Anatomical Segmentectomy Research Articles

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.

What Do We Talk About Now When We Talk About Segmentectomy for GGO?

Segmentectomy has been considered as a compromised procedure in patients with early-stage lung cancer who could not tolerate standard lobectomy. By computed tomography (CT) screening, lung cancers are increasingly detected in earlier stages, especially those appearing as ground glass opacity (GGO)-containing lesions on CT scan. This has led to the revival of segmentectomy as an intentional procedure with the aim of curing selected patients, as GGO-containing lesions represent a special group of diseases that are relatively indolent in nature and seldom have lymphatic involvement. Limited resections, especially anatomical segmentectomy, may, thus, be helpful in reducing perioperative risks and preserving higher pulmonary function for patients while retaining similar oncological outcomes. However, clinical trials focusing specifically on the role of segmentectomy in the treatment of GGO-containing lung cancers are still lacking, especially in the minimally invasive surgery setting. Emerging evidence suggests that for such lesions, the oncological non-inferiority of segmentectomy to standard lobectomymay not be limited to lesions with a size ≤ 2 cm. More importantly, it is still unclear whether segmentectomy could indeed minimize perioperative risks and to what extent it could help preserve higher pulmonary function in good-risk patients with less extent of lung parenchyma resection. Hence, it is critical to reevaluate the efficacies of minimally invasive segmentectomy including not only oncological outcomes but also perioperative results and pulmonary function changes compared with lobectomy in good-risk patients with GGO-containing lung cancers. All these remain to be explored in future studies and robust evidence is still needed to prove that patients would indeed benefit from the combination of segmentectomy and minimally invasive surgery.

“HRCT predictors of GGO surgical resection: Histopathological and molecular correlation in the era of lung sparing surgery”

ObjectivesGround-glass pulmonary opacities (GGOs) are increasingly encountered in routine clinical practice and an accurate differentiation between benign and malignant lesions is crucial. The aim of this study is to evaluate the relationship between radiological features and the actual biological behavior of these nodules. The secondary endpoint is to identify any radiological predictors able to choose the type of surgical resection and the extent of lymphadenectomy. Materials and MethodsThis single-center retrospective study included all patients, who underwent high resolution computed tomography (HRCT) and surgical resection for GGOs between 2010 and 2020. Histopathological sampling focused on lesion size, histology, growth pattern, amount of lepidic component, percentage of ground-glass (GG), grade of tumor and proliferation index (Ki67). ResultsIn 56 patients enrolled, 65 lesions (15 pure GG and 50 part-solid) were resected (44 lobectomies, 9 anatomical segmentectomies, 12 wedge resections). A direct significant correlation was found between: the GG at HRCT and the amount of lepidic component (p < 0.0001; R = 0.305), the tumor grading and the lepidic component at HRCT (p = 0.003), the percentage of GG and the expression of Ki67 (p = 0.016), the lepidic percentage and the expression of Ki67 (p = 0.004; R = 0.223). A total of 609 lymph-nodes were removed (stations N1 and N2) and histopathological analysis was negative for nodal involvement in all cases. ConclusionPure and part-solid GGOs could benefit from less invasive and lung sparing surgery with just nodal sampling. These would reduce surgical complications and guarantee a better quality of life for the patient. The major limitations are the number of patients and the lack of a longer follow-up.

Two micro-portal video-assisted thoracic surgery of right S8 segmentectomy with systemic lymphadenectomy

: Better management of lung cancer is crucial for improving the prognosis of such lethal malignancy, and surgical treatment is one of the most important strategies for early lung cancer. Anatomic segmentectomy, in particular, provides the complete resection of lesions with the retention of maximal normal lung tissue. Several different techniques for lung segmentectomy have been described previously, whereas how to perform with concerns of minimal invasiveness and better accessibility for surgeons familiar with single-direction video-assisted thoracic surgery (VATS) remains to be elucidated. In the presented case, we described the applications of our two-micro-portal video-assisted thoracic segmentectomy as well as the plug-in multi-edge cutting method to a patient with a mixed ground-glass nodule in the anterior basal segment of the right lower lobe, and systemic lymphadenectomy was performed following the pathological diagnosis of invasive adenocarcinoma. The patient was discharged after a 4-day well recovery and was without recurrence or metastasis after 6 months of follow-up. Considering that the two micro-portal VATS would be more accessible for surgeons who are already familiar with the single-direction VATS and could yield the similar minimal invasiveness and less pain as uniport VATS, we believe that the presented two-micro-portal video-assisted thoracic segmentectomy is technically safe and feasible in lung cancer treatment and is worthy of promotion.

Mediastinal basal pulmonary artery identification and classification by three-dimensional reconstruction

The primary objective of the present study was to use CT angiography and 3D reconstruction to assess and to classify the mediastinal pulmonary basal segmental arteries. We report a particular type of bifurcated left lower pulmonary artery, namely, the "mediastinal basal pulmonary artery" type, which is the first branch from the proximal the left pulmonary artery (LPA) between the left main bronchus (LMB) and the left superior pulmonary vein (LSPV) and proceeding directly into the lower lobe. There are many types of mediastinal basal pulmonary arteries, and these can be classified worldwide in a unified way and format, which will be beneficial for clinical records, annotation and academic exchange. The mediastinal basal pulmonary arteries are described either as "supernumerary" when duplicating or "displaced" when replacing the normal arterial branching pattern of the lower lobe. The displaced type is more frequent than the supernumerary type. There are 12 types of left mediastinal basilar arteries. This is the first report to categorize the mediastinal basal pulmonary artery, is the first to suggest a system for mediastinal basal pulmonary artery nomenclature, and creates simplified models for use when planning anatomical segmentectomy. Knowledge and recognition of this rare and special condition may facilitate better diagnosis and treatment of these patients.

Thoracoscopic segmentectomy versus lobectomy: A propensity score–matched analysis

ObjectivesThe aim of this study is to compare the postoperative complications, perioperative course, and survival among patients from the multicentric Spanish Video-assisted Thoracic Surgery Group database who received video-assisted thoracic surgery lobectomy or video-assisted thoracic surgery anatomic segmentectomy. MethodsFrom December 2016 to March 2018, a total of 2250 patients were collected from 33 centers. Overall analysis (video-assisted thoracic surgery lobectomy = 2070; video-assisted thoracic surgery anatomic segmentectomy = 180) and propensity score–matched adjusted analysis (video-assisted thoracic surgery lobectomy = 97; video-assisted thoracic surgery anatomic segmentectomy = 97) were performed to compare postoperative results. Kaplan–Meier and competing risks method were used to compare survival. ResultsIn the overall analysis, video-assisted thoracic surgery anatomic segmentectomy showed a lower incidence of respiratory complications (relative risk, 0.56; confidence interval, 0.37-0.83; P = .002), lower postoperative prolonged air leak (relative risk, 0.42; 95% confidence interval, 0.23-0.78; P = .003), and shorter median postoperative stay (4.8 vs 6.2 days; P = .004) than video-assisted thoracic surgery lobectomy. After propensity score–matched analysis, prolonged air leak remained significantly lower in video-assisted thoracic surgery anatomic segmentectomy (relative risk, 0.33; 95% confidence interval, 0.12-0.89; P = .02). Kaplan–Meier and competing risk curves showed no differences during the 3-year follow-up (median follow-up in months: 24.4; interquartile range, 20.8-28.3) in terms of overall survival (hazard ratio, 0.73; 95% confidence interval, 0.45-1.7; P = .2), tumor progression–related mortality (subdistribution hazard ratio, 0.41; 95% confidence interval, 0.11-1.57; P = .2), and disease-free survival (subdistribution hazard ratio, 0.73; 95% confidence interval, 0.35-1.51; P = .4) between groups. ConclusionsVideo-assisted thoracic surgery segmentectomy showed results similar to lobectomy in terms of postoperative outcomes and midterm survival. In addition, a lower incidence of prolonged air leak was found in patients who underwent video-assisted thoracic surgery anatomic segmentectomy.

Laparoscopic Segmentectomy IV Using Hepatic Round Ligament Approach Combined with Fluorescent Negative Staining Method

Laparoscopic segmentectomy, which maximizes the preservation of the functional hepatic reserve and the possibility for future repeat hepatectomy while ensuring adequate surgical margin, is a feasible alternative to hemihepatectomy for hepatocellular carcinoma (HCC) (Vigano et al. in Ann Surg 270(5):842-851, 2019, Ishizawa et al. in Ann Surg 256(6):959-964, 2012). Herein, we present a video of laparoscopic segmentectomy IV for HCC using hepatic round ligament approach combined with fluorescent negative staining method. A 44-year-old male with history of chronic hepatitis B virus (HBV) infection for 22 months was referred for treatment of a single HCC in segment IV. The procedure was performed according to the following steps: (1) lowering the hilar plate based on Laennec's capsule (Sugioka et al. in J Hepatobiliary Pancreat Sci 24(1):17-23, 2017) after cholecystectomy; (2) cutting the Glisson's pedicles to segment IV along the fissure for the round ligament; (3) the first parenchyma transection was along the falciform ligament, while cutting some deep pedicles to segment IV; (4) clamping the left Glisson's pedicle and using fluorescent negative staining method (Abo et al. in Eur J Surg Oncol 41(2):257-264, 2015, Funamizu et al. in J Hepatobiliary Pancreat Sci, 2021, Xu et al. in Surg Endosc 34(10):4683-4691, 2020); (5) the second parenchyma transection was performed along the boundary of negative fluorescence region to expose the middle hepatic vein (MHV) using a combination of cranial and caudal approaches. The operative time was 190 min, and blood loss during operation was 80 mL. The histopathologic examination showed a solitary HCC, 2.5 cm in diameter, with negative surgical margin and no microvascular invasion. The patient had an uneventful postoperative recovery and was discharged on postoperative day 5. The round ligament approach combined with fluorescent negative staining method for laparoscopic anatomic segmentectomy IV is a feasible and effective technique.

Techniques of Minimally Invasive Posterior Basal (S10) Segmentectomies of the Lower Lobes

Now, the standard treatment for clinical stage I non-small cell lung cancer (NSCLC) is lobectomy with systematic nodal dissection. Sublobar resections, such as segmentectomy and wedge resection are often performed in compromised patients with peripheral small-sized NSCLC who are unfit or at high risk for standard lobectomy or even in those with indolent NSCLC who are fit for lobectomy. Anatomical segmentectomy rather than non-anatomical wedge resection as sublobar resection is usually recommended. Segmentectomy could be subdivided according to the number and shape of intersegmental plane. Segmentectomy that creates one, linear intersegmental plane, with a relatively easier procedure, could be considered simple segmentectomy, that is, resection of the superior segmentectomy of the lower lobe, the upper division, or lingula segment of the left upper lobe. Segmentectomy that creates several, or intricate intersegmental planes, with more a complex procedure, could be considered complex segmentectomy, that is, one other than simple segmentectomy, such as non-superior segmentectomy of the basilar segment of the lower lobe. Because of procedural complexity and risk of increased complications and incurability, compared with simple segmentectomy, some general thoracic surgeons may have concerns to perform complex segmentectomies. In this article, we show the technique of posterior basal segmentectomies, which is one of the most challenging procedures in complex segmentectomy, through a hybrid video-assisted thoracic surgery approach.

Learning curve for uniportal video-assisted thoracoscopic anatomical segmentectomy.

BackgroundAnatomical segmentectomy by uniportal video-assisted thoracoscopic surgery (U-VATS) is a delicate surgical procedure. Hitherto, only few studies have assessed the learning curves of anatomical segmentectomy by U-VATS, with varying data available. The present study aimed to investigate the learning curve and clinical advantages for U-VATS segmentectomy.MethodsThe medical records of patients who underwent U-VATS or non-U-VATS segmentectomy between August 2017 and May 2020 were retrospectively reviewed. Cumulative sum (CUSUM) analysis was employed to illustrate the learning curve of U-VATS segmentectomy. Perioperative parameters were used to determine the structural intervals of the learning curve, and to compare U-VATS and non-U-VATS segmentectomy.ResultsIn total, 122 patients receiving U-VATS segmentectomy and 98 patients receiving non-VATS segmentectomy were included. Of these, 116 patients underwent successful U-VATS segmentectomy, while the other six patients underwent conversions. The structural intervals of 20–29 cases and 58–63 cases were determined as the threshold according to the CUSUM analyses. The learning process of U-VATS segmentectomy was therefore divided into three phases. Interestingly, the perioperative parameters differed significantly between Phases 1 and 3, including operative time (Op-T), postoperative hospital stays (Po-Hst), postoperative thoracic drainage (Po-D), and operative failure (Po-F) rates (P<0.05). Moreover, U-VATS segmentectomy in Phase 3 was associated with significantly shorter Po-Hst and Op-T, less Po-D, and reduced postoperative pain compared with non-U-VATS (P<0.05).ConclusionsU-VATS segmentectomy is an ideal alternative to non-U-VATS segmentectomy. Surgeons can preliminarily complete U-VATS anatomical segmentectomy after performing 20–29 cases, and can master the surgical techniques after completing 58–63 cases.

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.

Functional Preserving Sublobectomy: A Novel Method for Sublobectomy.

We introduce a new method for sublobectomy. It utilizes the easiness and rapidity of wedge resection, and the accuracy and functional preserving of anatomical segmentectomy. It can preserve lung function with less sacrifice of lung parenchyma.

Thoracoscopic anatomical individual basilar segmentectomy.

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. 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. 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. 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.

Completion lobectomy after anatomical segmentectomy.

Patient selection flowchart. OBJECTIVESCompletion lobectomy (CL) after anatomical segmentectomy in the same lobe can be complicated by severe adhesions around the hilar structures and may lead to fatal bleeding and lung injury. Therefore, we aimed to investigate the perioperative outcomes of CL after anatomical segmentectomy.METHODSAmong 461 patients who underwent anatomical segmentectomy (thoracotomy, 62 patients; thoracoscopic surgery, 399 patients) between January 2005 and December 2019, data of patients who underwent CL after segmentectomy were extracted and analysed in this study.RESULTSEight patients underwent CL after segmentectomy. CL was performed via video-assisted thoracic surgery in 3 patients and thoracotomy in 5 patients. In each case, there were moderate to severe adhesions. Four patients required simultaneous resection of the pulmonary parenchyma and pulmonary artery. Thoracotomy was not required after thoracoscopic surgery in any patient. Two patients experienced complications (air leakage and arrhythmia). The median duration of hospitalization after CL was 6 (range, 5–7) days. No postoperative mortality or recurrence of lung cancer was observed. All the patients with lung cancer were alive and recurrence-free at the time of publication.CONCLUSIONSAlthough individual adhesions render surgery difficult, CL after anatomical segmentectomy shows acceptable perioperative outcomes. However, CL by video-assisted thoracoscopic surgery may be considered on a case-by-case basis depending on the initial surgery.

The Tokyo 2020 terminology of liver anatomy and resections: Updates of the Brisbane 2000 system.

The Brisbane 2000 Terminology for Liver Anatomy and Resections, based on Couinaud's segments, did not address how to identify segmental borders and anatomic territories of less than one segment. Smaller anatomic resections including segmentectomies and subsegmentectomies, have not been well defined. The advent of minimally invasive liver resection has enhanced the possibilities of more precise resection due to a magnified view and reduced bleeding, and minimally invasive anatomic liver resection (MIALR) is becoming popular gradually. Therefore, there is a need for updating the Brisbane 2000 system, including anatomic segmentectomy or less. An online "Expert Consensus Meeting: Precision Anatomy for Minimally Invasive HBP Surgery (PAM-HBP Surgery Consensus)" was hosted on February 23, 2021. The Steering Committee invited 34 international experts from around the world. The Expert Committee (EC) selected 12 questions and two future research topics in the terminology session. The EC created seven tentative definitions and five recommendations based on the experts' opinions and the literature review performed by the Research Committee. Two Delphi Rounds finalized those definitions and recommendations. This paper presents seven definitions and five recommendations regarding anatomic segmentectomy or less. In addition, two future research topics are discussed. The PAM-HBP Surgery Consensus has presented the Tokyo 2020 Terminology for Liver Anatomy and Resections. The terminology has added definitions of liver anatomy and resections that were not defined in the Brisbane 2000 system.

A Percutaneous Portal Vein Puncture Under Artificial Ascites for Intraoperative Hepatic Segmentation Using Indocyanine Green Fluorescence: A Technical Report of Laparoscopic Anatomic Liver Resection.

Background:Laparoscopic liver resection have developed and is widely spread as standard procedure in these days, however, laparoscopic anatomic liver resection is still challenging, especially for posterosuperior lesions because of difficulties in segmental mapping and surgical techniques. Recently, the positive staining and negative staining method using fluorescent imaging techniques have been reported from experienced Asian centers, allowing to identify the tumor-bearing portal territory to be resected including the posterosuperior segment in laparoscopy. Those techniques are applicable in some cases; hence, it remains the room for improvement to establish as a feasible approach. Herein, we describe a percutaneous tumor-bearing portal vein puncture method under artificial ascites after the pneumoperitoneum for laparoscopic segmentectomy for segment 8.Case Presentation and Surgical Procedure:A male patient in his 60s was admitted for an incidentally diagnosed hepatic mass in segment 8. Findings of the computed tomography scan showed a 2.5-cm-sized hepatocellular carcinoma lesion. Then, laparoscopic anatomic liver resection for segment 8 was planned. The segmentation of the segment 8 was performed through a percutaneous tumor-bearing portal vein puncture using indocyanine green injection with extracorporeal ultrasound guidance under artificial ascites. According to indocyanine green fluorescence navigation, anatomic liver resection was completed. Operative time was recorded as 375 minutes. The estimated intraoperative blood loss was 50 mL without the requirement for an intraoperative transfusion. The planned resections were successful with histologically negative surgical margins. The patient was discharged on the 19th postoperative day with normal liver function test results. There was no operation-related complication during hospitalization.Conclusion:The intraoperative percutaneous portal vein puncture method under artificial ascites was useful for the identification of posterosuperior segment in laparoscopic anatomic segmentectomy.

Thoracoscopic segmentectomy and lobectomy assisted by three-dimensional computed-tomography bronchography and angiography for the treatment of primary lung cancer.

BACKGROUNDAnatomical segmentectomy has been proposed as a substitution for lobectomy for early-stage lung cancer. However, it requires technical meticulousness due to the complex anatomical variations of segmental vessels and bronchi.AIMTo assess the safety and feasibility of three-dimensional computed-tomography bronchography and angiography (3D-CTBA) in performing video-assisted thoracoscopic surgery (VATS) for lung cancers.METHODSIn this study, we enrolled 123 patients who consented to undergo thoracoscopic segmentectomy and lobectomy assisted by 3D-CTBA between May 2017 and June 2019. The image data of enhanced computed tomography (CT) scans was reconstructed three-dimensionally by the Mimics software. The results of preoperative 3D-CTBA, in combination with intraoperative navigation, guided the surgery.RESULTSA total of 59 women and 64 men were enrolled, of whom 57 (46.3%) underwent segmentectomy and 66 (53.7%) underwent lobectomy. The majority of tumor appearance on CT was part-solid ground-glass nodule (pGGN; 55.3%). The mean duration of chest tube placement was 3.5 ± 1.6 d, and the average length of postoperative hospital stay was 6.8 ± 1.8 d. Surgical complications included one case of pneumonia and four cases of prolonged air leak lasting > 5 d. Notably, there was no intraoperative massive hemorrhage, postoperative intensive-care unit stay, or 30-d mortality. Preoperative 3D-CTBA images can display clearly and vividly the targeted structure and the variations of vessels and bronchi. To reduce the risk of locoregional recurrence, the application of 3D-CTBA with a virtual 3D surgical margin help the VATS surgeon determine accurate distances and positional relations among the tumor, bronchial trees, and the intersegmental vessels. Three-dimensional navigation was performed to confirm the segmental structure, precisely cut off the targeted segment, and avoid intersegmental veins injury.CONCLUSIONVATS and 3D-CTBA worked in harmony in our study. This combination also provided a new pattern of transition from lesion-directed location of tumors to computer-aided surgery for the management of early lung cancer.

Anatomy of the left subsuperior segment for segmentectomy.

The subsuperior segmental bronchi (B*) forms the subsuperior segment (S*) between the superior (S6) and basal segment (S7, S8, S9, S10) of the lung. However, the anatomical planes of S* remains undefined. The present study clarified the anatomical features of S*. We reviewed the anatomical patterns of pulmonary vessels and the left lung bronchus in 539 patients using three-dimensional computed tomography. We report the anatomic structure in S*. A total of 537 patients were analyzed. B* was observed in 129 (24.0%) patients. The intersegmental vein between S6 and S* was complete in all cases. The absence of intersegmental veins of S* was observed in 77 (14.3%) patients, reaching 59.7% of B* cases. Twenty-two (4.1%) cases of B* diverged from the trunk of the basal bronchus, and about half of the B* branched to the dorsolateral (n = 77, 14.3%) or dorsal (n = 2, 0.37%) direction. Our study revealed the branching patterns of B* and anatomical intersegmental veins of S*. Our results provide useful information regarding anatomical segmentectomy including or adjusting to the left S*.

Feasibility Investigation of Fluorescence Method in Uniport Thoracoscopic Anatomical Segmentectomy for Identifying the Intersegmental Boundary Line

背景与目的肺段切除术逐渐成为影像学上表现为早期肺癌的肺部小结节的标准手术方式之一。本研究通过对比单孔胸腔镜下荧光法与改良膨胀萎陷法在界定段间交界线的围手术期结果，评估荧光法应用于肺段切除术的有效性和可行性。方法回顾性分析2018年2月-2020年8月期间在南京胸科医院胸外科接受单孔胸腔镜肺段切除术的连续198例患者的围手术期数据。在三维智能交互式定性和定量分析（intelligent/interactive qualitative and quantitative analysis-three dimensional, IQQA-3D）图像分析系统的指导下，精确识别和解剖离断靶段结构，继而通过荧光法或改良膨胀萎陷法确认段间交界线。评价两种方法的临床疗效和术后并发症。结果荧光法组有98%的患者呈现出清晰的段间交界线，甚至部分患者使用了较低剂量的吲哚菁绿（indocyanine green, ICG）。相比改良膨胀萎陷法，荧光法的段间交界线的清晰呈现时间[(23.59±4.47) s vs (1, 026.80±318.34) s, P < 0.01]和手术时间[(89.3±31.6) min vs (112.9±33.3) min, P < 0.01]明显缩短。改良膨胀萎陷法术后长时间漏气的发生率高于荧光法组（8.0% vs 26.5%, P=0.025）。两组的术中失血量、术后胸管持续引流时间、术后住院时间、手术切缘宽度及其他术后并发症均无明显差异（P均 > 0.05）。结论荧光法可以高度准确地识别段间交界线，使得解剖性肺段切除术更加简单、更加快速，因此荧光法有可能成为一种可行且有效的技术，以提高单孔胸腔镜肺段切除术的质量。

Three-dimensional interactive quantitative surgical planning inferior pulmonary ligament approach VATS right S9+10 segmentectomy

: With the rapid development of thoracic surgical technology, a series of new surgical methods have been applied in clinical practice. Thoracoscopic pulmonary segmentectomy has become a common surgical procedure in thoracic surgery. Compared with traditional lobectomy, anatomic segmentectomy can preserve more lung function and is suitable for patients with early lung cancer. More and more patients and doctors prefer anatomical segmentectomy. Anatomical segmentectomy is a much more complex procedure than lobectomy, and it’s challenging and technique demanding, especially when performed under total thoracoscopic visualization. The main reason lies in the difficulty in dissecting the frequently variable segmental structures (vein, artery, and bronchus) and identifying the accurate intersegmental planes. While the basal segment of the lower lobe is relatively complex and variable, the thoracoscopic S9+10 segmentectomy is one of the most technically challenging anatomical segmentectomies, because of deeper intraparenchymal localization of the hilar structures, more frequent variations, and more complex neighboring relationships of the intersegmental planes. The three-dimensional reconstruction images obtained by computed tomography (CT) scan show that anatomy is excellent. It can help us understanding the anatomic relationship of bronchi, pulmonary arteries and veins clearly before operation, nodal location, ensuring the safety of the segmental margin, estimating the volume of the target segment, making the operation plan, planning of surgical approach and the operation steps, which is absolutely necessary for safe anatomy.

A video of left superior anatomical segmentectomy. Harmonic Scalpel was used for lymph node dissection and pulmonary artery branch sealing. A pulmonary artery >7 mm and the segmental bronchus were sealed with endostaplers. The segment border was marked with indocyanine green.

A video of left superior anatomical segmentectomy. Harmonic Scalpel was used for lymph node dissection and pulmonary artery branch sealing. A pulmonary artery >7 mm and the segmental bronchus were sealed with endostaplers. The segment border was marked with indocyanine green.