Absent Fissure Research Articles

Pulmonary Fissures Including Accessory and Azygos Fissures and their Clinical Significance

Introduction: The lungs are divided into lobes by oblique and horizontal fissures. Knowledge of extent of completeness of fissures is important for surgical planning. This study highlights the variation in Pulmonary fissures including accessory and azygos fissure and their clinical relevance. Materials and Methods: The sample consists of fifty (50) lung specimens (25 right and 25 left), collected from formalin fixed cadavers, which were dissected during undergraduate teaching. The lungs were observed for complete, incomplete, and absent fissures. Additional fissures including accessory and azygos fissures were also observed and findings compared with previous studies. Results: Accessory fissure was found in 35% right and 40% left lungs. Horizontal fissure was found to be absent in 30% right lungs. Oblique fissure was found absent in 5% right and left lungs. Four right lungs had azygous fissure. Inferior accessory fissures were found in 15% right lungs. 20% left lungs had both inferior accessory and left minor fissures. Conclusion: It is important to assess the incompleteness or absence of fissures, when planning any surgical procedure. Lung fissure variations are frequently encountered during surgical procedures and knowledge of pattern of these fissures is important to avoid and reduce associated mortality and morbidity.

Learnable interpolation and extrapolation network for fuzzy pulmonary lobe segmentation

AbstractPulmonary lobe segmentation is an important prerequisite for accurately quantifying pulmonary damage in many pulmonary diseases and planning treatment. However, due to the incomplete lobar structures and morphological changes caused by diseases, the lobe segmentation still encounters great challenges. In this study, a Learnable Interpolation and Extrapolation Network (LIE‐Net) is proposed to form complete and consecutive fissure surfaces by learning to extract information of the fissures from existing fissure points and absent points (unsegmented points belonging to fissures) to predict the z coordinate of the absent fissure points. The completed pulmonary fissures are further used for accurate pulmonary lobe segmentation. Specifically, LIE‐Net takes the coordinate information of existing fissure points (their (x, y, z) coordinates) and absent fissure points (their (x, y) coordinates) as two independent inputs, and predicts the z coordinates of absent points. The proposed LIE‐Net makes voxel‐wise predictions based on the spatial structure characteristics of the lung fissure, and is able to provide a consecutive fissure surface in space. According to the evaluation of radiologists, the lobe segmentation performance was remarkably enhanced in approximately 76% of patients in our additional dataset after the application of LIE‐Net, especially for those cases with large‐scale missing fissures.

Variations in Pulmonary Fissure: A Source of Collateral Ventilation and Its Clinical Significance.

Introduction: Oblique and horizontal fissures divide the lungs into lobes. Assessing the incompleteness or absence of fissures is important when planning any surgical procedure in this region. This study aimed to investigate the incidence of variations in the fissures and their implication in clinical practice.Methods: The sample consists of 70 formalin-fixed lungs (32 right and 38 left lungs). These lungs were assessed for complete, incomplete, and absent fissures and any variations in the fissures on the sternocostal and mediastinal surfaces.Results: Oblique fissure was incomplete on the sternocostal surface in 18.75% and 21% and on the mediastinal surface in 25% and 21% on the right and left lungs, respectively. Additionally, it was absent in 10.5% of the left lung samples. The horizontal fissure was incomplete in 12.5% on both surfaces and was absent in 25% on the right lung samples, of which 50% had no oblique fissure. No accessory fissure was seen in any of the lungs.Conclusion: Incomplete and absent fissures can be observed in the right as well as the left lung, suggesting the source of collateral ventilation. This study imparts important information to pulmonologists doing bronchoscopic lung volume reduction therapy or bronchopulmonary segment resection and also to radiologists and anatomists.

Liver morphology: anatomical study about the outer aspects.

Hepatobilliary surgery is nowadays increasingly done throughout the world with advent of newer liver imaging modalities. Considering recent interest for accurate interpretation of different radiological images and performing surgical procedures, a precise understanding of hepatic surface anatomy is challenging due to high prevalence of previously identified morphological variations. Accordingly, a cadaveric study was attempted to revisit the morphological details of liver updating the unusual configurations along with their clinico-anatomical correlations and thus, compare the analysis of present study with previous published data. We studied 110 formalin-fixed adult cadaveric livers of unknown age and sex having no pathological lesion or damage. More than one morphological variation in combination was observed on repeated occasions in same liver specimen. The anatomical classification based on Netter's criteria was chosen in order to be coherent with previous studies to define different variations with addition of other subtypes. Accordingly, classical wedgeshaped livers were present in 57.3% specimens. Considering different morphological features, 78 (70.9%) variant livers were noted in terms of shape (as transverse saddle shaped, square shaped, globular, quadrilateral, pyriform or boot-shaped), altered numbers and position of fissures (affecting either one or more lobe in addition to absent fissure for ligamentum teres) or lobes (as aplasia, hypoplasia or hypertrophy) or processes (in addition to abnormalities of processes extending from caudate or quadrate lobe tongue-like process or appendix fibrosa hepatis or mini-accessory lobe) or impressions (as costal or variant visceral impressions affecting inferior surface) or evidence of pons hepatis(35.5%) orin combinations of all above. Awareness of hepatic surface variation is worth knowing in successful planning of hepatobilliary surgeries with least complications.

Does fissure status affect the outcome of thoracoscopic pulmonary lobectomy?

We studied fissure status and devices used to divide lung parenchyma during thoracoscopic pulmonary lobectomy (TPL). 52 consecutive TPL indicated for congenital pulmonary airway malformation or interlobar pulmonary sequestration performed between 2009 and 2019 were reviewed prospectively to compare patients with absent fissure and no visible interlobar pulmonary artery (IPA) treated by stapling (group A; n = 10), incomplete fissure with partially visible IPA treated with an Enseal® or LigaSure™ device (group I; n = 17), and complete fissure with fully visible IPA treated by electrocautery (group C; n = 25). Patient demographics were similar. Mean age at TPL was 2.82years (range 0.03-9.81). Mean duration of follow-up was 4.77years (range 0.33-10.19). Operative time and duration of chest tube insertion were similar (p = NS). Intraoperative blood loss was significantly lower in group C compared with group I (p = 0.028). Complications were minor bronchial artery hemorrhage during anterior-to-posterior bronchial dissection (group A: n = 1; group I: n = 1), problematic single lung ventilation (group I: n = 1), and persistent postoperative air leak (group I: n = 1). While fissure status does not appear to affect the outcome of TPL in children, the choice of device for dividing lung parenchyma relies specifically on fissure status.

Subxiphoid complex uniportal video-assisted major pulmonary resections.

In recent years, the search for a less invasive and thus, less painful approach has driven technical innovation in modern thoracic surgery. In this context, subxiphoid uniportal approach has emerged as an alternative to avoid intercostal space manipulation and decrease postoperative pain and intercostal nerve chronic impairment. Subxiphoid uniportal major lung resections have been safe and effective procedures when performed by experienced surgeons even in complex cases or unexpected intraoperative situations. We present six of these surgical scenarios such as big tumors, incomplete or absent fissures, hilar calcified lymph nodes, active bleeding and massive adhesions to show the feasibility of subxiphoid approach to manage even these conditions.

OC031: Sonographic nomograms of the fetal vermial fastigium between 15–40 weeks gestation

ROI direction on the lateral aspect; then, the inversion visualization mode was activated and the threshold increased until the voxels started to bleed into the vermis, highlighting the fissures, paying no attention to the surrounding structures. Finally, it was analysed if the primary and/or additional fissures could be confidently detected. Results: The primary fissure was consistently detected at 20 weeks of gestation on 3DUS vs 28 weeks on 2DUS. The earliest recognition of the primary fissure was by transvaginal approach with 6–12 MHz probe at 16 weeks. By 26 weeks, both the primary and the secondary fissures were recognisable at least in part in all cases of normalcy, MCM and BPC. At 32 weeks of gestation, fissures were recognisable in all volumes, if of good quality. Abnormal or absent fissures were seen in case of DW and DWv. Conclusions: 3DUS can identify vermian fissures more reliably and earlier than 2DUS in normal and abnormal PF conditions. This technique may contribute to the differential diagnosis of vermian abnormalities.

Simultaneously stapled lobectomy: A safe technique for video-assisted thoracic surgery

Currently, techniques for video-assisted thoracic surgery are being borrowed from the open conventional thoracotomy. However, these same techniques have made video-assisted lobectomy difficult, burdensome, and even dangerous. Simultaneously stapled lobectomy (simultaneous stapling of all hilar structures in their natural anatomic configuration) has been performed successfully in 16 patients. Every attempted simultaneously stapled lobectomy is included. The lesions included 14 malignant tumors, one giant benign pulmonary cyst, and one large necrotizing granuloma. Three right upper lobes, one right middle lobe, six right lower lobes, four left upper lobes, and two left lower lobes were resected uneventfully. Nine adenocarcinomas, two large cell carcinomas, and three squamous cell carcinomas ranging in size from 2.5 to 5 cm were removed. Lung fissures, the hilum, and the mediastinum were explored for lymph nodes in each patient. Median operative time was 110 minutes. Average blood loss was less than 100 ml. Median hospitalization was 6 days, altough eight patients were discharged within 3 and 5 days. Three patients had air leaks for an average of 14 days and one patient had mild subcutaneous emphysema for 5 days. There was no surgical mortality. Median follow-up is 15 months (range 8 to 20 months). Simultaneously stapled lobectomy is not meant to replace conventional lobectomy by open thoracotomy. Indications are cardiac or renal problems, contralateral chest wall paralysis, neurogenic deficiencies, adamant refusal to undergo open lobectomy, psychologic abberations, and pain from a previous thoracotomy. Contraindications include absent fissures, enlarged matted invasive nodes, fibrotic hilium, central or bulky lesions, calcific bronchi, chest wall invasion, and lesions crossing a fissure. Precedent for this technique will be discussed. When used with discretion in carefully selected patients, in whom an open lobectomy would be contraindicated, simultaneously stapled lobectomy might eventually prove to be another available option. Time and further experience will be necessary to determine its true merits. (J T HORAC C ARDIOVASC S URG 1995;109:619-25)

Bilobectomy for Bronchogenic Carcinoma

During a 12-year period, bilobectomy was performed on 166 patients for the treatment of primary lung carcinoma: 108 patients (65%) underwent right upper and middle lobectomy, while 58 patients (35%) underwent right middle and lower lobectomy. Indications for bilobectomy were tumor extending across a fissure (45%), absent fissure (21%), endobronchial tumor (14%), extrinsic tumor or nodal invasion of bronchus intermedius (10%), and vascular invasion (5%). Thirty-one patients (19%) suffered 41 perioperative complications, and 7 patients (4.2%) died. Upper and middle lobectomies were not associated with a significantly different morbidity ( p > 0.10) or mortality ( p > 0.10) when compared with middle and lower lobectomy. The postoperative chest roentgenograms of all patients demonstrated ipsilateral volume loss, and 31 patients were found to have asymptomatic hydropneumothoraces, which cleared during the follow-up period. Late complications occurred in 4 patients (2%) and included two empyemas, one bronchopleural fistula, and one superficial wound infection. These results indicate that bilobectomy is associated with morbidity and mortality that lie between those currently reported for lobectomy and pneumonectomy.

SEGMENTAL PULMONARY RESECTION

Summary On a basis of six cases segmental pulmonary resection is found to be eminently practicable at least as far as the middle lobe, lingula, apical or first dorsal and lower basal segments go. Convalescence on the whole has been good to excellent. In three of the cases post-operative bronchograms show healthy bronchi in the portions conserved, but no late results are available. The principle of securing bronchus and vessels and then peeling the segment off through an avascular plane has also been applied with success in lobectomy in cases with poor or absent fissures.