Anatomical Pulmonary Segmentectomy Research Articles

Current trends in minimally invasive anatomical pulmonary segmentectomy using a robotic platform

Current trends in minimally invasive anatomical pulmonary segmentectomy using a robotic platform

Uniportal thoracoscopic pulmonary segmentectomy provides good perioperative results and early postoperative recovery.

BackgroundAlthough video-assisted thoracoscopic surgery (VATS) segmentectomy has become widespread, the advantage of uniportal VATS (U-VATS) segmentectomy over multiportal VATS (M-VATS) remains controversial. The purpose of this study was to verify the safety and usefulness of U-VATS segmentectomy compared with conventional hybrid/multiportal segmentectomy.MethodsHere, we retrospectively reviewed the data from anatomical pulmonary segmentectomy cases in a single institution from March 2010 to March 2021. Patients were divided into the U-VATS and hybrid/multiportal VATS (H/M-VATS) groups. Perioperative results were compared between the groups after matching for patient background characteristics. In addition, cases of complex segmentectomy were selected from each group and compared in terms of perioperative results.ResultsA total of 180 patients underwent pulmonary segmentectomy during the study period at this institution, comprising 57 cases in the U-VATS group and 123 cases in the H/M-VATS group. After matching for age, sex, disease, tumor location, and type of segmentectomy, no significant differences between the groups were seen in blood loss, major intraoperative bleeding, rate of conversion to thoracotomy, postoperative complications, or re-hospitalization within 30 days after discharge. Operation time (141±46 vs. 174±45 min, P<0.001), postoperative drainage duration (1.5±1.2 vs. 2.3±1.8 days, P=0.007), and postoperative hospital stay (3.4±2.0 vs. 4.6±2.5 days, P=0.006) were significantly lower in the U-VATS group. Subgroup analysis of the complex segmentectomy cases also revealed that operation time (146±34 vs. 185±47 min, P<0.001), postoperative drainage duration (1.5±1.3 vs. 2.2±1.2 days, P=0.021), and postoperative hospital stay (3.0±1.4 vs. 4.9±2.1 days, P<0.001) were significantly reduced in the U-VATS group.ConclusionsU-VATS segmentectomy appears as safe and feasible as H/M-VATS segmentectomy. An experienced surgeon can make a smooth transition to U-VATS.

Thoracoscopic anatomic pulmonary segmentectomy for the treatment of congenital lung malformation in children

BackgroundLung-sparing surgery has been used to treat congenital lung malformation in children, and segmentectomy has been advocated as a lung-preservation strategy. However, thoracoscopic pulmonary segmentectomy has gained limited popularity considering the complications, the potential for residual lesions, and the technical difficulties associated with this procedure. Therefore, this study aimed to investigate the safety and feasibility of pediatric thoracoscopic anatomic pulmonary segmentectomy for the treatment of congenital lung malformations. MethodsWe conducted a retrospective review of the medical records of 568 patients who were treated at West China Hospital, Sichuan University, from January 2014 to January 2020. The patients were divided into segmentectomy and lobectomy groups according to the surgical procedures they underwent. Clinical and follow-up outcomes were compared between the two groups. ResultsThe segmentectomy and lobectomy groups included 206 and 361 cases, respectively. The mean intraoperative blood loss was significantly higher in the segmentectomy group (6.9 mL vs. 4.5 mL; p = 0.03). The mean surgical time was also significantly longer in the segmentectomy group, (55.6 min vs. 41.5 min; p = 0.018). However, the incidence of complications did not differ significantly between the two groups (2.9% vs. 1.1%, p = 0.21). Patients in both groups did not require reoperation or show residual lesions during hospitalization and follow-up. ConclusionsThoracoscopic anatomic pulmonary segmentectomy is a safe and feasible definitive lung-sparing treatment for specific cases of congenital lung malformation, and has a complication rate comparable to that of thoracoscopic lobectomy.

Progress in three‐dimensional computed tomography reconstruction in anatomic pulmonary segmentectomy

The number of minimally invasive surgeries, such as video‐assisted thoracoscopic surgery and robot‐assisted thoracoscopic surgery, has increased enormously in recent years. More and more relevant studies report that anatomic pulmonary segmentectomy has the same effect as traditional lobectomy in the surgical treatment of early stage non‐small cell lung cancer (diameter less than 2.0 cm). Segmentectomy requires sufficient knowledge of the location of the pulmonary nodules, as well as the anatomy of the target segments, blood vessels, and bronchi. With the rapid development of imaging technology and three‐dimensional technology, three‐dimensional reconstruction has been widely used in the medical field. It can effectively assess the vascular branching patterns, discover the anatomic variations of the blood vessels and bronchi, determine the location of the lesion, and clarify the division of the segments. Therefore, it is helpful for preoperative positioning, surgical planning, preoperative simulation and intraoperative navigation, and provides a reference for formulating an individualized surgical plan. It therefore plays a positive role in anatomic pulmonary segmentectomy. This study reviews the progress made in three‐dimensional computed tomography reconstruction in anatomic pulmonary segmentectomy.

Application of three-dimensional reconstruction of left upper lung lobes in anatomical segmental resection.

BackgroundThe lobar and segmental anatomy are the basis for anatomical pulmonary segmentectomy.MethodsFrom October 2017 to June 2021, 136 patients with small pulmonary nodules scheduled for anatomical pulmonary segmentectomy at our institution underwent three‐dimensional (3D) lung reconstruction. The anatomy of the left upper lobe (LUL) was statistically analyzed and graphically mapped using the reconstructed models, and the role of this reconstruction method in performing pulmonary segmentectomy was explored.ResultsThrough the analysis of the reconstructed models, the upper stem (S1 + 2 + 3) bronchus was classified as having two (94/136 cases) or three branches (42/136 cases). The upper stem artery had two branches in 24/136 patients, three in 60/136 cases, four in 44/136 cases, and five in 8/136 cases. A total of 103/136 upper stem veins had two branches, 26/136 had three branches, and 7/136 had four branches. The lingual stem (S4 + 5) bronchus was two‐branched in 116/136 cases and three‐branched in 20/136 cases, while the lingual artery was single‐branched in 61/136 cases, two‐branched in 70/136 cases, and three‐branched in rare cases (5/136 cases). The lingual stem vein was unbranched in 119/136 cases and two‐branched in 17/136 cases. Additionally, six unusual variants (<5%) were identified: one in the bronchus, with four cases; three in the pulmonary artery, with six cases; and two in the pulmonary vein, with two cases.Conclusions3D reconstruction can yield results similar to specimens for lung segment studies. The reconstruction strategy and the data presented in this article will be valuable references for thoracic surgeons performing anatomic resections.

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

BackgroundA 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.MethodsA 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.ResultsSix (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%).Conclusions3D-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.

Segment-specific lymph node dissection and evaluation during anatomical pulmonary segmentectomy

: Lung cancer continues to be the leading cause of cancer related deaths both in men and women. Most patients present with locally advanced disease and are not candidates for resection. A recent surge of lung cancer screening programs for high-risk patients across the western world has led to a rising number of patients with early stage lung cancer. These patients with clinical stage I lung cancer and compromised pulmonary reserves can be candidates for sub-lobar resection with curative intention and similar outcomes as compare to lobectomy. Systemic or lobe-specific mediastinal lymph node dissection is an integral part of lung cancer surgery, especially during lobectomy as nodal upstaging can occur up to 18% of clinical stage I lung cancers and is associated with a worse prognosis. Nodal upstaging can occur in N1 lymph nodes only or as a skip metastasis to the N2 lymph nodes or both. The characteristics and location of the tumor plays an important role in lymph node metastasis. Recently, it has been suggested that a lobe-specific mediastinal lymph node dissection is equivalent to multi-station aggressive nodal dissection for early stage lung cancer detected during screening. Determining mediastinal and intersegmental lymph node metastasis is important during segmentectomy as it is associated with an increase recurrence rate and poor survival. These patients are perhaps better served with lobectomy rather than segmentectomy. The techniques and method of standard mediastinal lymph node dissection are well described in literature but description of a systematical approach for N1 lymph node dissection during a segmentectomy to efficiently identify the nodal upstaging intra-operatively, is lacking. We describe a methodological evaluation of N1 lymph node during segmentectomy in an effort to avoid failure to recognize nodal upstaging.

Lung segmentectomy assisted by highly selective independent segmental ventilation: a series of three cases

BackgroundThe identification of targeted intersegmental planes and resection with adequate surgical margins are among the crucial steps in anatomical pulmonary segmentectomy, and technical improvements are still needed.Case presentationWe reported three cases of intersegmental plane identification using highly selective independent segmental ventilation during segmentectomy. All cases required cooperation with an anesthesiologist who was able to perform segmental ventilation and double confirmation of segmental bronchus branches by the surgeon. The surgical procedure provides a direct visualization of spare segment inflation and saves time in deflation over the conventional residual segment inflation method.ConclusionsHighly selective independent segmental ventilation could be considered a suitable option for pulmonary intersegmental plane identification and could be universally used for lung segmentectomy.

The technique of robotic anatomic pulmonary segmentectomy II: left sided segments

Anatomic pulmonary segmentectomy and mediastinal nodal dissection has been advocated in patients with smaller tumors or patients with limited pulmonary reserve. The overall 5-year survival and the lung cancer-specific 5-year survival following anatomic segmentectomy have been shown to be equivalent to that of lobectomy. Robotic surgical systems have the advantage of magnified, high-definition three-dimensional visualization and greater instrument maneuverability in a minimally invasive platform. These robotic systems can facilitate the dissection of the bronchovascular structures and replicate the technique of segmentectomy by thoracotomy. Greater experience with the robotic platform has resulted in a reproducible anatomic segmentectomy technique. This is a companion paper to The Technique of Robotic Anatomic Segmentectomy I: Right Sided Segments. This paper outlines the technique of anatomic pulmonary segmentectomy for the left lung: Left Upper Lobe (LUL) Anterior Segment (S3), LUL Apicoposterior Segment (S1 + S2), LUL Lingulectomy (S4, S5), Left Lower Lobe (LLL) Superior Segmentectomy (S6), and LLL Basal Segmentectomy (S7-S10).

The technique of robotic anatomic pulmonary segmentectomy I: right sided segments

Anatomic pulmonary segmentectomy and mediastinal nodal dissection have been advocated in patients with smaller tumors or patients with limited pulmonary reserve. The overall five-year survival and lung cancer-specific five-year survival following anatomic segmentectomy have been shown to be equivalent to lobectomy. Robotic surgical systems have the advantage of magnified high-definition three-dimensional visualization and greater instrument maneuverability in a minimally invasive platform. Robotics can facilitate the dissection of the broncho-vascular structures and replicate the technique of segmentectomy by thoracotomy. Greater experience with the robotic platform has resulted in a reproducible technique. The Technique of Robotic Anatomic Segmentectomy Part I outlines a stepwise approach to robotic segmentectomy of S1, S2, S3, S4, S5, S6, and S7-S10 of the right lung. The Technique of Robotic Anatomic Segmentectomy Part II outlines a stepwise approach to robotic segmentectomy to the left lung.

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

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

The safety and feasibility of thoracoscopic uncommon pulmonary segmentectomy

Opportunities to treat patients requiring uncommon pulmonary segmentectomy are increasing because small pulmonary nodules are being incidentally detected more often. Uncommon segmentectomy is frequently performed via thoracotomy because uncommon pulmonary segmentectomies are associated with various technical difficulties compared to common segmentectomies. In this study, we investigated the safety and feasibility of thoracoscopic uncommon segmentectomy. A total of 105 patients underwent thoracoscopic anatomic pulmonary segmentectomy in our department between March 2006 and September 2018. Among them, 37 received an uncommon segmentectomy and 68 received a common segmentectomy. Uncommon segmentectomy was defined as any segmentectomy, except for segmentectomies of the lingual, basilar, or superior segment of the lower lobe, or upper division of the left upper lobe. We retrospectively compared characteristics and perioperative outcomes between patients receiving uncommon versus common segmentectomy. Uncommon segmentectomies were performed in the left S1+2 in nine patients, S3 in three, S9+10 in one, others including the sub-segment area in one, right S1 in four, S2 in six, S3 in two, S7+8 in two, S9+10 in six, and others including the sub-segment area in three. No significant differences were observed in patient characteristics between the two groups, or in perioperative results, including operative time, blood loss, postoperative drainage, hospitalization, morbidity, mortality, rate of conversion to thoracotomy, or rate of significant bleeding. No local recurrence was detected on the intersegmental plane in either group. Thoracoscopic uncommon segmentectomy is feasible and safe. It also helps ensure an oncological safety margin by division of the appropriate intersegmental plane.

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.

One hundred and fifty-six cases of anatomical pulmonary segmentectomy by uniportal video-assisted thoracic surgery: a 2-year learning experience.

Our goal was to explore the outcome of the study and the feasibility for patients of the technique of anatomical pulmonary segmentectomy by uniportal video-assisted thoracic surgery (VATS). A total of 156 consecutive patients with lung lesions who received anatomical pulmonary segmentectomy by VATS between 2015 and 2016 in our hospital were enrolled. All the subjects had high-resolution, thin-section chest computed tomography (CT) examinations with 3-dimensional reconstruction, a pulmonary function test, abdominal ultrasonography, electrocardiogram and cardiac ultrasonography. The lung lesion was localized before the operation using CT reconstruction or a hookwire to plan the operative method. Uniportal VATS pulmonary segmentectomy was successfully completed in 151 (96.8%) patients. Most cases involved the right apical and apical posterior segments and the left trisegment. Only 1 patient had a right middle interior segmentectomy, left upper apical anterior segmentectomy or a right lower posteriolateral segmentectomy, respectively. There were 26 cases of benign lesions (including 17 cases of atypical hyperplasia) and 130 cases of non-small-cell lung cancer. Operation time (146 ± 56 vs 113 ± 32 min), blood loss (63 ± 17 vs 54 ± 13 ml) and complication rates (13.5% vs 5.8%) were obviously lower in 2016 compared with 2015 (P < 0.01). In contrast, the preoperative hookwire localization rate was markedly higher in 2016 compared with 2015. Uniportal VATS anatomical pulmonary segmentectomy is safe and feasible in clinical applications. Compared with the 2- or 3-port method, there were some technical difficulties in the early phase of the learning curve for uniportal VATS that were overcome through a period of practice.

Impact of near-infrared angiography on the quality of anatomical resection during video-assisted thoracic surgery segmentectomy.

The aim of the present study was to assess the impact of near-infrared angiography in guiding intraoperatively sublobar anatomical resection by video-assisted thoracic surgery (VATS). We retrospectively analyzed data from 67 patients who underwent segmentectomy by VATS from November 2014 to November 2017 at the University Hospitals of Geneva, Switzerland. The need to modify arterial or parenchymal resection based on intraoperative near-infrared imaging was considered the primary study outcome. A total of 67 patients (28 men, 39 women, mean age 66±10 years) underwent anatomical pulmonary segmentectomy by VATS. Histological analysis revealed a primary lung tumor in 59 patients. The mean ± standard deviation (SD) operation time was 154±51 minutes. Identification of the intersegmental plane (ISP) with near-infrared angiography was achieved in 88% of patients and led to modification of the resection during segmentectomy in 7 patients (10%), avoiding inappropriate resection; 2 patients had distant tumor recurrences (3%). Near-infrared angiography during VATS segmentectomy is effective for identifying ISPs, with respect to the oncological margins, as well as for correcting the anatomical resection.

Three-dimensional (3D)- computed tomography bronchography and angiography combined with 3D-video-assisted thoracic surgery (VATS) versus conventional 2D-VATS anatomic pulmonary segmentectomy for the treatment of non-small cell lung cancer.

BackgroundCompared to the pulmonary lobe, the anatomical structure of the pulmonary segment is relatively complex and prone to variation, thus the risk and difficulty of segmentectomy is increased. We compared three‐dimensional computed tomography bronchography and angiography (3D‐CTBA) combined with 3D video‐assisted thoracic surgery (3D‐VATS) to perform segmentectomy to conventional two‐dimensional (2D)‐VATS for the treatment of non‐small cell lung cancer (NSCLC).MethodsWe retrospectively reviewed the data of randomly selected patients who underwent 3D‐CTBA combined with 3D‐VATS (3D‐CTBA‐VATS) or 2D‐VATS at the Department of Thoracic Surgery, The First Affiliated Hospital of Soochow University Hospital, from January 2014 to May 2017.ResultsThe operative duration of 3D group was significantly shorter than the 2D group (P < 0.05). There was no significant difference in the number of dissected lymph nodes between the two groups (P > 0.05). The extent of intraoperative bleeding and postoperative drainage in the 3D group was significantly lower than in the 2D group (P < 0.05). Chest tube duration in the 3D group was shorter than in the 2D group (P < 0.05). Incidences of pulmonary infection, atelectasis, and arrhythmia were not statistically different between the two groups (P > 0.05). However, hemoptysis and pulmonary air leakage (>3d) occurred significantly less frequently in the 3D than in the 2D group (P < 0.05).Conclusion3D‐CTBA‐VATS is a more accurate and smooth technique and leads to reduced intraoperative and postoperative complications.

Management of Intersegmental Plane on Pulmonary Segmentectomy Concerning Postoperative Complications

For primary lung cancer, anatomic pulmonary segmentectomy may have a functional advantage over lobectomy; however, persistent air leak or delayed pneumothorax after segmentectomy is prevalent and increases surgical morbidity. To prevent pulmonary complications after pulmonary segmentectomy, we used 2 methods for the involved intersegmental plane: coverage using polyglycolic acid mesh and fibrin glue (mesh cover) or closing it by suturing the pleural edge (pleural suture). We aimed to compare postoperative pulmonary function and complications between the 2 groups. A total of 133 patients who underwent pulmonary segmentectomy for stage IA non-small cell lung cancer were analyzed retrospectively. A pulmonary function test, including vital capacity and forced expiratory volume in 1 second, was performed preoperatively and at 1 and 6 months postoperatively. Propensity score analysis generated 2 matched pairs of 46 patients in the pleural suture and mesh cover groups. In each group, there was no significant difference in the recovery rate of vital capacity and forced expiratory volume in 1 second at 1 and 6 months postoperatively. Compared with the pleural suture group, the mesh cover group had higher incidence of prolonged air leak (8.7% versus 0%; p= 0.042), delayed pneumothorax (10.9% versus 2.2%; p= 0.051). On logistic regression analysis, management of intersegmental plane by either mesh cover or pleural suture was the only independent factor related to pulmonary complications (prolonged air leak or delayed pneumothorax) after pulmonary segmentectomy (odds ratio: 5.26, p= 0.047; odds ratio: 13.39, p= 0.018, respectively). Pleural suturing of the involved intersegmental plane during pulmonary segmentectomy appeared to be an acceptable method to reduce postoperative pulmonary complications.

OA15.05 Anatomical Pulmonary Segmentectomy and Sub-Sebmentectomy for Lung Cancer Using the Novel Fluorescence Technique with Vitamin B2

The identification of an accurate segment is essential for successful anatomic pulmonary segmentectomy. We have previously developed a new fluorescence technique using a PDD endoscope systemTM and vitamin B2 for identification of pulmonary segments in animal experiments. In this study, we applied this technique clinically to examine the efficacy and safety in anatomical pulmonary segmentectomy and sub-segmentectomy for pulmonary malignancies. Our technique requires two key instruments, a PDD endoscope systemTM(KARL STORZ GmbH and Co., Tuttlingen, Germany) as a fluorescence sensing device and vitamin B2 solution as a fluorescent substance. 17 patients with small lung nodules were enrolled in this study. Regarding our surgical technique, after identification of the target segmental or sub-segmental bronchus, vitaminB2 solution is injected via the bronchus. The target segment is identified as a fluorescent segment with the PDD endoscope systemTM. The identified segment is resected with an electric cautery, stapling devices, or combination of them. In case patient’s lung has severe abnormal change such as emphysema or fibrosis, another technique is indicated. After ligation of the target segmental or sub-segmental artery, vitaminB2 solution is systemically administrated with intravenous injection. The target segment is identified as a defect of fluorescence with the PDD endoscope systemTM. Following outcomes were collected; success rate of identifying the pulmonary segments, pathological evaluation of dissection margin, duration of chest drainage, and perioperative complications. A total of 18 procedures were performed using this technique. Performed segmentectomy or sub-segmentectomy were as follows; Right S1, S2, S3, S2a+3b, S6, S9, Left S1+2, S3, S4+5, S6, S8a+9b, S9+10. Resected nodules were 14 primary lung cancers, 1 MALT-lymphoma, 1 metastatic lung cancer, and 2 benign lung nodules. Histology of primary lung cancer was adenocarcinoma in all 14 cases. Pathological stage of lung cancer was 12 stageIA (pT1a; 10, pT1b; 2), 1 stageIIA (pT1aN1), and 1 stageIIIA (pT1aN2). The success rate of identifying pulmonary segments was 100%. Dissection of segmental border was performed with only electric cautery in 12 procedures, and with both of electric cautery and stapling device in 6 procedures. In all cases, no cancer cells were found on the resection margin pathologically. Mean drainage time was 1.7 days (1-4 days). Regarding perioperative complications, veno-vagal reflex was occurred after systemic injection of vitaminB2 in one case, and 1 delayed pneumothorax was found in one case. Our novel fluorescence technique involving a PDD endoscope systemTM and vitaminB2 allowed performing accurate and safe pulmonary segmentectomy and sub-segmentectomy.

Thoracoscopic anatomic pulmonary segmentectomy: a 3-dimensional guided imaging system for lung operations.

To evaluate the Lung Operation Three-dimensional Imaging System software by Xiamen TRONG Technology Co. Ltd in detecting the precise position of solitary pulmonary nodules or ground-glass opacity nodules before surgery. Chest, arterial phase, portal venous phase, enhanced and delayed-phase images of 10 cases with 12 nodules were obtained with a Toshiba Aquilion One 320 computed tomography (CT) scanner. According to the image data of the nodules, 0.5 mm thick images of 320-row multislice CT scanners were reconstructed as 3D images, and the boundary of each segment was automatically partitioned and pigmented in accordance with the pulmonary artery system. To locate the nodules, the 3D images and coloured segments were merged. The clearly labelled lung structure was utilized in a preoperative virtual segmentectomy and the subsequently planned thoracoscopic surgery. In all 10 cases, the reconstruction of the pulmonary artery could image branches as far as Grade 5. The anatomically adjacent relationship of the nodules among the arteries, veins and bronchi in the target pulmonary segments could be displayed in any view. The thoracoscopic anatomic pulmonary segmentectomy was performed successfully. All 12 nodules, which had deeply settled in the parenchyma, were resected using the virtual planning software and diagnosed pathologically. The software can be used preoperatively as a tracing method to identify the location of nodules in most general thoracic surgeries, subsequently providing guidance during the surgery.

A new fluorescent anatomic pulmonary segmentectomy using PDD endoscope system™ and vitamin B2: evaluation in a clinical setting using living animal

Identification of intersegmental planes is essential for successful anatomic pulmonary segmentectomy. We have previously reported a new fluorescence technique using a PDD endoscope system™ and vitamin B2 for identification of intersegmental planes in ex vivo experiments. In the present study, we investigated and evolved this technique to perform ideal anatomic segmentectomy in a clinical setting using living pig models. Cranial segmentectomy in the cranial lobe of the right lung was performed in six pigs using our fluorescence technique. The fluorescent cranial segmentectomy was as follows. After identification of the cranial segmental bronchus, vitamin B2 solution as a fluorescent substance was injected via bronchoscopy. The fluorescent segment was observed using a PDD endoscope system, and the identified intersegmental plane was cut using electric cautery. The operative data collected were the rates of accurate identification of the pulmonary segment and perioperative complications. The duration and light intensity of fluorescence of the target segment were recorded to provide an objective measurement of success. In all procedures, it was possible to identify the target segment by its clear yellow-green fluorescence. The rate of accurate identification of the pulmonary segment was 100%. The fluorescence continued for more than 1 h with adequate light intensity. No perioperative complications were encountered. No unexpected injuries of the major segmental bronchi or vessels occurred. Hemorrhage and air leakage from the transected intersegmental plane were negligible. Our new fluorescence technique in a clinical setting involving a PDD endoscope system™ vitamin B2 enabled accurate and safe anatomic pulmonary segmentectomy, with enough strong and long fluorescence in living pig lungs.