[The Main Technical Points of Thoracoscopic Anatomical Lung Segment Resection]

Staplers versus energy devices for the intersegmental plane separation in thoracoscopic segmentectomy: a comparative study

BACKGROUND

In segmentectomy, in addition to the anatomy of the segmental hilum, the identification and separation of the intersegmental plane is also an important step of the operation. Because of its simplicity and high efficiency, most thoracic surgeons choose the staplers. But the energy devices also have its unique advantages in the separation of the intersegmental plane. This study compared the clinical efficacy of staplers and energy devices in the separation of the intersegmental planes during the uniport thoracoscopic segmentectomy through the clinical data.

METHODS

Clinical data of 89 patients undergoing uniport VATS lung segmentectomy from January 2019 to October 2020 at the First Affiliated Hospital of Soochow University were analyzed retrospectively. According to the different treatment methods of intersegmental plane, the patients were divided into two groups, 55 in the stapler group and 34 in the energy device group. The clinical data of the two groups were compared and analyzed statistically. And the univariate and multivariate logistic regression were also used to explore the influencing factors of postoperative complications.

RESULTS

Lung segmentectomy was successfully operated in both groups. There were statistically significant differences in operative duration, number of staplers used, surgical expenses and postoperative complications (P < 0.05). In terms of general data, including tumor location, operative hemorrhage, drainage volume on the first postoperative day, total postoperative drainage volume, postoperative chest tube retention duration, postoperative hospital stay, postoperative blood routine indexes, and postoperative pulmonary function indexes after 3 months, no significant differences were observed (P > 0.05). Smoking history (OR 5.08, 95% CI 1.05-24.56, P = 0.043) and intersegmental plane treatment (OR 3.18, 95% CI 1.11-9.14, P = 0.031) were risk factors for postoperative complications. Patients of the energy device group had a higher incidence of postoperative complications.

CONCLUSIONS

In uniport thoracoscopic segmentectomy, the use of energy devices to treat the intersegmental plane will result in longer operative duration and higher postoperative complication rate, but it does not affect postoperative recovery and can help reduce surgical expenses. Both methods are safe and reliable. Clinically, the two methods can be reasonably selected according to the specific situation.

Application of three-dimensional computed tomography bronchography and angiography in thoracoscopic anatomical segmentectomy of the right upper lobe: A cohort study

Objective

Three-dimensional computed tomography bronchography and angiography (3D-CTBA) can provide detailed imaging information for pulmonary segmentectomy. This study aimed to investigate the safety and effectiveness of 3D-CTBA guidance of anatomical segmentectomy of the right upper lobe (RUL).

Methods

This was a retrospective analysis of anatomical segmentectomy of the RUL at the Thoracic Surgery Department of the Fourth Hospital of Hebei Medical University from December 9, 2013, to June 2, 2021. Preoperatively, all patients underwent contrast-enhanced CT of the chest (to determine the size of the pulmonary nodule) and a lung function test. 3D-CTBA has been performed since 2018; patients with vs. without 3D-CTBA were compared. Segmentectomy was performed according to nodule location.

Results

Of 139 patients (46 males and 93 females, aged 21–81 years), 93 (66.9%) completed single segmentectomy, 3 (2.2%) completed single subsegmentectomy, 29 had combined subsegmentectomy, 7 had segmentectomy combined with subsegmentectomy, and 6 had combined resection of two segments. Eighty-five (61.2%) patients underwent 3D-CTBA. 3D-CTBA cases had decreased intraoperative blood loss (67.4 ± 17.6 vs. 73.1 ± 11.0, P = 0.021) and shorter operation time (143.0 ± 10.8 vs. 133.4 ± 20.9, P = 0.001). 3D-CTBA (Beta = −7.594, 95% CI: −12.877 to −2.311, P = 0.005) and surgical procedure (Beta = 9.352, 95% CI: 3.551–15.153, P = 0.002) were independently associated with intraoperative blood loss. 3D-CTBA (Beta = −13.027, 95% CI: −18.632 to 17.422, P < 0.001) and surgical procedure (Beta = 7.072, 95% CI: 0.864–13.280, P = 0.026) were also independent factors affecting the operation time.

Conclusion

Preoperative use of 3D-CTBA to evaluate the pulmonary vessels and bronchial branch patterns of the RUL decreased blood loss and procedure time and so would be expected to improve the safety and effectiveness of thoracoscopic segmentectomy.

Thoracoscopic Lobectomy versus Segmentectomy in the Treatment of Patients with Early-Stage Lung Cancer

Objective

To assess the clinical efficacy of thoracoscopic lobectomy and segmentectomy in the treatment of patients with early-stage lung cancer.

Methods

A total of 70 patients with early-stage non-small cell lung cancer who were treated in our hospital from April 2018 to May 2020 were recruited and assigned at a ratio of 1 : 1 to receive either segmentectomy (observation group) or lobectomy (control group). Outcome measures included clinical efficacy, surgery-related indicators, pulmonary function indicators (forced vital capacity (FVC) and forced expiratory volume in one second (FEV1)), postoperative complications, and recurrence and metastasis.

Results

There was no significant difference in the clinical efficacy between the two groups (P > 0.05). Segmentectomy was associated with a longer operation time and shorter hospital stay compared to lobectomy (P < 0.05). There was no statistical significance in the amount of intraoperative blood loss and the number of lymph nodes dissected (P > 0.05). Segmentectomy resulted in significantly higher FVC and FEV1 levels in patients compared to lobectomy (P < 0.05). There was no significant difference in the incidence of postoperative complications between the two groups (P > 0.05). The two groups of patients were followed up for 12 months after the operation, and there was no recurrence or metastasis in either group.

Conclusion

The two surgical methods have similar efficacy and safety profiles, but for the treatment of patients with early-stage lung cancer, thoracoscopic segmentectomy is associated with a shorter hospital stay and better protection of the lung function of patients compared to lobectomy.

A localization-independent approach for invisible and impalpable ground-glass opacity nodules detection in an in vitro lung specimen: two case reports

A growing number of ground-glass opacity (GGO) nodules are screened out in lungs. Small GGOs are frequently neither visible nor palpable, thus undetectable during operation. Various nodule localization techniques have been developed to facilitate the intraoperative detection of GGO nodules; however, general localization techniques are infeasible or inappropriate in some cases. The detection of small GGO is a great challenge, even within a surgical specimen in the absence of preoperative localization. A localization-independent approach for GGO detection is urgently needed. Herein, we report two cases with invisible and impalpable small GGO which were not appropriate for preoperative localization. The lesions were anatomically resected under the guidance of three-dimensional (3D) reconstruction and got an adequate margin distance. A vessel (artery, vein, or bronchus) which had advanced into or immediately adjacent to the nodule was assigned as a reference vessel. By dissecting and tracing the reference vessel from proximal to distal, the GGO lesions were successfully detected in the surgical specimens, to the eventual obtainment of an accurate pathological diagnosis. Via the two case reports, we introduced an easily handled approach, namely dissecting and tracing a reference vessel, for GGO detection. The novel approach was first described. Combined with precise anatomical segmentectomy guided by 3D reconstruction, it provides an alternative scheme for GGO resection with no need for preoperative localization.

Right apical-posterior segmentectomy with abnormal anterior segmental bronchus and artery: a case report

Background

Displaced anterior segmental bronchus and pulmonary artery is extremely rare. A keen knowledge of such variations is required in the field of pulmonary segmentectomy, for unawareness of the structural variation could lead to intra- and postoperative complications.

Case presentation

A 50-year-old female presented to our department with suspected lung adenocarcinoma. Preoperative 3-dimensional computed tomographic bronchography and angiography revealed anterior segmental bronchus and anterior segmental pulmonary artery variation: the anterior segmental bronchus derived from the middle lobe bronchus, accompanied by a distally distributed anterior segmental pulmonary artery branch. A right apical-posterior segmentectomy using inflation-deflation technique was performed successfully.

Conclusions

The keen observation and proper application of modern imaging technology and operative technique could greatly aid segmentectomy, preventing intra- and postoperative complications from happening.

[Assessment of the Accuracy of Modified Inflation-deflation Methods for Distinguishing the Intersegmental Border]

背景与目的

对于早期肺癌，肺段切除术可以获得和肺叶切除术相同的肿瘤学疗效。肺段间交界面的精准界定是肺段手术的关键。本研究采用“改良膨胀萎陷法”行扩大肺段、亚段切除术治疗肺段间、亚段间磨玻璃结节（ground-glass nodules, GGN），评价“改良膨胀萎陷法”界定肺段交界面的精确性，和对扩大切除确保安全切缘宽度的有效性。

方法

回顾性分析本中心采用扩大肺段、亚段切除术治疗的患者83例。术前三维CT支气管血管成像（three-dimensional computed tomography bronchography and angiography, 3D-CTBA）显示结节累及段间静脉。根据三维重建设计手术，扩大切除结节所属的优势肺段或亚段，无法确定优势肺段、亚段时，选择较为简单的肺段、亚段切除方式。术中切断靶段血管、支气管后采用“改良膨胀萎陷法”确定肺段间或亚段间交界面，应用切割缝合器距离膨胀萎陷交界线2 cm-3 cm扩大切除部分相邻肺段或亚段肺组织。观察标本中膨胀萎陷交界线与结节的关系，测量切缘宽度，收集围术期临床资料。

结果

实施扩大肺段切除术56例，扩大肺亚段切除术27例，肺结节平均直径（0.9±0.3）cm。出现清晰可辨膨胀萎陷交界线79例，交界线形成时间（13.6±6.5）min。解剖标本观察发现，结节累及膨胀萎陷交界线55例，其余24例结节距交界线的最小距离（0.6±0.3）cm，平均切缘宽度（2.1±0.3）cm。无术后30 d死亡和重大并发症。

结论

改良膨胀萎陷法可有效界定肺段间、亚段间交界面，以此为标准可确保扩大肺段、亚段切除术治疗段间、亚段间小肺癌的安全切缘。

How far will minimally invasive thoracic surgery go? Uniportal video-assisted thoracoscopic lingulectomy with 1 cm incision complicated by a mediastinal lingual artery: A case report

Here, we present the case of a 36‐year‐old female patient who was found to have a ground‐glass nodule (GGN) in the left lingual segment on chest computed tomography (CT) and who successfully underwent lingulectomy via 1 cm incision uniportal video‐assisted thoracoscopic surgery (VATS). This is a technically safe and feasible procedure in selected patients and produces better cosmetic results than traditional thoracoscopic surgery.

Three-dimensional printing technology for localised thoracoscopic segmental resection for lung cancer: a quasi-randomised clinical trial

Background

Three-dimensional (3D) computed tomography (CT) reconstruction technology has gained attention owing to its potential in locating ground glass nodules in the lung. The 3D printing technology additionally allows the visualisation of the surrounding anatomical structure and variations. However, the clinical utility of these techniques is unknown. This study aimed to establish a lung tumour and an anatomical lung model using 3D printing and 3D chest CT reconstruction and to evaluate the clinical potential of 3D printing technology in uniportal video-assisted thoracoscopic segmentectomy.

Methods

Eighty-nine patients with ground glass nodules who underwent uniportal video-assisted thoracoscopic segmentectomy were classified into the following groups: group A, lung models for pre-positioning and simulated surgery that were performed with 3D chest CT reconstruction and 3D printing, and group B, patients who underwent chest CT scans with image enhancement for 3D reconstruction. The differences in the surgery approach transfer rate, surgical method conversion rate, operative time, intraoperative blood loss, and postoperative complication rate were compared between the two groups.

Results

Between groups A and B, there were significant differences in the approach transfer rate (0% vs.10.5%, p = 0.030), operative time (2.07 ± 0.24 h vs. 2.55 ± 0.41 h, p < 0.001), intraoperative blood loss volume (43.25 ± 13.63 mL vs. 96.68 ± 32.82 mL, p < 0.001) and the rate of surgical method conversion to lobectomy (0% vs. 10.5%, p < 0.030). In contrast, there was an insignificant difference in the postoperative complication rate between groups A and B (3.9% vs. 13.2%, p = 0.132).

Conclusions

3D printing technology facilitates a more accurate location of nodules by surgeons, as it is based on two-dimensional and 3D image-based findings, and therefore, it can improve surgical accuracy and safety. This technique is worth applying in clinical practice.

[Chinese Expert Consensus Statement on Clinical Evaluation System of Medical Endoscopy]

医用内窥镜的发展速度及普及程度非常快，国际大厂品牌统领内窥镜市场半壁江山，目前国产品牌的市场规模也迅速增长，硬镜、软镜电子化技术迅速发展，逐渐接近国际先进水平。但是，目前适用于评价医用内窥镜的国家标准、行业规定等相关标准缺乏，国内外产品差距缺少定量、明确的认识，国产品牌多而杂，需要对医用内窥镜给予全面、准确的评价。在此背景下，专家组经过科学地遴选和严谨地实践提出了一套科学、系统、适用的标准化医用内窥镜临床评价体系，以期规范化各类内窥镜评价指标。

Feasibility and validity of double-arm specimen extraction method after partial lung resection in single-port thoracoscopic surgery

Background

Few previous reports have evaluated lung specimen extraction method or how to improve lung specimen extraction method, especially with single-port thoracoscopic surgery. We evaluated the feasibility and surgical advantages of double-arm lung specimen extraction method by comparing double-arm vs. single-arm specimen extraction times.

Methods

We retrospectively analyzed data for 268 patients undergoing partial lung resection via single-port thoracoscopy and specimen extraction using a specimen extractor in the Union Medical College Hospital of Fujian Medical University from November 2017 to June 2018. We divided patients into groups based on the specimen location as an upper-lobe group (group I), lower-lobe group (group II), and lung-segment group (group III). We then performed a subgroup analysis based on the degree of collapse of the lung lobe specimens during extraction as follows: good in group IA and IIA, and poor in group IB and IIB.

Results

The double-arm method required statistically significantly less time than the single-arm method: (69.6±31.9 vs. 89.9±47.8 s, respectively, P=0.037). We found no significant difference in lung specimen extraction time for double-arm vs. single-arm extraction in group I, II, or III (P=0.093, P=0.153, P=0.174, respectively). We also found no significant difference in lung specimen extraction time between the two methods in group IA and group IIA (P=0.165, P=0.649, respectively). However, in groups IB and IIB, extraction time with the double-arm method was significantly shorter compared with the single-arm method (64.4±12.3 vs. 89.1±12.1 s, P=0.034 and 113.8±27.1 vs. 160.0±31.8 s, P=0.042, respectively).

Conclusions

In single-port thoracoscopic partial lung resection, double-arm specimen extraction method is more convenient and can shorten sample extraction time, especially for upper- and lower-lung lobes with poor degree of collapse. Double-arm specimen extraction method is feasible and effective after single-port thoracoscopic partial lung resection.

[The Initial Experience of Video-assisted Thoracic Surgery Segmentectomy for Early Stage Lung Cancer]

背景与目的

肺段切除较肺叶切除能够更多地保留健康肺组织，但其在早期肺癌根治性方面仍存在争议。本研究分析35例完全胸腔镜下解剖性肺段切除术临床病理资料并复习文献，探讨胸腔镜下肺段切除术在早期肺癌治疗中面临的问题。

方法

回顾北京大学第三医院2013年5月-2017年7月单一手术组35例完全胸腔镜下肺段切除术患者的临床病理资料，观察术中及术后并发症等安全性指标及淋巴结清扫数目、转移情况，并将术后病理类型与术前影像类型比对分析。35例肺段切除术中男性11例，女性24例，平均年龄57.7岁。病灶位于右肺上叶者8例，右肺下叶者8例，左肺上叶者13例，左肺下叶者6例。计算机断层扫描（computed tomography, CT）影像学肿瘤最大径平均12.7 mm，肺门及纵隔淋巴结最大直径均小于10 mm，以磨玻璃成为主者23例，以实性成分为主者12例。

结果

35例均顺利完成电视辅助胸腔镜手术（video-assisted thoracic surgery, VATS）解剖性肺段切除术，平均手术时间为153 min，出血量为51 mL。术后漏气10例，均未超过3天。健侧肺不张1例，乳糜胸1例。平均住院时间为6.1天。出院后30天内门诊复查未发生其他院外手术相关并发症。病理为转移瘤者2例，良性肺病8例，原发肺癌25例。25例原发肺癌中浸润性肺腺癌14例[CT以肺磨玻璃影（ground-glass opacity, GGO）为主者7例]，微小浸润腺癌4例（GGO为主者3例），原位腺癌6例（CT均为纯GGO），肺鳞癌1例（CT以实性成分为主）。25例肺癌平均切除淋巴结7.2枚，所有淋巴结无癌转移。

结论

VATS解剖性肺段切除术技术上安全可靠，其在肺癌治疗中适应症需严格掌握，其优势仍需前瞻性随机对照实验来证实。

[Combining 3D-CTBA and 3D-VATS Single-Operation-Hole to Anatomical Segmentectomy in the Treatment of Non-small Cell Lung Cancer]

背景与目的

中国是肺癌高发地区，其发病率及死亡率在恶性肿瘤中均占首位。目前低剂量CT检查的普及使早期肺癌检出率显著提高，解剖性肺段切除目前广泛应用于Ia期非小细胞肺癌（non-small cell lung cancer, NSCLC）及不能耐受肺叶切除肺癌患者。但因肺段解剖结构及手术操作相对复杂，使得其具有较高的手术风险与难度。我们应用三维计算机断层扫描支气管血管成像（three-dimensional computed tomography bronchography and angiography, 3D-CTBA）及三维电视辅助胸部外科技术（three-dimensional video-assisted thoracic surgery, 3D-VATS）单操作孔行解剖性肺段切除微创手术技术治疗NSCLC，以探讨其临床效果，为其临床应用提供相关可行性及理论依据。

方法

回顾性分析苏州大学附属第一人民医院胸外科2015年10月-2017年04月共施行57例术前对肺部病灶予以3D-CTBA重建以及术中应用3D-VATS单操作孔进行解剖性肺段切除治疗NSCLC病例。

结果

全组均全腔镜下顺利完成，无中转开胸。手术时间平均（142.2±28.3）min，术中出血量平均（93.8±46.5）mL。平均淋巴结清扫数目（9.1±2.2）个，术后胸腔引流量平均（429.8±181.2）mL。术后留置胸管时间（2.8±1.1）d。平均住院时间（5.2±1.3）d。术后病理示良性病变9例，约占15.7%，恶性病变48例，约占84.2%。术后并发症：肺部感染3例（5.2%），肺不张1例（1.7%），少量咯血1例（1.7%），肺漏气2例（> 3 d, 3.5%），心律失常4例（7.0%）。术后平均随访10个月，无支气管胸膜瘘、乳糜胸、包裹性胸腔积液等并发症，随访患者中无复发及远处转移病例。

结论

应用3D-CTBA及3D-VATS单操作孔行解剖性肺段切除治疗NSCLC的安全有效，适用于早期NSCLC以及不能耐受肺叶切除患者。