How to decrease technical obstacles to difficult video-assisted thoracoscopic surgery segmentectomy?

Learning curve for complex segmentectomy via uniportal video-assisted thoracoscopic surgery for the treatment of early-stage lung cancer

Background

Recently, segmentectomy has emerged as a viable treatment option for early-stage lung cancer. Segmentectomy can be divided into simple segmentectomy and complex segmentectomy. While simple segmentectomy is a relatively straightforward surgical procedure, complex segmentectomy poses a considerable challenge because of its intricate anatomical variations and the need for a complex surgical approach. The introduction of uniportal video-assisted thoracoscopic surgery (VATS) further complicates matters. This study aimed to assess whether thoracic surgeons, who have previously conducted only uniportal VATS lobectomy and simple segmentectomy, could effectively navigate the learning curve when undertaking their first complex segmentectomy procedure.

Methods

A single surgeon with experience limited to uniportal VATS lobectomy and simple segmentectomy began performing uniportal VATS complex segmentectomy in 2019, completing 167 cases of complex segmentectomy during the same period and performing 70 cases of simple segmentectomy. We analyzed the learning curve by comparing the surgical outcomes and operative time curves between simple segmentectomy and complex segmentectomy.

Results

The complex segmentectomy group exhibited similarities with the simple segmentectomy group in terms of patient and tumor characteristics, operative outcomes, and postoperative outcomes, with the exception of the complex segmentectomy group showing slightly reduced chest tube drainage and shorter hospital stays. The operative times and time curve patterns showed no significant difference between the two groups, indicating a potential lack of a distinct learning curve for complex segmentectomy.

Conclusions

Complex segmentectomy via uniportal VATS, when performed by surgeons proficient in simple segmentectomy and lobectomy techniques, has comparable outcomes and potentially eliminates the need for an extensive learning curve. This approach expands the options for treating early-stage non-small-cell lung cancer (NSCLC), allowing for tailored patient care. Further studies are needed to assess long-term outcomes.

A comparison of the short-term outcomes of simple and complex segmentectomy via uniportal video-assisted thoracoscopic surgery

Background

Performing complex segmentectomy via uniportal video-assisted thoracoscopic surgery (VATS) is a more demanding and intricate procedure than simple segmentectomy or lobectomy. Thus, the aim of our study is to evaluate the safety and feasibility of uniportal VATS complex segmentectomy compared to uniportal VATS simple segmentectomy by investigating surgical outcomes of patients undergoing those procedures.

Methods

We conducted a review of medical records for all patients who underwent uniportal VATS segmentectomy for lung cancer from May 2019 to February 2023. The characteristics of the patients and tumors, as well as the operative and postoperative outcomes, were compared between the group of patients who underwent simple segmentectomy and the group who underwent complex segmentectomy.

Results

Among 199 patients, 67 underwent simple segmentectomy through uniportal VATS, while 132 patients received complex segmentectomy through the same technique. There were no significant differences between the two groups regarding patient and tumor characteristics, operative outcomes, and postoperative outcomes, except for the surgical margin distances. Uniportal VATS complex segmentectomy resulted in shorter duration of postoperative stay (6 vs. 7 days, P=0.0116) but a closer surgical margin distance (20 vs. 22 mm, P=0.0175).

Conclusions

Our study supports the use of uniportal VATS complex segmentectomy as a safe and feasible treatment option compared to uniportal VATS simple segmentectomy for patients with clinical stage 1A non-small-cell lung cancer (NSCLC). However, it is important to note that a short resection margin is probable in complex segmentectomy cases. Therefore, the location of the tumor should be thoroughly evaluated when performing uniportal VATS complex segmentectomy.

Initial experience of thoracoscopic segmentectomy of basal segment through the inferior pulmonary ligament approach in treating congenital lung malformations in children

PURPOSE

This study aimed to evaluate the feasibility and limitations of thoracoscopic segmentectomy of the basal segment (S10).

METHODS

Clinical data of 15 children with congenital lung malformations (CLM) who underwent thoracoscopic segmentectomy of S10 via the inferior pulmonary ligament approach from January to October 2022 were retrospectively analyzed. The demographics, clinical presentation, intraoperative time, blood loss, postoperative events, and follow-up duration were assessed.

RESULTS

There were 15 patients in this group (nine males and six females). Age ranges from 4.3 to 96.0 months (median, 7.7 months). Fourteen patients underwent S10 segmentectomy, with one undergoing right S10 segmentectomy and right S6 partial wedge resection. The surgical time was 57-125 min (median, 80 min), intraoperative bleeding volume (5-20 ml; median, 10 ml), postoperative drainage tube indwelling (2-4 d; median, 3 d), and postoperative hospitalization time (4-7 d; median, 5 d). No intraoperative conversions, surgical mortalities, or major complications were observed among these patients. Subcutaneous emphysema appeared in three patients; however, it disappeared following conservative observation without pneumothorax or bronchopleural fistula occurrence.

CONCLUSIONS

Thoracoscopic segmentectomy of S10 via the inferior pulmonary ligament approach is technically feasible for treating CLM; however, this surgical approach may have certain limitations for CLM with large cysts.

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.

Elucidating the anatomy of the quadrivial pattern of the right upper lobe bronchus using 3D-CT images

Background

A preoperative understanding of the thoracic anatomy of the patients with the quadrivial pattern of branching of the right upper lobe is key to successful surgery. We analyzed the quadrivial pattern of division of the right upper lobe bronchus of patients using three-dimensional (3D) computed tomography (CT) angiography and bronchography.

Methods

A total of 212 consecutive adult patients who had undergone thoracic CT scans before surgery at the Zhujiang Hospital of the Southern Medical University from August 2020 to August 2021 was used for retrospective study. The 3D-CT images were taken using Mimics software. Radiology technicians processed all the 3D images, and thoracic surgeons confirmed the validity of all the reconstructions.

Results

Six (2.83%) were identified as having a quadrivial pattern of division of the right upper lobe bronchus with 1 female, and 5 males. Based on the number of pulmonary artery branches, 5 (83.3%) and 1 (16.7%) were classified as “trunk superior (Tr.sup) + ascending artery (A.asc) and Tr.sup + trunk inferior (Tr.inf) + ascending artery (A.asc) (1/6, 16.7%). Based on the number of ascending artery branches, the patients were also divided into type A (3/6, 50%) and type B (3/6, 50%). The patients were also divided into 1 of the following three types based on the origins of the A2: (I) A2 originates from A6 (1/6, 16.7%); (II) A2 originates from the pulmonary trunk (4/6, 66.7%); and (III) A2a originates from A3, and A2b originates from the pulmonary artery stem (1/6, 16.7%). According to the number of A1b branches, patients were divided into two types: (I) 1 branch (4/6, 66.7 %); and (II) 2 branches (2/6, 33.3 %). In the present study, anterior + central type was observed which classified into two types: (I) type Iab, the anterior vein ran from V1a to V1b (4/6, 66.7%); and (II) type Ib, the anterior vein ran from V1b only (2/6, 33.3%).

Conclusions

3D-CT was successfully used for analyzing the quadrivial bronchovascular patterns of the right upper lobe bronchus. Our study provides certain references to perform anatomical pulmonary segmentectomy, which should improve the success rate of operations.

Complex segmentectomy is not a complex procedure relative to simple segmentectomy

OBJECTIVES

Segmentectomies can be classified as simple or complex and are increasingly performed for early-stage lung cancer. Complex segmentectomy requires the creation of multiple intersegmental planes and is considered a more arduous procedure with higher risks of postoperative complications, relative to simple segmentectomy.

METHODS

This retrospective study evaluated patients who underwent simple or complex segmentectomy for primary lung cancer during 2012-2018. Perioperative factors were compared according to the procedure type.

RESULTS

The 538 eligible segmentectomies included 251 complex segmentectomies and 287 simple segmentectomies. There were no significant differences in terms of age, sex, smoking history or comorbidities. The most common procedure in the complex segmentectomy group was upper-lobe segmentectomy (e.g. S1, S2, S3 and S1 + 2; n = 170), which was followed by S8 segmentectomy (n = 39) and two-segment segmentectomies (e.g. S7 + 8, S8 + 9 and S9 + 10; n = 24). Simple segmentectomies involved left upper division (n = 117), the lingular segment (n = 30) and the S6 segment (n = 140). Comparing complex and simple segmentectomies revealed equivalent median operative times (113 vs 113 min) and blood loss (20 vs 20 ml). Complex segmentectomy had fewer postoperative complications (2.0% vs 7.0%, P = 0.006), including prolonged air leak (0.8% vs 3.5%, P = 0.035) and shorter median postoperative stays (3 vs 4 days, P < 0.001). However, median surgical margins were closer for complex segmentectomy (22 vs 25 mm, P = 0.005).

CONCLUSIONS

The perioperative outcomes of complex segmentectomy were satisfactory and comparable to those of simple segmentectomy. Surgeons should pay careful attention to the surgical margins during complex segmentectomy.

Impact of complex segmentectomies by video-assisted thoracic surgery on peri-operative outcomes

Background

Pulmonary segmentectomies are generally classified into simple (tri-segmentectomy or lingulectomy as well as apical or basilar segmentectomy) and complex (individual or bi-segmentectomy of the upper, middle and lower lobes). Complex segmentectomies are technically feasible by video-assisted thoracic surgery (VATS) but remain challenging, and reports on post-operative outcomes are scarce. This study analyzes the differences between simple and complex VATS segmentectomy in terms of peri- and post-operative outcomes.

Methods

We retrospectively reviewed records of all patients who underwent anatomical pulmonary segmentectomy by VATS from 2014 to 2018 in two university hospitals.

Results

A total of 232 patients (114 men; median age 67 years; range, 29-87 years) underwent VATS segmentectomy for primary lung cancer (n=177), metastases (n=26) and benign lesions (n=29). The overall 30-day mortality and morbidity rates were 0.8% and 29.7%, respectively. The re-operation rate was 4.7%. Complex segmentectomy was realized in 111 patients including 86 (77.5%) upper lobe segmentectomies and 44 (39.6%) bi-segmentectomies. There was no statistical difference between complex and simple segmentectomy in terms of operative time (145 vs. 143 min, respectively; P=0.79) and chest tube duration [median: 1 (range, 0-33) vs. 2 (range, 1-19) days, respectively; P=0.95]. Post-operative overall complication rates were similar for both groups (30% vs. 30%, respectively; P=0.99) and were not correlated with the type of segmentectomy. However, complex segmentectomy patients had a shorter length of hospitalization compared to simple segmentectomy patients [median: 5 (range, 1-36) vs. 7 (range, 2-31) days; P=0.026]. Interestingly, complex segmentectomies were realized most frequently 2 years after implementation of VATS segmentectomy (23% vs. 77%; P=0.01).

Conclusions

In comparison with simple segmentectomy, complex segmentectomy by VATS seems to present similar post-operative complication rates. Learning curve and progressive increase in acceptance by surgeons seem to be key elements for successful implementation of complex segmentectomies and could explain the shorter length of stay we observed.