Results

All of the baseline characteristics between the groups were comparable (all P > 0.05). There was no 30-day postoperative mortality and conversion in the two groups. The operation time of the 3D group was significantly shorter than that of the routine group (111.4 ± 20.8 min vs. 127.1 ± 32.3 min, P = 0.007). The number of stapler reloads during surgery in the 3D group was less than that in the routine group (9.0 ± 2.2 vs. 10.4 ± 2.6, P = 0.009). The rate of air leakage on postoperative days 1–3 was lower in the 3D group (11.9% vs. 30.9%, P = 0.027). In addition, the resection margins of all patients in the 3D group were adequate, while four patients in the routine group had inadequate resection margins, although there was no statistically significant difference (P = 0.131). Intraoperative blood loss, postoperative drainage, postoperative hospital stay, pneumonia/atelectasis, and hemoptysis were similar between the two groups.

Conclusions

For performing complex segmentectomy of the lower lung lobe, the procedure of 3D reconstruction may shorten the operation time, decrease the number of stapler reloads, prevent postoperative air leakage, and guarantee a safe surgical margin. Therefore, 3D reconstruction is recommended for complex segmentectomy of the lower lung lobe.

Preoperative Three-Dimensional Lung Simulation Before Thoracoscopic Anatomical Segmentectomy for Lung Cancer: A Systematic Review and Meta-Analysis

Background

Whether the utilization of preoperative three-dimensional (3D) lung simulation can improve the outcomes of segmentectomy for lung cancer (LC) is still controversial. Our meta-analysis was performed to compare preoperative 3D lung simulation with non-3D procedures in terms of perioperative outcomes.

Methods

Seven databases (Embase, Ovid Medline, ScienceDirect, PubMed, Web of Science, Cochrane Library, and Scopus) were searched for eligible articles. Intraoperative outcomes (conversion, operative time, etc.), postoperative indicators (postoperative hospital stay, total number of complications, etc.) and postoperative complications were endpoints.

Results

After applying predefined inclusion criteria, we included 8 studies and 989 patients (3D group: 552 patients; non-3D group: 437 patients) in our meta-analysis. The results of the meta-analysis showed that preoperative 3D lung simulation could significantly decrease the blood loss (mean difference [MD]: -16.21 [-24.95 to -7.47]ml, p = 0.0003), operative time (MD: -13.03 [-25.56 to -0.50]ml, p = 0.04), conversion rate (conversion from segmentectomy to thoracotomy or lobectomy) (MD: 0.12 [0.03-0.48], p = 0.003), postoperative hospital stay (MD: -0.25 [-0.46 to 0.04]days, p = 0.02) and total number of complications (MD: 0.59 [0.43-0.82], p = 0.001) compared with non-3D procedures. The number of resected lymph nodes (LNs), postoperative drainage time, postoperative forced expiratory volume in the first second (postoperative FEV1) and postoperative drainage volume were similar in the two groups. Arrhythmia (5.30%), pulmonary air leakage (2.72%), atrial fibrillation (2.20%), pulmonary infection (2.04%), and pneumonia (1.73%) were the top 5 postoperative complications in the 3D group.

Conclusions

Preoperative 3D lung simulation was better than non-3D procedures in segmentectomy for LC, with better intraoperative and postoperative outcomes. However, our results should be confirmed in larger prospective randomized controlled trials.

Systematic Review Registration

PROSPERO, identifier: CRD42021275020.

A modified system for classifying the bilateral superior pulmonary veins using three-dimensional computed tomography bronchography and angiography images

Background

Identifying the distribution of pulmonary veins with three-dimensional reconstruction images is of great significance for surgical guidance. Existing models neglect the consistency of the bilateral superior pulmonary veins (SPVs) and lack a simple unified classification pattern. This study aimed to analyze the distributional features of bilateral SPVs, based on a cohort of patients undergoing CT examination.

Methods

The three-dimensional computed tomography bronchography and angiography (3D-CTBA) images of 1,520 cases were retrospectively analyzed. The reconstructed images of the right upper lobes were read in 715 cases, and left upper lobes in 805 cases. Through symmetrical analysis, the circulation of main venous branches and the spatial relationships of confluences with adjacent bronchus were compared.

Results

The SPVs of bilateral upper lobes showed common distributional features and were divided into three main types. The central vein type, the semi-central vein type, and the non-central vein type accounted for 83.35% [596], 7.84% [56], 8.11% [58] of the 715 cases with right scanning, and 25.71% [207], 62.61% [504], 10.81% [87] of the 805 cases with left scanning, respectively. There were 5 (0.70%) cases with rare variations in the right upper lobe and 7 (0.87%) in the left upper lobe. The attribution of intersubsegmental vein in the posterior segment (V²b) and its position relative to the anterior segmental bronchus (B³) was the basis of classification in the right upper lobe, and the attribution of intersubsegmental vein in the apicoposterior segment (V¹⁺²c) and its position relative to B³ was the basis of classification in the left upper lobe. In this classification system, the branching pattern of the intersegmental vein between the apical segment and the anterior segment (V¹b) in the right upper lobe, and the intersegmental vein between the apicoposterior segment and the anterior segment (V^{1+ 2}a) in the left upper lobe were used for subdivision.

Conclusions

Our modified system had a high degree of consistency in classifying SPVs in bilateral upper lobes, thus providing guidance for preoperative and intraoperative procedures.