Thoracoscopic stapler-based "bidirectional" segmentectomy for posterior basal segment (S10) and its variants

Uniportal Thoracoscopic Bisegmentectomy of Medial and Posterior Basal Segment (S7+S10)

When a tumor is located in the medial (S7) or posterior (S10) basal segment, it is sometimes necessary to perform a bisegmentectomy of S7 and S10 (S7+S10) to achieve a sufficient surgical margin. In this report, we present surgical techniques for uniportal thoracoscopic S7+S10 bisegmentectomy. The surgical technique consists of anterior and posterior procedures to dissect the basal pulmonary vein. This approach allows en bloc resection of S7+S10 and en bloc preservation of the remaining lobe.

Learning Curve for Thoracoscopic Individual Basilar Segmentectomy: 18-Year Experience

BACKGROUND

Thoracoscopic anatomical individual basilar segmentectomy remains challenging owing to the deep intraparenchymal location of the hilar structures and anatomical variations. We analyzed and reported the experience and progress of thoracoscopic anatomical individual basilar segmentectomy at our university hospital.

METHODS

We retrospectively examined the patients who underwent anatomical basilar segmentectomy at our institution from January 2004 to December 2021. We divided our analysis period into two parts: the first period (2004-2012) was the introductory period of video-assisted thoracoscopic surgery (VATS) segmentectomy, and the second period (2013-2021) was the maturity period of VATS segmentectomy. The learning curve of the leading surgeon in the second period was also evaluated based on the operative time and cumulative sum value of the operative time.

RESULTS

Overall, 127 cases were evaluated, among whom 33 and 94 cases were assessed during the introductory and maturity periods of thoracoscopic segmentectomy, respectively. Age (P = 0.003) and Charlson comorbidity index (P = 0.002) were higher in the second period than in the first period. Use of a uniport (P = 0.006) was higher, and postoperative hospitalization duration (P =  < 0.001) and operative time (P = 0.024) were shorter in the second period than in the first period. A learning curve obtained during the maturity period showed: The inflection point for the learning curve of thoracoscopic basilar segmentectomy was reached after 42 cases.

CONCLUSIONS

We have demonstrated a single institution's progress and learning curve for difficult segmentectomies. This may be helpful to institutions considering performing this surgery.

Simplified Segmentectomy of Right Subsuperior and Posterior Basal Segments

Thoracoscopic segmentectomy, involving the posterior basal segment of the lower lobe, is one of the most challenging procedures and often requires incision of irrelevant lung parenchyma from the interlobar fissure and complex stapling techniques for dividing intersegmental planes. This report describes a simplified thoracoscopic segmentectomy for the subsuperior and posterior basal segments (S∗ + S10), without interlobar fissure dissection or complex intersegmental division.

Inferior pulmonary ligament approach and/or interlobar fissure approach for posterior and/or lateral basal segment resection: a case-series of 31 patients

Background

Thoracoscopic posterior and/ or lateral basal segment resection is a major difficult segmentectomy for thoracic surgeons, because of its high surgical difficulty and high incidence of postoperative complications. Here we describe the surgical procedure and techniques of the transpulmonary ligament approach and/or interlobar fissure approach for the thoracoscopic posterior and/or lateral basal segment resection.

Methods

The clinical data of 31 patients who underwent thoracoscopic posterior and/or lateral basal segment resection from January 2020 to June 2022 were included. All patients underwent posterior and/or lateral basal segment resection via the inferior pulmonary ligament and/or interlobar fissure approach. Follow-up was continued to September 2022.

Results

All patients including 7 males and 24 females, with a median age of 51 [31-62] years, completed the operation successfully. One patient was converted to lobectomy due to insufficient margins intraoperatively. Two patients were treated using the interlobar fissure approach, 25 patients were treated via the inferior pulmonary ligament approach, and four patients were treated by employing both methods. Also, 20 patients had a single lesion and 1 patient had two lesions. Eleven patients underwent surgical resections on other lesions when posterior and/or lateral basal segment lesions resected. The median operation time was 120 [50-290] minutes, the median intraoperative blood loss was 50 [10-100] mL, the median postoperative drainage time was 4 [2-10] days, and the median postoperative hospital stay was 4 [2-13] days. There was no perioperative death. Postoperative complications included five cases of persistent air leakage longer than 5 days (7, 7, 8, 9, and 10 days), and one patient developed a pulmonary infection and abnormal liver function after the operation. The median maximum diameter of the lesion was 0.8 [0.2-1.5] cm, lymph nodes were resected in a median of 8 [4-15] case.

Conclusions

The approach of the inferior pulmonary ligament to resect posterior and/or the lateral basal segment can optimize the surgical procedure. The surgical trauma and postoperative complications are reduced, which is worthy of popularization and application.

Uniportal thoracoscopic lateral and posterior basal segmentectomy using intersegmental tunneling: Comparison with multiportal approach

Thoracoscopic lateral and posterior basal (S9 + 10) segmentectomy (or S10 segmentectomy) is one of the most technically challenging anatomical segmentectomies. We have used "intersegmental tunneling" in the multiportal approach, and we now apply this with a little ingenuity in the uniportal approach. However, because of interference between instruments and the limited insertion angles in the uniportal approach, complex segmentectomies such as S9 + 10 or S10 become even more difficult. The perioperative outcomes were compared between uniportal and multiportal thoracoscopic lateral and posterior basal segmentecomy using intersegmental tunneling. There were no significant differences between the groups in patient characteristics and perioperative outcomes other than operation time, which was significantly shorter in the uniportal group than in the multiportal group (169 ± 21 vs 216 ± 34 min, P = .011). Thoracoscopic S9 + 10 (S10) segmentectomy can be safely performed through the uniportal approach without any difficulties using an intersegmental tunneling method and adding a little ingenuity.

Uniportal video-assisted thoracic surgery basal segmentectomy: a single-center retrospective cohort study

BACKGROUND

Uniportal video-assisted thoracic surgery (VATS) basal segmentectomy is technically challenging and requires a deep understanding of the segmental anatomy of the lung. This report describes the uniportal VATS segmentectomy of basal segments using a single-direction approach.

METHODS

A total of 49 patients who underwent uniportal VATS basal segmentectomy between April 2019 and April 2021 were included in this retrospective study. All the surgeries were conducted using a single-direction approach. The resections of segments 7-8 were mainly performed using the interlobar fissure approach, while the resections of segments 9-10 were performed using the inferior pulmonary ligament approach.

RESULTS

A total of 33 patients underwent a single basal segmentectomy and 16 patients underwent combined basal segmentectomy/sub-segmentectomy. The median operative time was 120 min (range, 60-180 min), and the median blood loss was 20 mL (range, 10-100 mL). The median chest tube duration was 2 days (range, 1-5 days), and the median hospital stay after surgery was 4 days (range, 2-15 days). The morbidity rate after surgery was 6.1% (3/49). There were no perioperative deaths. The pathological examinations revealed 3 cases of adenocarcinoma in situ (AIS), 33 cases of minimally invasive adenocarcinoma, and 13 cases of lepidic-predominant invasive adenocarcinoma. No recrudescence or mortality was reported during the median follow-up time of 7 months (range, 2-25 months).

CONCLUSIONS

Uniportal VATS basal segmentectomy is a feasible and reliable technique based on our experience. This single-direction method allows the uniportal VATS basal segmentectomy to be performed in an easy manner with the targeted segmental bronchi and vessels exposed from superficial to deep in order of their appearance while avoiding the repeated turnover of the lung.

Modified thoracoscopic wedge resection of limited peripheral lesions in S10 for children with congenital pulmonary airway malformation: Initial single-center experience

OBJECTIVE

The present study aimed to evaluate the safety and feasibility of modified thoracoscopic wedge resection of limited peripheral lesions in the posterior basal segment (S10) in children with congenital pulmonary airway malformation (CPAM).

MATERIALS AND METHODS

We retrospectively analyzed the clinical data of children with CPAM who underwent thoracoscopic modified wedge resection at our institution from November 2020 to February 2022. The surgical method was as follows: we marked the external boundary of the lesion with an electric hook, dissected and retained the segmental vein between the lesion and normal lung tissue as the internal boundary, cut the arteries, veins, and bronchus entering the lesion, and cut and sealed the lung tissue between the internal and external boundaries with LigaSure™ to complete the modified wedge resection.

RESULTS

A total of 16 patients were included, aged 3.8-70.0 months and weighing 6.5-21.0 kg. The intraoperative course was uneventful in all patients. The median operation time and intraoperative bleeding volume were 74 min (50-110 min) and 5 mL (5-15 mL), respectively. The median postoperative drainage tube indwelling time was 3 days (2-4 days), and the median postoperative hospital stay was 6 days (4-8 days). Pathological diagnosis included two cases of type 1, 10 cases of type 2, and four cases of type 3 CPAM. There were no cases of intraoperative conversion, surgical mortality, or major complications. However, subcutaneous emphysema occurred in two children, which spontaneously resolved without pneumothorax orbronchopleural fistula development. All patients were followed up for a median period of 10 months (3-18 months), and there were no cases of hemoptysis or residual lesions on chest computed tomography.

CONCLUSION

Modified thoracoscopic wedge resection via the inferior pulmonary ligament approach is safe and feasible for children with CPAM with limited peripheral lesions in S10.

Thoracoscopic anatomical individual basilar segmentectomy

OBJECTIVES

Thoracoscopic anatomical single or combined anatomical individual basilar segmentectomy, including subsegmentectomy, is technically challenging due to variations and the deep location of vessels and bronchi in the parenchyma. However, the long-term perioperative outcomes of various anatomical subsegmentectomy approaches have not been reported. Thus, we investigated the effectiveness of thoracoscopic basilar segmentectomy.

METHODS

We evaluated the records of 119 patients who underwent thoracoscopic single or complex basilar segmentectomy between January 2005 and December 2020 and compared the fissure and non-fissure approach for S9 and/or S10.

RESULTS

A total of 29 patients underwent single segmentectomy, and 90 patients underwent various combined anatomical segmentectomies via video-assisted thoracoscopic surgery and planning using three-dimensional simulation. There were 39 cases of S9 and/or S10 segmentectomy. The median chest tube in-dwell duration and postoperative hospital stay were 1 and 4 days, respectively. The postoperative morbidity (Clavien-Dindo grade II/IIIa) rate was 5.9% without perioperative mortality. Pathological examination revealed 83 cases of lung cancer, 21 cases of metastasis and 15 cases of benign lesions. The postoperative hospitalization duration showed significant differences in the perioperative outcomes between the fissure and non-fissure approaches for S9 and/or S10.

CONCLUSIONS

Thoracoscopic anatomical basilar individual segmentectomy has emerged as a safe and feasible procedure. The non-fissure approach enabled anatomic resection of a single segment or combined basal segments, helped avoid dissection of an incomplete fissure and facilitated surgical outcomes similar to the fissure approach.

Uniportal Thoracoscopic Single-Direction Basal Subsegmentectomy (Left S10a+ci): Trans-Inferior-Pulmonary-Ligament Approach

Thoracoscopic segmentectomy and subsegmentectomy have been widely accepted for the treatment of peripheral small lung cancers. Thoracoscopic basal subsegmentectomy, especially when performed through a uniportal procedure, is extremely technically challenging, and therefore there are seldom reports of its technical details. In this article, we present a uniportal thoracoscopic left S10a+ci subsegmentectomy following the single-direction strategy through the inferior pulmonary ligament approach.

Efficacy of the Segment-Counting Method in Predicting Lung Function and Volume Following Stapler-Based Thoracoscopic Segmentectomy

Purpose: To investigate the accuracy of a segment-counting method in predicting lung function and volume after stapler-based thoracoscopic segmentectomy in comparison with lobectomy.

Methods: Between 2014 and 2018, patients who underwent these procedures were retrospectively reviewed. Thoracic computed tomography and spirometry data before and 1 year after the surgery were assessed. We evaluated the differences between the predicted values using a segment-counting method and the actual postoperative values for lung function and volume in each group. Sub-analyses were also performed to assess the impact of the number of staples and resected segments in predicting patient outcomes.

Results: We included 116 patients (segmentectomy, 69; lobectomy, 47). Actual postoperative lung function and volume values matched the predicted values in the stapler-based segmentectomy group, and significantly exceeded the predictions in the lobectomy group (P <0.01). Sub-analyses revealed lower postoperative lung function values than predicted existed after single segmentectomy, with an odds ratio of 3.29 (95% confidence interval: 1.02–10.70, P = 0.04) in a multivariable analysis. The degree of predicted error regarding lung function was negligible.

Conclusions: The segment-counting method was useful in predicting lung function after stapler-based thoracoscopic segmentectomy. Segmentectomy rarely yielded lower- than-predicted lung function and volume values.

Thoracoscopic complex basilar segmentectomies: an analysis of 63 procedures

Background

Thoracoscopic complex basilar segmentectomies are technically demanding and challenging. We review our experience to check whether this complexity can lead to specific surgical issues or increased post-operative morbidity.

Methods

Complex basilar segmentectomies were defined as the anatomical resection of at least one segment composing the basilar pyramid, excluding S⁶. Data of patients who had an intention-to-treat thoracoscopic complex basilar segmentectomy were retrospectively collected from 2007 to 2019: indications, preoperative assessment, clinical features, operative technical aspects and early post-operative outcome.

Results

Sixty-three patients, 26 men (41%) and 37 women (59%) with a median age of 66 years and a median body mass index (BMI) of 26 kg/m2 were included. Interventions performed were mostly S⁹⁺¹⁰ (n=32) and S⁸ (n=12) segmentectomies. Forty-five planned operations (71%) were completed. Extension to a larger resection was necessary in 17 patients (27%) and 4 patients underwent conversion to open surgery (6%). Median operative time was 168 minutes with a median intraoperative bleeding of 30 mL. Complications occurred in 11 patients (17%). There was no mortality. Median length of pleural drainage was 2 days (range, 1–2 days) and median hospital stay 4 days.

Conclusions

The extension rate of complex basilar segmentectomy is higher than that of other sublobar resections but their post-operative morbidity is identical.

Predictors of failure of intersegmental line creation using bronchoscopic jet ventilation for thoracoscopic pulmonary segmentectomy

BACKGROUND

During pulmonary segmentectomy, identification of the target segment is essential. We used bronchoscopic jet ventilation (BJV) to delineate the intersegmental plane by selectively sending air into the target segment. The purpose of this study was to investigate the factors associated with BJV failure.

METHODS

Data were retrospectively collected from 48 patients who underwent pulmonary segmentectomy with BJV between March 2014 and May 2019 at a single center. Data were compared between BJV succeeded cases and failed cases.

RESULTS

In 13 cases (27%), BJV were unsuccessful. The Brinkman index was significantly higher in failed cases (962 ± 965 failed vs. 395 ± 415 successful, P = 0.0067). The success rate was significantly lower when BJV was applied to the posterior basal segmental bronchus (B10) (B10: 1/5 (20%) vs others: 34/43 (79%), P = 0.015).

CONCLUSION

Long-term smoking and the bronchus corresponding to the posterior basal segment might make successful performance of BJV difficult.

VATS right posterior segmentectomy with anomalous bronchi and pulmonary vessels: a case report and literature review

Background

Anatomic variation may increase the difficulty and risk of anatomic segmentectomy. The preoperative three-dimensional computed tomography bronchography and angiography (3D-CTBA) can provide a detailed model of the segmental structure, and contribute to precise and safe segmentectomy.

Case presentation

This is a case of anomalous bronchi and pulmonary vessels in the right upper posterior segment (RS²). Under the guidance of 3D-CTBA, anatomic RS² segmentectomy was performed accurately and safely. The postoperative condition was uneventful.

Conclusions

This rare case highlights the importance of 3D-CTBA to guild accurate segmentectomy with anatomic variation.

Single-direction thoracoscopic basal segmentectomy

OBJECTIVE

Thoracoscopic anatomic single or combined basal segmentectomy is technically challenging because of the variation and deep location of vessels and bronchi in the parenchyma. This study aimed to describe thoracoscopic segmentectomy of basal segments using a single-direction method.

METHODS

This retrospective study included 137 patients who underwent single or combined thoracoscopic basal segmentectomy between April 2015 and August 2019. All procedures were performed via the preferred inferior pulmonary ligament approach or an interlobar fissure approach following a single-direction strategy.

RESULTS

Ninety patients underwent single basal segmentectomy, and 47 patients underwent combined basal segmentectomy. Median operative time was 125 minutes (range, 52-237 minutes), and median blood loss was 30 mL (range, 5-250 mL). Median chest tube duration was 2 days (range, 1-22 days), and median postoperative hospital stay was 4 days (range, 2-24 days). The postoperative morbidity rate was 5.1% (7/137). No perioperative deaths were identified. Pathological examination revealed 133 cases of lung cancer, 2 cases of metastasis, and 2 cases of benign tumors. No recurrence or mortality was observed during the median follow-up period of 15 months (range, 1-53 months).

CONCLUSIONS

The single-direction method for thoracoscopic single or combined basal segmentectomy was feasible and safe in our experience. This method exposes the targeted vessels and bronchi from superficial to deep in order of their appearance and enables anatomic resection of a single segment or combined basal segments to be performed in a simple manner while avoiding dissection of a hypoplastic fissure or inessential splitting of the lung parenchyma.

The AMAGAMI technique: an easy technique to achieve precise stapling in thoracoscopic segmentectomy

The "AMAGAMI" or "incomplete grasping" technique is used to adjust the location of the lung while gently grasping the lung tissue with a stapler. Thoracoscopic segmentectomy requires precise but complex stapling, while the surgical view and the number of available instruments are limited. In the AMAGAMI technique, instead of moving the stapler to the targeted position of the lung tissue, an unlocked stapler is used to hold the lung tissue at an easily accessible position, and the lung tissue can then be slid to the ideal resection line using forceps. To use the AMAGAMI technique effectively, "standing stitches" are very helpful in enabling visualization of the ideal resection lines. Standing stitches are placed along intersegmental lines that have been determined based on the information provided by virtual-assisted lung mapping (VAL-MAP) or other marking techniques; these stiches are usually placed at the corner of the targeted segment and in-between if necessary. Monofilament suture is used for standing stitches, and about 1 cm lengths are left to enable later visualization. As these stitches stick out of the lung surface even when viewed from a tangential angle, the direction of stapling is easily visualized in thoracoscopic surgery. These techniques are particularly useful in challenging segmentectomy requiring complex staple lines, such as S10 segmentectomy, and in surgery with limited instrumental access, such as uniportal thoracoscopic surgery.

Concepts and techniques: how to determine and identify the appropriate target segment in anatomical pulmonary segmentectomy?

Anatomical segmentectomy is gathering increasing interest among thoracic surgeons because of increased detection of pulmonary nodules with ground-glass opacity (GGO) as well as an increase in the number of compromised patients. Accurate determination of intersegmental planes is a challenge in anatomical segmentectomy, and multiple methods have been proposed including developing inflation/deflation lines and injecting indocyanine green either intravenously or intrabronchially. Considering resection margins, adding a localization technique to conventional methods, or conducting virtual-assisted lung mapping (bronchoscopic multi-spot dye marking) may be an optional approach for optimal anatomical segmentectomy to identify intersegmental planes and obtain adequate resection margins. To determine optimal resection lines in anatomical segmentectomy, surgeons must also consider oncological validity such as venous and lymph drainage, resection margins, and lung anatomy to avoid complications such as venous congestion, infarction, and air leakage. Although anatomical segmentectomy is an attractive approach to resect small early-stage lung cancer and some metastatic lung tumors, caution is needed to optimally perform this technically demanding surgery.

Latest update about virtual-assisted lung mapping in thoracic surgery

Virtual-assisted lung mapping (VAL-MAP) is a preoperative bronchoscopic multi-spot dye-marking technique using virtual images developed to assist in navigational lung resection. The technique of VAL-MAP has been shown to be safe and effective surgical assistive tool for performing pulmonary sublobar resections. The technique is applicable for treating multiple small pulmonary lesions that are hardly palpable including ground glass nodules (GGNs). It also may help shorten surgical duration in wedge resection cases. Electromagnetic navigation bronchoscopy (ENB) may eliminate the need for post-mapping computed tomography (CT) scans in logistically challenged situations. In the most recent, multicenter prospective single-arm study, conventional VAL-MAP had reasonable efficacy for obtaining good surgical margin in pulmonary sublobar resections, although the successful resection rate did not reach the primary goal most significantly due to deep resection margins. The technique of VAL-MAP in combination with microcoil may be the next step to acquire better surgical margins.