Uniportal VATS S9 segmentectomy: The ligamentum-based approach

Isolated resection of the lateral-basal segment (S9) is uncommon, and it is considered one of the most complex anatomic segmentectomies. First, the segmental arterial and venous supply is located deeply in the lung parenchyma, making the dissection difficult. Second, the cuboidal shape of the lateral basilar segment hampers the identification of the intersegmental plane. Although identifying the segmental arterial branches is easier from a fissure-based technique, the ligamentum-based approach emerges as a valid and safe alternative in cases of a fused fissure.

Identification of The Intersegmental Plane By Arterial-Ligation Method During Thoracoscopic Segmentectomy

Purpose The purpose of this study is to explore the feasibility of identifying the intersegmental plane by arterial ligation alone during thoracoscopic anatomical segmentectomy. Methods We selected 35 patients with peripheral small lung nodules who underwent thoracoscopic anatomical segmentectomy between May and December 2020. First, the targeted segmental arteries were distinguished and ligated during the operation. Then, bilateral pulmonary ventilation was performed with pure oxygen to fully inflate the entirety pulmonary lobes. After waiting for a while, the intersegmental plane appeared. Finally, the intersegmental plane was observed using thoracoscopy after indocyanine green was injected into the peripheral vein. The intersegmental planes determined by these two methods were compared. Results Thirty-four patients underwent segmental resection and one patient finally underwent lobectomy. The intersegmental planes were successfully observed in all patients using the arterial ligation method. The time from contralateral pulmonary ventilation to the appearance of the intersegmental plane was 13.7±3.2 min (6-19 min). The intersegmental planes determined by the arterial ligation method and the fluorescence method were comparable. After the operation, CT examinations showed that the remaining lung segments of all patients were well inflated. The mean duration of closed thoracic drainage was 3.1±0.9 days. Conclusion The arterial ligation method can be used to determine the intersegmental plane in anatomical segmentectomy. The method is feasible, reliable, and safe.

“Non-Triangle Plane” Surgical Technique of Video-Assisted Thoracic Surgery Atypical Segmentectomy for Stage IA Non-Small-Cell Lung Cancer: Early Experience

Objectives: To evaluate the safety and feasibility of a novel surgical technique (“non-triangle plane” technique) of two-port (mini-utility) video-assisted thoracic surgery (VATS) atypical segmentectomy (S3+S1+2c) with tunneling stapler for small-sized non-small-cell lung cancers (NSCLCs) located in left S3 close to the intersegmental plane between S3 and S1+2c.Materials and Methods: This retrospective descriptive study included 16 patients who, between April 2016 and December 2019, underwent a single two-port (mini-utility) VATS atypical segmentectomy (S3+S1+2c) with tunneling stapler technique for small-sized NSCLCs with a ground-glass opacity (GGO) rate of more than 50% by a constant surgical team in two hospitals. Perioperative data and survival data were collected and retrospectively analyzed. Postoperative follow-up was performed every 6 months.Results: Six patients were with adenocarcinoma in situ, and ten were with minimally invasive adenocarcinoma. The mean surgical margin was 14.06 ± 3.02 mm. The mean operation time was 53.88 ± 9.76 min. The mean duration of chest tube drainage was 4 ± 1.21 days, and the median length of postoperative hospital stay was 4 days. There was no perioperative morbidity and mortality. The median follow-up was 47.5 months (17–61 months). No recurrences occurred, and all patients were still alive at the last registered follow-up (May 31, 2021).Conclusion: Two-port (mini-utility) VATS atypical segmentectomy (S3+S1+2c) with tunneling stapler technique is a safe and feasible option for the treatment of small-sized NSCLCs located in left S3 close to the intersegmental plane between S3 and S1+2c.

Uniportal thoracoscopic lateral and posterior (S9+10) segmentectomy using a modified intersegmental tunneling procedure

The lateral and posterior basal (S9+10) segmentectomy is one of the most challenging operations because it requires exposure and recognition of pulmonary vessel branches and bronchi that are located deep in the lung parenchyma. To perform this difficult operation appropriately, even via a uniportal approach, we adopted a modified version of the intersegmental tunneling procedure. Intersegmental tunneling followed by division of the intersegmental plane between S6 and S9-10 was performed before the division of the A9+10 in the modified version. In addition to the clear recognition of the dominant vessels and bronchi permitted by the tunneling procedure, we were able to divide them smoothly using a stapler in the modified version, although the tip of the inserted stapler stuck to the lung parenchyma in the previous version. This method might be universally preferable, even for less experienced surgeons, when they perform this challenging operation.

Uniportal thoracoscopic apical (S1) segmentectomy of the right upper lobe via an anterior approach

An apical (S1) segmentectomy of the right upper lobe is considered one of the most challenging procedures among the uncommon pulmonary segmentectomies. However, we consider that the uniportal thoracoscopic approach, for which the single port access is located at the 4th intercostal space of the anterior axillary line, makes this challenging operation easier because we can recognize any intrathoracic vessels and bronchi that should be divided just under the incision. Moreover, it is easy to insert a stapler to divide an intersegmental plane between S1 and the other segments because of the good surgical view provided by this approach. In this video tutorial, we describe the successful results of a patient undergoing uniportal thoracoscopic S1 segmentectomy of the right lower lobe and explain the nuances of performing it.

Electrocautery vs. Stapler in Comparing Safety for Segmentectomy of Lung Cancer: A Meta-Analysis

Background: Electrocautery and staplers are regarded as the two most common surgical instruments for dissecting the intersegmental plane in segmentectomy. We performed a meta-analysis to compare electrocautery and staplers in terms of their safety and effects.Methods: A systematic search strategy was performed using PubMed, and the retrieval time was up to April 1, 2020. Odds ratio (OR) and mean differences (MDs) with 95% CI were applied to determine the effectiveness of dichotomous or continuous variables, respectively.Results: Six studies including 385 patients were included. The electrocautery had a higher incidence rate of postoperative complication [OR= 1.92, 95% CI (1.12, 3.28), P = 0.02)] and air leak [OR: 3.91, 95% CI (1.64, 9.35), P = 0.002)]. No significant difference was found in the comparison of surgery time, blood loss, and duration of tube days or hospitality days.Conclusions: Our study indicated that patients under segmentectomy were associated with better safety by using stapler than electrocautery in the reduction of postoperative complications.