Segmentectomy for Early-Stage Lung Cancer: 3D Navigation 9819901421, 9789819901425

Table of contents :
Foreword
Foreword
Preface
Contents
Editors and Contributors
About the Editors
Drawing
English Review
Associate Editors
Contributors
1: A Brief History of Thoracoscopic Anatomical Segmentectomy by 3D Navigation
Suggested Reading
2: Nomenclature of Segments
2.1 Section 1: Nomenclature of Segmental and Subsegmental Lung
2.1.1 Right Upper Lobe (Fig. 2.1)
2.1.2 Right Middle Lobe (Fig. 2.1)
2.1.3 Left Upper Lobe (Fig. 2.1)
2.1.4 Lower Lobe (Fig. 2.1)
2.2 Section 2: Nomenclature of Segmental and Subsegmental Bronchus
2.2.1 Right Upper Lobe (Fig. 2.2)
2.2.2 Right Middle Lobe (Fig. 2.2)
2.2.3 Left Upper Lobe (Fig. 2.2)
2.2.4 Lower Lobe (Fig. 2.2)
2.3 Section 3: Nomenclature of Segmental and Subsegmental Artery
2.3.1 Right Upper Lobe (Fig. 2.3)
2.3.2 Right Middle Lobe (Fig. 2.3)
2.3.3 Left Upper Lobe (Fig. 2.4)
2.3.4 Lower Lobes (Figs. 2.3 and 2.4)
2.4 Section 4: Nomenclature of Segmental and Subsegmental Vein
2.4.1 Right Upper Lobe (Fig. 2.5)
2.4.2 Right Middle Lobe (Fig. 2.6)
2.4.3 Left Upper Lobe (Figs. 2.7 and 2.8)
2.4.4 Lower Lobes (Fig. 2.9)
Suggested Reading
3: 3D Reconstruction of Lung by MIMICS
3.1 Introduction to MIMICS Software
3.2 Introduction to MIMICS Lung 3D Reconstruction
3.3 MIMICS Reconstruction Steps
Suggested Reading
4: Indications and Technical Details of Segmentectomy for Lung Cancer
4.1 Indications of Segmentectomy for Lung Cancer
4.2 Technical Key Point of Segmentectomy with 3D Navigation
4.2.1 Choice of Incision
4.2.2 Selection of Surgical Instruments
4.2.3 Operational Skills
4.2.3.1 “From the Shallower to the Deeper” to Dissect the Targeted Segmental Structures
4.2.3.2 “Wang’s Technique”
4.2.3.3 Dissection of Segmental Vessels and Bronchus
4.2.3.4 Vessel-Dissected Inflation-Deflation Method
4.2.3.5 Definition of Targeted Segments or Subsegments
4.2.3.6 Segmental Gate Dissection
Suggested Reading
5: LS1 + 2 + LS3 Segmentectomy by 3D Navigation
5.1 Summary of Medical Records
5.1.1 Indications and Contraindications
5.2 Preoperative 3D-CTBA Reconstruction
5.2.1 Anatomical Features
5.3 Surgery Planning and Procedure
5.3.1 Surgical Planning
5.3.2 Surgical Procedure
5.3.3 Key Points of the Surgical Procedure
5.4 Schematic Diagram of the Surgical Procedure
Suggested Reading
6: LS4 + 5Segmentectomy by 3D Navigation
6.1 Summary of Medical Records
6.1.1 Indications and Contraindications
6.2 Preoperative 3D-CTBA Reconstruction
6.2.1 Anatomical Features
6.3 Surgery Planning and Procedure
6.3.1 Surgical Planning
6.3.2 Surgical Procedures
6.3.3 Key Operation Points
6.4 Schematic Diagram of the Surgical Procedure
Suggested Reading
7: Extended LS3 Segmentectomy by 3D Navigation
7.1 Summary of Medical Records
7.1.1 Indications and Contraindications
7.2 Preoperative 3D-CTBA Reconstruction
7.2.1 Anatomical Features
7.3 Surgery Planning and Procedure
7.3.1 Surgical Planning
7.3.2 Surgical Procedures
7.3.3 Key Points of the Surgical Procedure
7.4 Schematic Diagram of the Surgical Procedure
Suggested Reading
8: RS1 Segmentectomy by 3D Navigation
8.1 Summary of Medical Records
8.1.1 Indications and Contraindications
8.2 Preoperative 3D-CTBA Reconstruction
8.2.1 Anatomical Features
8.3 Surgery Planning and Procedure
8.3.1 Surgical Planning
8.3.2 Surgical Procedures
8.3.3 Key Points of the Surgical Procedure
8.4 Schematic Diagram of the Surgical Procedure
Suggested Reading
9: Extended RS2 Segmentectomy by 3D Navigation
9.1 Summary of Medical Records
9.1.1 Indications and Contraindications
9.2 Preoperative 3D-CTBA Reconstruction
9.2.1 Anatomical Features
9.3 Surgery Planning and Procedure
9.3.1 Surgical Planning
9.3.2 Surgical Procedures
9.3.3 Key Points of the Surgical Procedure
9.4 Schematic Diagram of the Surgical Procedure
Suggested Reading
10: RS3 Segmentectomy by 3D Navigation
10.1 Summary of Medical Records
10.1.1 Indications and Contraindications
10.2 Preoperative 3D-CTBA Reconstruction
10.2.1 Anatomical Features
10.3 Surgery Planning and Procedure
10.3.1 Surgical Planning
10.3.2 Surgical Procedures
10.3.3 Key Points of the Surgical Procedure
10.4 Schematic Diagram of the Surgical Procedure
Suggested Reading
11: RS2b + RS3a Segmentectomy by 3D Navigation
11.1 Summary of Medical Records
11.1.1 Indications and Contraindications
11.2 Preoperative 3D-CTBA Reconstruction
11.2.1 Anatomical Features
11.3 Surgery Planning and Procedure
11.3.1 Surgical Planning
11.3.2 Surgical Procedures
11.3.3 Key Points of the Surgical Procedure
11.4 Schematic Diagram of the Surgical Procedure
Suggested Reading
12: RS1 + RS2 + RS3c Segmentectomy by 3D Navigation
12.1 Summary of Medical Record
12.1.1 Indications and Contraindications
12.2 Preoperative 3D-CTBA Reconstruction
12.2.1 Anatomical Features
12.3 Surgery Planning and Procedure
12.3.1 Surgical Planning
12.3.2 Surgical Procedures
12.3.3 Key Points of the Surgical Procedure
12.4 Schematic Diagram of the Surgical Procedure
Suggested Reading
13: LS6 Segmentectomy by 3D Navigation
13.1 Summary of Medical Records
13.1.1 Indications and Contraindications
13.2 Preoperative 3D-CTBA Reconstruction
13.2.1 Anatomical Features
13.3 Surgery Planning and Procedure
13.3.1 Surgical Planning
13.3.2 Surgical Procedures
13.3.3 Key Points of the Surgical Procedure
13.4 Schematic Diagram of the Surgical Procedure
Suggested Reading
14: RS8a Segmentectomy by 3D Navigation
14.1 Summary of Medical Records
14.1.1 Indications and Contraindications
14.2 Preoperative 3D-CTBA Reconstruction
14.2.1 Anatomical Features
14.3 Surgery Planning and Procedure
14.3.1 Surgical Planning
14.3.2 Surgical Procedures
14.3.3 Key Points of the Surgical Procedure
14.4 Schematic Diagram of the Surgical Procedure
Suggested Reading
15: LS9 + LS10 Segmentectomy by 3D Navigation
15.1 Summary of Medical Records
15.1.1 Indications and Contraindications
15.2 Preoperative 3D-CTBA Reconstruction
15.2.1 Anatomical Features
15.3 Surgery Planning and Procedure
15.3.1 Surgical Planning
15.3.2 Surgical Procedures
15.3.3 Key Points of the Surgical Procedure
15.4 Schematic Diagram of the Surgical Procedure
Suggested Reading
16: LS10b + c Segmentectomy by 3D Navigation
16.1 Summary of Medical Records
16.1.1 Indications and Contraindications
16.2 Preoperative 3D-CTBA Reconstruction
16.2.1 Anatomical Features
16.3 Surgery Planning and Procedure
16.3.1 Surgical Planning
16.3.2 Surgical Procedures
16.3.3 Key Points of the Surgical Procedure
16.4 Schematic Diagram of the Surgical Procedure
Suggested Reading

Citation preview

Jixian Liu Da Wu Editors

Segmentectomy for Early-Stage Lung Cancer 3D Navigation

·北 京·

123

Segmentectomy for Early-Stage Lung Cancer

Jixian Liu • Da Wu Editors

Segmentectomy for Early-Stage Lung Cancer 3D Navigation

Editors Jixian Liu Department of Thoracic Surgery Peking University Shenzhen Hospital Shenzhen, China

Da Wu Department of Thoracic Surgery Peking University Shenzhen Hospital Shenzhen, China

ISBN 978-981-99-0142-5    ISBN 978-981-99-0143-2 (eBook) https://doi.org/10.1007/978-981-99-0143-2 Jointly published with Scientific and Technical Documentation Press The print edition is not for sale in China (Mainland). Customers from China (Mainland) please order the print book from: Scientific and Technical Documentation Press. The translation was done with the help of artificial intelligence (machine translation by the service DeepL.com). A subsequent human revision was done primarily in terms of content. © Scientific and Technical Documentation Press 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publishers, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publishers nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publishers remain neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Foreword

With the popular use of low-dose chest CT, lung cancer is being diagnosed and treated earlier than ever. Meanwhile, the efficacy of thoracoscopic segmentectomy for early lung cancer has been confirmed by numerous retrospective and prospective clinical studies. Segmentectomy meets the treating criterion of lung cancer, that is, maximum resection of tumor with maximum preservation of lung tissue. With increasing demands in treatment and rapid developments of 3D technology in recent years, thoracoscopic precise segmentectomy, subsegmentectomy, and combined subsegmentectomy have flourished all over the world. However, the procedure is complicated by extensive anatomical variability. With the technological advancement of 3D reconstruction technologies, surgeons can understand the anatomical relationship between segmental vessels and bronchi before surgeries, simplifying the segmentectomy procedure. The book summarizes the practical experiences of the thoracic surgery team of Peking University Shenzhen Hospital over the years by illustrating the technical details of thoracoscopic precise segmentectomy with 12 simple and practical examples. Each case comes with CT pictures, individualized anatomical pictures of 3D reconstruction, screenshots of surgical videos demonstrating important anatomical structures, operative videos, and most importantly, exquisite hand-drawn pictures with detailed labeling of crucial anatomical structures. The book simplifies the technology, allowing the reader to grasp the technical essentials with ease. At the same time, the concept of “Simplifying Standard Segmentectomy” is also proposed. The commencement of the book in its English version will further promote the recognition and adoption of this segmentectomy technology worldwide. Peking University People’s Hospital Beijing, China

Jun Wang

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Foreword

The efficacy of the segmentectomy in the treatment of peripheral small lung cancer has been validated in global multicenter clinical trials and recommended by NCCN, ESMO, and CACA guidelines. Due to the complexity of this technology, the application of this technology is limited. The difficulty of segmentectomy lies in the fact that the bronchi, arterial, and venous variations of each lung segment are obvious. This atlas applies 3D reconstruction technology to segmentectomy, so that the procedure becomes visualized, the surgeon can clarify the complex lung segment anatomy from the 3D reconstruction pictures before the operation. The combination makes the surgical process more refined and precise, which meets the treatment principles of lung cancer: the maximum range of resection of lesions and the maximum preservation of lung function. The combination opens up preoperative thinking models for clinicians. In the meanwhile, the atlas staticized and simplified the dynamic surgical process, splitting the surgical process step by step, which is convenient for clinicians to learn and review the procedure of the surgery. Because of focus, so professional, because of persistence, so excellent, I believe that the advent of the atlas will help clinicians master the technology of segmentectomy more easily and will promote the technology popularizing worldwide. President of China Anti-Cancer Association, Tianjin, China International Member of USA National Academy of Medicine, Washington, DC, USA International Member of French National Academy of Medicine, Paris, France

Daiming Fan

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Preface

I was honored to inspect the segmentectomy procedure operated by Prof. Chen Liang at Jiangsu Provincial People’s Hospital in August 2018. Prof. Liang’s astonishingly distinct procedure caught my eyes immediately, as the methodology set itself apart from a usual lobectomy. I had read Prof. Hiroaki Nomori’s Illustrated Anatomical Segmentectomy for Lung Cancer twice before my visit, but my perception had only remained at a theoretical stage until I witnessed Prof. Chen’s procedure onsite, which led me to obtain a deeper understanding of the methodology. After returning to the Peking University Shenzhen Hospital, I called for a discussion with Dr. Guangxian Mao and Dr. Yuancai Xie, a deputy chief physician and a chief physician, who had just learned the surgical method of segmentectomy from Prof. Mingqiang Kang in Union Hospital of Fujian Medical University. Soon after that, we decided to perform the thoracoscopic precise segmentectomy with 3D navigation. With the help of Zhenyuan (Tianjin) Medical Device Technology Co. (MIMICS), the first seminar on this procedure was successfully held in September 2018 in South China. Up until now, we have successfully held eight in-person and six online sessions, accumulating invaluable experiences. However, I have always had a perpetual thought: even though I have been a thoracic surgeon for more than 20 years, my experiences cannot help me shorten the long and strenuous learning curve when practicing segmentectomy techniques. Can we summarize our experiences and extract the essences to help more thoracic surgeons shorten the learning curve and master these techniques more easily? Seeing the drawing skills of my graduate student, Dr. Junbin Wang, has made me more determined to compose the Atlas. The core of segmentectomy is to determine the resection boundary, which is along the intersegmental veins. Identifying the intersegmental veins helps determine the scope of the operation. As long as the operation is performed within the intersegmental veins with the approach “From the Shallower to the Deeper,” the blood vessels and bronchi within them can be dissected precisely, avoiding accidental injuries to the surroundings. This methodology is also known as “Simplified Standard Segmentectomy.” To identify the intersegmental veins, one must determine the lung segment or subsegment along the safe margin of the nodule and carefully study the adjacent relationships and travel directions among arteries, veins, and bronchi in the 3D reconstruction drawings. This procedure technique inherits from the “Wang’s Technique” of Academician Wang Jun and launches further developments of the “Wave Opening Technique,” “Vessel-Dissected Inflating and Deflating Method,” “3D Guided Standard Segmentectomy with Intersegmental Veins as Anatomical Landmarks,” etc. The book contains individualized 3D reconstruction drawings of arterial, venous, and bronchial relations, images of intraoperative surgical, and most importantly, simplified hand drawings that help readers grasp the full range of segmentectomy smoothly. In fact, the spatial adjacency and branching directions among the arteries, veins, and bronchi vary vastly in each lung segment, making it difficult for surgical operators to mentally formulate the spatial 3D relationship simply by looking at 2D Chest CTs. However, with the help of 3D reconstruction software that integrates the spatial relationship among the three tubes, surgical operators can combine it with the “2.5 D” images seen during surgery (as the pulling direction of lung during a procedure can change the spatial relationship between the ix

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Preface

three tubes) to form a closed loop learning curve. This, in turn, increases an operator’s ability to read 2D Chest CTs for spatial imagery. The book selects 12 examples of segmentectomy as a mere beginning to guide readers to gain proficiency in this technique. In the process of writing the book, I have received tremendous support from my wife, Yi Li. Without her support and encouragement, it is hard to imagine how to complete this book in such a short period of time. The book was conceived under the careful guidance of Prof. Lijian Zhang from Peking University Cancer Hospital and obtained the support of all doctors of the Thoracic Surgery Department at Peking University Shenzhen Hospital during composition. The intraoperative images and videos included in this book were recorded with high-definition equipment provided by Karl Storz. The surgical video recording process received devoted help from the operating room nurses, especially Mrs. Che Jia-Ping. The images were carefully organized and edited by Mrs. Guan-Nan Liu. During the translation process, I received great help from Andrew Chang, Suen Hon Chi, and Jingjing Liu. Last but not least, the book received unparalleled support from Yun Chen, President of Peking university Shenzhen Hospital. Huaigu Tian, Yu Shi et al. also helped a lot during the publishing process. With their support and dedication, we make our dream come true. Due to limited experience, the book leaves much to be desired, and I would appreciate corrections from all readers. Shenzhen, China 

Jixian Liu

Contents

1 A  Brief History of Thoracoscopic Anatomical Segmentectomy by 3D Navigation���������������������������������������������������������������������������������������������������������   1 Jixian Liu and Guangxian Mao 2 Nomenclature of Segments�����������������������������������������������������������������������������������������   3 Jixian Liu and Junbin Wang 3 3D  Reconstruction of Lung by MIMICS �����������������������������������������������������������������  11 Songtao Liu 4 Indications  and Technical Details of Segmentectomy for Lung Cancer ���������������  23 Jixian Liu and Guangxian Mao 5 LS1 + 2 + LS3 Segmentectomy by 3D Navigation�������������������������������������������������������  29 Jixian Liu, He Wang, and Xuxing Peng 6 LS4 + 5Segmentectomy by 3D Navigation�������������������������������������������������������������������  37 Jixian Liu and Junbin Wang 7 Extended LS3 Segmentectomy by 3D Navigation�����������������������������������������������������  45 Jixian Liu and Wei Yue 8 RS1 Segmentectomy by 3D Navigation���������������������������������������������������������������������  53 Jixian Liu and Xiaoqiang Li 9 Extended RS2 Segmentectomy by 3D Navigation ���������������������������������������������������  61 Jixian Liu and Xiaoqiang Li 10 RS3 Segmentectomy by 3D Navigation���������������������������������������������������������������������  69 Jixian Liu and Lei Yang 11 RS2b + RS3a Segmentectomy by 3D Navigation�������������������������������������������������������  77 Jixian Liu and Yiwang Ye 12 RS1 + RS2 + RS3c Segmentectomy by 3D Navigation�����������������������������������������������  85 Jixian Liu and Zichun Wei 13 LS6 Segmentectomy by 3D Navigation���������������������������������������������������������������������  93 Jixian Liu and Feihu Long 14 RS8a Segmentectomy by 3D Navigation������������������������������������������������������������������� 101 Jixian Liu and Xinyu Luan 15 LS9 + LS10 Segmentectomy by 3D Navigation ��������������������������������������������������������� 107 Jixian Liu and Xinyu Luan 16 LS10b + c Segmentectomy by 3D Navigation ����������������������������������������������������������� 115 Jixian Liu and Dan Ma

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Editors and Contributors

About the Editors Jixian  Liu  Doctor of Medicine (M.D.), Professor of Peking University, Chief Surgeon, Doctoral Supervisor, and the Director of the Thoracic Surgery Department at the Peking University Shenzhen Hospital. In 1993, he graduated from Harbin Medical University with a bachelor’s degree. In 2006, he graduated from Peking University Health Science Center with a master’s degree under the supervision of Professor Bengu Zhang. In 2011, he received his M.D. from Peking University Health Science Center, and his supervisor was Academician Jun Wang. Academic positions: Member of European Society of Thoracic Surgeons (ESTS); Director of Lung Nodule Treatment Committee of China AntiCancer Association Rehabilitation Society; Deputy Director of Esophageal MDT Committee of Guangdong Chest Disease Society; Deputy Director of Thoracic Surgery Committee of Shenzhen Medical Association. Specialties: Proposed the “Concept of Simplifying Standard Lung Segmentectomy” and hosted nine offline and six online seminars in China, training more than 1000 thoracic surgeons to undergo segmentectomies with 3D navigation. He is skilled in single port VATS lobectomy and segmentectomy, minimally invasive radical esophageal cancer surgery, NUSS, and subxiphoid mediastinal tumor resection. Dr. Liu has published more than 20 SCI-indexed articles and supervises three undergoing research projects.

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Editors and Contributors

Da Wu  Chief Surgeon, is the Consultant of Thoracic Surgery Department in Peking University Shenzhen Hospital. In 1986, he graduated from the Medical Department of Baiqiu’en Medical University with a master’s degree. He studied in the Department of Thoracic Surgery at the Cancer Hospital of the Chinese Academy of Medical Sciences under Professor Dechao Zhang and Professor Shugeng Gao in 1997 and in the Department of Respiratory Surgery at Tokyo Cancer Research Ariake Hospital under Prof. Ken Nakagawa in 2004. Academic position: Director of the Thoracic Surgery Committee of Shenzhen Medical Association; Vice President of the Association of Thoracic Surgeons of Shenzhen. Specialties: Dr. Wu has engaged in clinical work in thoracic surgery for more than 30 years and has deep insight on early screening of lung cancer (especially on lung nodules) and specializes in the diagnosis and surgical treatment of lung cancer, esophageal cancer, mediastinal and chest wall tumors. He has also undertaken many research projects and published more than 50 articles.

Drawing Junbin Wang  graduated from Shantou University in 2014. He practices all aspects of thoracic surgery under Professor Jixian Liu in Peking University Shenzhen Hospital, performing minimally invasive surgery of the lung, esophagus, mediastinum, and diaphragm, and specializes in the comprehensive diagnosis and treatment of lung cancer, esophageal cancer, mediastinal diseases, complex pneumothorax, pulmonary nodules and masses, palmar hyperhidrosis, etc. Painting is his hobby. He finds it fascinating to link painting with medicine.

Editors and Contributors

xv

English Review Suen Hon Chi  graduated from the University of Hong Kong in 1982. After local training in cardiothoracic surgery in Hong Kong, he pursued further training at Harvard University (under Dr. Hermes Grillo) and Washington University in St. Louis (under Drs. Joel Cooper and Alexander Patterson). He then practiced in St. Louis for 20 years before returning to Hong Kong in 2019. Dr. Suen practices all aspects of cardiothoracic surgery, performing the most minimally invasive to the most maximally aggressive surgery of the heart, lung, esophagus, mediastinum, and diaphragm. In 2021, he was appointed Honorary Clinical Associate Professor at the Department of Surgery of the Chinese University of Hong Kong. Andrew C. Chang, M.D.  , is the John Alexander Distinguished Professor, Head of the Section of Thoracic Surgery at the University of Michigan. After completing his undergraduate education at the Massachusetts Institute of Technology and medical education at Johns Hopkins University, he pursued general surgical residency at Vanderbilt University. He received an individual National Research Service Award from the National Institutes of Health to study cardiothoracic transplantation with Richard N. Pierson, III, M.D. He continued as a thoracic surgical resident and thoracic surgical fellow at the University of Michigan where he then joined the faculty in the Department of Surgery. Dr. Chang’s clinical interests include thoracic oncology, esophageal diseases, pulmonary transplantation, minimally invasive surgery, and interventional endoscopy. Jingjing (May) Liu  graduated from Vanderbilt University in 2021 concentrating on Psychology and Computer Science studies. She is a Software Engineer in Microsoft.

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Associate Editors Guangxian  Mao Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China Junbin  Wang Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China Yuancai  Xie Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China

Contributors Jixian Liu  Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China Songtao Liu  Zhenyuan (Tianjin) Medical Device Technology Co., Tianjin, China Xiaoqiang  Li Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China Feihu  Long Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China Xinyu  Luan Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China Dan Ma  Johnson & Johnson Medical Shanghai Ltd., Shanghai, China Xuxing  Peng Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China He Wang  Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China Zichun  Wei Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China Da Wu  Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China Lei Yang  Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China Yiwang Ye  Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China Wei Yue  Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China

Editors and Contributors

1

A Brief History of Thoracoscopic Anatomical Segmentectomy by 3D Navigation Jixian Liu and Guangxian Mao

The concept of “Bronchopulmonary Segmental Anatomy” was first introduced by Ewart in England in 1889. In 1932, Kramer and Glass applied the concept to the clinical setting for the first time during their studies in pulmonary abscesses. In 1939, Churchill and Belsev performed the first case of Lingular Segmentectomy. In 1942, Kent and Blades proposed the technique of “Separate Treatment to Hilar Structures,” known as the early form of “Anatomical Segmentectomy.” In 1958, Church et  al. began to use the technique of “Anatomical Segmentectomy” to treat early-­ stage lung cancer. In 1993, the first Thoracoscopic Segmentectomy was conducted by Roviaro in Italy. In the past, segmentectomy was not a popular technique due to complicated anatomical variants, exquisite technical requirements, and overmuch postoperative air leakage. In the twenty-first century, with rapid development of thoracoscopic techniques and an increasing number of patients diagnosed with early lung cancer, more clinical applications of segmentectomy have taken place. In 2011, Illustrated Anatomical Segmentectomy for Lung Cancer edited by Dr. Hiroaki Nomori and Morihito Okada from Japan have systematically summarized the anatomical features and surgical essences of segmentectomy, promoting the development of segmentectomy all over the world. Emerging reconstruction software, such as MIMICS, in segmentectomy empowers surgeons to easily navigate individualized segmental anatomy more precisely prior to operations. In the past 10 years, Dr. Chen Liang and his team in Jiangsu Province People’s Hospital have independently developed a software named DeepInsight. They have con-

ducted in-depth research and practice on 3D-Computed Tomography, Bronchography, and Angiography (3D-CTBA) and anatomic segmentectomy guided by 3D-CTBA.  The team later summarized their practices in the book The Atlas of Thoracoscopic Anatomical Pulmonary Segmentectomy, which has been reprinted for the 4th edition. Their work has promoted the development of segmentectomy techniques in China. Dr. Chen Tsun’s team at Union Hospital of Fujian Medical University, Dr. Bin Qiu’s team at Cancer Hospital of the Chinese Academy of Medical Sciences, Dr. Yongfu Ma at PLA General Hospital, and Dr. Jixian Liu at Peking University Shenzhen Hospital have held several seminars on Standard Segmentectomy by 3D navigation. All efforts have promoted a wider use of segmentectomy in China.

Suggested Reading 1. Andolfi M, Potenza R, Capozzi R, Liparulo V, Puma F, Yasufuku K. The role of bronchoscopy in the diagnosis of early lung cancer: a review. J Thorac Dis. 2016;8:3329–37. 2. Refai M, Andolfi M, Gentili P, Pelusi G, Manzotti F, Sabbatini A.  Enhanced recovery after thoracic surgery: patient information and care plans. J Thorac Dis. 2018;10:S512–6. 3. Ginsberg RG, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1N0 non-small cell lung cancer. Lung cancer study group. Ann Thorac Surg. 1995;60:615–22. 4. Cao C, D’Amico T, Demmy T, Dunning J, Gossot D, Hansen H, et al. Less is more: a shift in the surgical approach to non-small-cell lung cancer. Lancet Respir Med. 2016;4:e11–2. 5. Schuchert M, Pettiford B, Keeley S, D’Amato T, Kilic A, Close J, et al. Anatomic segmentectomy in the treatment of stage I non-small cell lung cancer. Ann Thorac Surg. 2007;84:926–33.

J. Liu (*) · G. Mao Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 J. Liu, D. Wu (eds.), Segmentectomy for Early-Stage Lung Cancer, https://doi.org/10.1007/978-981-99-0143-2_1

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Nomenclature of Segments Jixian Liu and Junbin Wang

2.1 Section 1: Nomenclature of Segmental and Subsegmental Lung 2.1.1 Right Upper Lobe (Fig. 2.1) 1. 2. 3.

S1 [Segmentum.apicale] (a) S1a [Subsegmentum.apicale proprius] (b) S1b [Subseg.ventrale] S2 [S.dorsale] (a) S2a [Subseg.dorsale] (b) S2b [Subseg.horizontale] S3 [S.ventrale] (a) S3a [Subseg.laterale] (b) S3b [Subseg.mediale]

2.1.2 Right Middle Lobe (Fig. 2.1) 1. 2.

S4 [S.medium laterale] (a) S4a [Subseg.laterale] (b) S4b [Subseg.mediale] S5 [S.medium mediale] (a) S5a [Subseg.laterale] (b) S5b [Subseg.mediale]

2.1.3 Left Upper Lobe (Fig. 2.1) 1.

S1 + 2 [S.apicodorsale] (a) S1 + 2a [Subseg.apicale] (b) S1 + 2b [Subseg.dorsale] (c) S1 + 2c [Subseg.horizontale]

2. S3 [S.ventrale] (a) S3a [Subseg.laterale] (b) S3b [Subseg.mediale] (c) S3c [Subseg.superius] 3. Lingular Division (S4 + S5) (a) S4 [S.lingulare superius] (i) S4a [Subseg.laterale] (ii) S4b [Subseg.mediale] (b) S5 [S.lingulare inferius] (i) S5a [Subseg.superius] (ii) S5b [Subseg.inferius]

2.1.4 Lower Lobe (Fig. 2.1) 1. 2. 3. 4. 5. 6.

S6 [S.superius] (a) S6a [Subseg.superius] (b) S6b [Subseg.laterale] (c) S6c [Subseg.mediale] S* [S.subsuperius] S7 [S.mediobasale] (only right side) (a) S7a [Subseg.dorsale] (b) S7b [Subseg.ventrale] S8 [S.ventrobasale] (a) S8a [Subseg.laterale] (b) S8b [Subseg.basale] S9 [S.laterobasale] (a) S9a [Subseg.laterale] (b) S9b [Subseg.basale] S10 [S.dorsobasale] (a) S10a [Subseg.dorsale] (b) S10b [Subseg.laterale] (c) S10c [Subseg.mediale]

J. Liu (*) · J. Wang Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 J. Liu, D. Wu (eds.), Segmentectomy for Early-Stage Lung Cancer, https://doi.org/10.1007/978-981-99-0143-2_2

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Fig. 2.1 Anatomical subdivisions of lung segments (courtesy of Bin Qiu)

right lung

2.2 Section 2: Nomenclature of Segmental and Subsegmental Bronchus 2.2.1 Right Upper Lobe (Fig. 2.2) 1. 2. 3.

B1 [R.apicalis] (a) B1a [Rm.apicalis proprius] (b) B1b [Rm.ventralis] B2 [R.dorsalis] (a) B2a [Rm.dorsalis] (b) B2b [Rm.horizontalis] B3 [R.ventralis] (a) B3a [Rm.latelasis] (b) B3b [Rm.medialis]

2.2.2 Right Middle Lobe (Fig. 2.2) 1. B4 [R.medius lateralis] (a) B4a [Rm.lateralis] (b) B4b [Rm.medialis]

left lung

2. B5 [R.medius medialis] (a) B5a [Rm.lateralis] (b) B5b [Rm.medialis]

2.2.3 Left Upper Lobe (Fig. 2.2) 1. 2. 3. 4.

B1 + 2 [R.apicodorsalis] (a) B1 + 2a [Rm.apicalis] (b) B1 + 2b [Rm.dorsalis] (c) B1 + 2c [Rm.horizontalis] B3 [R.ventralis] (a) B3a [Rm.lateralis] (b) B3b [Rm.medialis] (c) B3c [Rm.superius] B4 [R.lingualis superius] (a) B4a [Rm.lateralis] (b) B4b [Rm.medialis] B5 [R.lingualis inferius] (a) B5a [Rm.superius] (b) B5b [Rm.inferius]

5

2  Nomenclature of Segments Fig. 2.2  Lung subsegmental bronchi (courtesy of Junbin Wang)

B1a

B1b

B1+2a

B2a

B1+2b

B2b

B1

B2

B1+2c

B1+2

B3a

B3 B4

B6a B6a

B3b 4

B

B4a B4b

B5a B5b B8a

B6b

B9

B7b B10 B10c

B9a

2.2.4 Lower Lobe (Fig. 2.2) 1. 2. 3. 4. 5. 6.

B6 [R.superius] (a) B6a [Rm.superius] (b) B6b [Rm.lateralis] (c) B6c [Rm.medialis] B* [R.subsuperius] B7 [R.mediobasalis] (only right side) (a) B7a [Rm.dorsalis] (b) B7b [Rm.ventralis] B8 [R.ventrobasalis] (a) B8a [Rm.lateralis] (b) B8b [Rm.basalis] B9 [R.laterobasalis] (a) B9a [Rm.lateralis] (b) B9b [Rm.basalis] B10 [R.dorsobasalis] (a) B10a [Rm.dorsalis] (b) B10b [Rm.lateralis] (c) B10c [Rm.medialis]

2.3 Section 3: Nomenclature of Segmental and Subsegmental Artery 2.3.1 Right Upper Lobe (Fig. 2.3) 1. A1 [R.apicalis] (a) A1a [Rm.apicalis proprius] (b) A1b [Rm.ventralis]

B10a

B10b

2. 3.

B10

B7+8b

B10a B10c

B4a B4b 5a

B7+8a

B7a

B8

B8b B10b

B B5b

B6b B7+8

B7

B3b

B5

B6c

B6c

B5

B3c

B3c

B3

B9 B10b

B9b

B9a

A2 [R.dorsalis] (a) A2a [Rm.dorsalis] (b) A2b [Rm.horizontalis] A3 [R.ventralis] (a) A3a [Rm.latelasis] (b) A3b [Rm.medialis]

2.3.2 Right Middle Lobe (Fig. 2.3) 1. 2.

A4 [R.medius lateralis] (a) A4a [Rm.lateralis] (b) A4b [Rm.medialis] A5 [R.medius medialis] (a) A5a [Rm.lateralis] (b) A5b [Rm.medialis]

2.3.3 Left Upper Lobe (Fig. 2.4) 1. 2. 3.

A1 + 2 [R.apicodorsalis] (a) A1 + 2a [Rm.apicalis] (b) A1 + 2b [Rm.dorsalis] (c) A1 + 2c [Rm.horizontalis] A3 [R.ventralis] (a) A3a [Rm.lateralis] (b) A3b [Rm.medialis] (c) A3c [Rm.superius] A4 [R.lingualis superius] (a) A4a [Rm.lateralis] (b) A4b [Rm.medialis]

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4. A5 [R.lingualis inferius] (a) A5a [Rm.superius] (b) A5b [Rm.inferius]

2.3.4 Lower Lobes (Figs. 2.3 and 2.4) 1. 2. 3.

A6 [R.superior] (a) A6a [Rm.superius] (b) A6b [Rm.lateralis] (c) A6c [Rm.medialis] A* [R.subsuperius] A7 [R.mediobasalis] (only right side) (a) A7a [Rm.dorsalis] (b) A7b [Rm.ventralis]

Fig. 2.3  Right lung artery branches

4. 5. 6.

A8 [R.ventrobasalis] (a) A8a [Rm.lateralis] (b) A8b [Rm.basalis] A9 [R.laterobasalis] (a) A9a [Rm.lateralis] (b) A9b [Rm.basalis] A10 [R.dorsobasalis] (a) A10a [Rm.dorsalis] (b) A10b [Rm.lateralis] (c) A10c [Rm.medialis]

Fig. 2.4  Left lung artery branches

2  Nomenclature of Segments

7

Fig. 2.5  Vein branches of right upper lobe (Red for arteries; Green for bronchi; Blue for veins)

2.4 Section 4: Nomenclature of Segmental and Subsegmental Vein 2.4.1 Right Upper Lobe (Fig. 2.5) 1. 2. 3. 4.

V1 (V.apicalis) (a) V1a: between S1a and S1b (b) V1b: between S1b and S3b V2 (V.dorsalis) (a) V2a: between S1a and S2a (b) V2b: between S2a and S2b (c) V2c: between S2b and S3a (d) V2t: below S2a V3 (V. ventralis) (a) V3a: between S3a and S3b (b) V3b: below S3b (c) V3c between S3bi and S3bii Central vein: V2a + V2b + V2c (+V3a)

2.4.2 Right Middle Lobe (Fig. 2.6) 1. V4 (V.media.lateralis) (a) V4a: between S4a and S4b

2.

(b) V4b: between S4b and S5b V5 (V.media.medialis) (a) V5a: between S5a and S5b (b) V5b: below S5b

2.4.3 Left Upper Lobe (Figs. 2.7 and 2.8) 1. 2. 3. 4.

V1 + 2 (V.apicodorsalis) (a) V1 + 2a: between S1 + 2a and S3c (b) V1 + 2b: between S1 + 2a and S1 + 2b (c) V1 + 2c: between S1 + 2b and S1 + 2c (d) V1 + 2d: between S1 + 2c and S3a V3 (V.ventralis) (a) V3a: between S3a and S3b (b) V3b: between S3b and S4b (c) V3c: between S3b and S3c V4 (V.lingualis superius) (a) V4a:between S4a and S4b (b) V4b: between S4b and S5a V5 (V.lingualis inferius) (a) V5a: between S5a and S5b (b) V5b: below S5b

8 Fig. 2.6  Venous branches of right middle lobe (Red for arteries; Green for bronchi; Blue for veins)

Fig. 2.7  Veins branches of proper lobe in left upper lobe (Red for arteries; Green for bronchi; Blue for veins)

J. Liu and J. Wang

2  Nomenclature of Segments Fig. 2.8  Veins branches of a lingual segment of left upper lobe (Red for arteries; Green for bronchi; Blue for veins)

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2.4.4 Lower Lobes (Fig. 2.9) 1.

V6 (V.superius) (a) V6: between S6a and S6b + c (b) V6b: between S6b and S6c, and between S6 and S8 + 9 (c) V6c: between S6c and S10a (or S7a only in the right side)

2. 3. 4. 5.

V7 (V.mediobasalis) (only right side) (a) V7a: between S7a and S7b (b) V7b: between S7b and S8b V8 (V.ventrobasalis) (a) V8a: between S8a and S8b (b) V8b: between S8b and S9b V9 (V.laterobasalis) (a) V9a: between S9a and S9b (b) V9b: between S9b and S10b V10 (V.dorsobasalis) (a) V10a: between S10a and S10c (b) V10b: between S10b and S10c (c) V10c: among S10c

Suggested Reading 1. Ginsberg RG, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1N0 non-small cell lung cancer. Lung cancer study group. Ann Thorac Surg. 1995;60:615–22. 2. Cao C, D’Amico T, Demmy T, Dunning J, Gossot D, Hansen H, et al. Less is more: a shift in the surgical approach to non-small-cell lung cancer. Lancet Respir Med. 2016;4:e11–2. 3. Schuchert M, Pettiford B, Keeley S, D’Amato T, Kilic A, Close J, et al. Anatomic segmentectomy in the treatment of stage I non-small cell lung cancer. Ann Thorac Surg. 2007;84:926–33.

Fig. 2.9  Veins branches of the lower lobe (Red for arteries; Green for bronchi; Blue for veins)

3

3D Reconstruction of Lung by MIMICS Songtao Liu

3.1 Introduction to MIMICS Software MIMICS is an interactive tool for 3D visualization, tomographic image segmentation processing, and 3D rendering. The tool reads DICOM image formats (CT, MRI, MicroCT, MicroMRI, Industrial CT, etc.) and non-DICOM common image formats (BMP, TIFF, etc.) interactively. Users can use segmentation and editing tools to manipulate image data to select regions of interest (ROI) such as bone, soft tissue, and skin. Once an ROI has been segmented, it can be reconstructed to obtain a comprehensive observative 3D model, which can be rotated, panned, zoomed in, zoomed out, changed in transparency, clipped, etc. The software compares 2D images with 3D data for accurate model detections and makes regular anatomical measurements such as distance, angle, and area calculations. With the foundation of accurate 3D models and the use of optional MIMICS modules, we can realize 3D-based models in the fields of biomedical, medical, and materials for measurement and analysis, simulation, forward design, additive

manufacturing, 3D printing, Finite Element Analysis (FEA), and Computational Fluid Dynamics (CFD) modeling.

3.2 Introduction to MIMICS Lung 3D Reconstruction The MIMICS software (Fig. 3.1) implements a new module targeting lung reconstruction that uses innovative software algorithms to help users segment the trachea, lungs, and lobes more efficiently and accurately. There is a built-in fast centerline calculation function that automatically marks the anatomy of lung trachea using the internationally acknowledged lung trachea marking method. It automatically matches the light-cured stereolithography (STL) files of the two sets of lung trachea during inhalation and expiration to analyze the volume changes before and after breathing. Depending on a user’s needs, the software can digitally cut the ends of the lung trachea at an angle tangent to the centerline, facilitating FEA and CFD analysis.

S. Liu (*) Zhenyuan (Tianjin) Medical Device Technology Co., Tianjin, China © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 J. Liu, D. Wu (eds.), Segmentectomy for Early-Stage Lung Cancer, https://doi.org/10.1007/978-981-99-0143-2_3

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Fig. 3.1 Automatic segmentation of bronchial and pulmonary boundaries by MIMICS software

3.3 MIMICS Reconstruction Steps 1. Select and import the required CT file (Fig. 3.2) 2. Second, start the lung reconstruction and use this command for tracheal reconstruction (Fig. 3.3) 3. Third, nodal screening was performed and reconstruction was performed (Fig. 3.4) 4. Performing revascularization (a) Select the appropriate threshold box, and select the region (Fig. 3.5) (b) Raise the desired vessel from the soft tissue (Fig.3.6) (c) The proposed vessels are divided by arterioles (Fig. 3.7)

(d) Modify the incorrect arterial vein (Fig. 3.8) (e) Generate the modified vessels from the top masks layer to the bottom objects layer (Fig. 3.9) 5. Perform reconstruction of the distal trachea (Fig. 3.10) 6. Undertaking reconstruction of the lung lobes (a) Perform a tracheal centerline extraction (Fig. 3.11) (b) Generation of bilateral lung contours and lobar fissures by tracheal centerline (Fig. 3.12) (c) Click Next to segment the lung lobes (Fig. 3.13) 7. Performing segmentation of lung segments (Fig. 3.14) 8. Completion of lung reconstruction (Fig. 3.15)

3  3D Reconstruction of Lung by MIMICS Fig. 3.2  Importing CT files

13

14 Fig. 3.3  Start of lung reconstruction

S. Liu

3  3D Reconstruction of Lung by MIMICS Fig. 3.4  Performing nodal screening

Fig. 3.5 Vascular reconstruction by first selecting the appropriate threshold box

15

16 Fig. 3.6  Extraction of the desired blood vessels

S. Liu

3  3D Reconstruction of Lung by MIMICS Fig. 3.7 Arteriovenous segmentation

17

18 Fig. 3.8  Modify the incorrect arterial vein

S. Liu

3  3D Reconstruction of Lung by MIMICS Fig. 3.9  Modify the angiogenesis

19

20 Fig. 3.10  Reconstruction of the distal trachea

Fig. 3.11  Tracheal centerline extraction

S. Liu

3  3D Reconstruction of Lung by MIMICS Fig. 3.12  Bilateral lung contours and generation of lobar fissures

Fig. 3.13  Segmented lung lobes

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Fig. 3.14  Segmentation of lung segments

Suggested Reading 1. Ginsberg RG, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1N0 non-small cell lung cancer. Lung cancer study group. Ann Thorac Surg. 1995;60:615–22. 2. Cao C, D’Amico T, Demmy T, Dunning J, Gossot D, Hansen H, et al. Less is more: a shift in the surgical approach to non-small-cell lung cancer. Lancet Respir Med. 2016;4:e11–2. 3. Schuchert M, Pettiford B, Keeley S, D’Amato T, Kilic A, Close J, et al. Anatomic segmentectomy in the treatment of stage I non-small cell lung cancer. Ann Thorac Surg. 2007;84:926–33.

Fig. 3.15  Completed lung reconstruction

4

Indications and Technical Details of Segmentectomy for Lung Cancer Jixian Liu and Guangxian Mao

4.1 Indications of Segmentectomy for Lung Cancer In 1995, Lobectomy had been established as the standard method by the Lung Cancer Study Group (LCSG) in the treatment of early-stage lung cancer by showing that lobectomy provides a significant survival advantage over sublobar resection. Sublobar resection had been considered a compromise option for patients who could not tolerate lobectomy (e.g., comorbidities of high-risk, advanced age, and low cardiopulmonary function). However, the study (a) included subjects whose tumors measured over 2 cm in diameter, or who had received non-anatomic wedge resections; (b) did not identify significantly different overall survival; and (c) lacked complete pulmonary function testing data. In recent years, as low-dose CT lung cancer screening has become more prevalent, an increasing number of patients have been diagnosed with small pulmonary nodules or with predominantly ground glass opacities (GGOs). Notably, the histology of GGOs is usually adenocarcinoma in situ (AIS) or microinvasive adenocarcinoma (MIA). The results of many retrospective studies also suggest that thoracoscopic sublobar resection has comparable local recurrence and long-term survival rates to lobectomy in the treatment of subsolid pulmonary nodules. The choice of surgical approach for small nodules, especially small ground glass nodules, has been a controversial topic in the general thoracic surgery community. The current surgical indications recommended for intentional segmentectomy for lung cancer by National Comprehensive Cancer Network (NCCN) guidelines are

peripheral nodules ≤2 cm in diameter for which at least one of the following criteria are met: (1) the histological type is AIS; (2) the pulmonary nodule has more than 50% GGO component by CT; and (3) The tumor doubling time has more than 400 days by CT follow-up. Supported by published reports of the Japan Clinical Oncology Group clinical trials, notably JCOG0802, JCOG0804, and JCOG1211 (Fig.  4.1), sublobar resection can be a good choice for early lung cancer. In the JCOG1211 study, segmentectomy was found to be a suitable choice for early cancer when the diameter of the lung nodule is less than 3  cm and the consolidation/tumor ratio (C/T ratio) is less than 0.5, if adequate margins are secured. The JCOG0802 study demonstrated that for peripheral non-small cell lung cancer with nodules ≤2 cm in diameter and C/T ratio ≥0.5, segmentectomy was no worse than lobectomy in terms of 5-year overall survival, and lung function was better preserved than lobectomy. In our clinical practice, we have found that in patients with completely solid nodules with a diameter of less than 1  cm diagnosed as NSCLC (non-small cell lung cancer), intrapulmonary metastases, pleural spread, and N2 lymph node metastases are still identified. Our indications for intentional segmentectomy for NSCLC are as follows: (i) Nodule is located in the middle one-third part of lung. (ii) The diameter of nodule is less than 3 cm. (iii) The C/T ratio was 0.5 or less. (iv) The intraoperative frozen pathology of parenchymal lymph nodes (N1) sampled in the corresponding surgical area is negative.

J. Liu (*) · G. Mao Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 J. Liu, D. Wu (eds.), Segmentectomy for Early-Stage Lung Cancer, https://doi.org/10.1007/978-981-99-0143-2_4

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Fig. 4.1 Recommended surgical approach determined by tumor size and consolidation/tumor ratio, as summarized by the Japan Clinical Oncology Group (Courtesy of GCOG)

C/T ratio 0

Tumor size

0 cm

0.25

1.0

0.5

JCOG0804 PII Wide wedge resection

JCOG0802 PIII Lobectomy vs Segmentectomy

2.0 cm JCOG1211 PII Segmentectomy 3.0 cm Standard procedure Lobectomy

4.2 Technical Key Point of Segmentectomy with 3D Navigation

A

4.2.1 Choice of Incision The location and number of incisions are selected according to the planned anatomic resection. Due to the adjustable angle of the thoracoscope, the bending properties of the ­surgical instruments, and ability to adjust the angle of the stapler, most procedures can be performed through a single port by experienced surgeons. In our single port approach, operative visualization (thoracoscope) A, placement of the assistant’s retraction instruments (oval forceps) B, and the primary operating instruments (curved suction and electrocautery hook or Ultrasonic knife) C, are all accessed through a single port (Fig. 4.2). Upper lobe segmentectomies are performed through a single port in the fourth intercostal space of the mid-axillary line. Middle and lower lobe segmentectomies are performed through the fifth intercostal space between the mid-axillary and posterior axillary lines. The upper apical segmentectomies can be performed through the third intercostal port in the mid-axillary line, which provides a better inline vision. When the operating angle is not good, a “modified single operating port” approach is pursued, in which another port (Fig. 4.3) can be added for the procedure which is mainly for retraction and the access of the stapler, with the endoscope still entering through the main operating port. The method not only adapts to the operating habits of most surgeons, it also reduces the difficulty of procedure. When the basal segmentectomy (S9 and S10) of both lower lungs are resected, a conventional three-port procedure is recommended, allowing for different operating angles.

B

C

Fig. 4.2  Incision layout

Fig. 4.3  Modified single operating port

4  Indications and Technical Details of Segmentectomy for Lung Cancer

25

a b c

d

Fig. 4.5  Wang’s technique Fig. 4.4  Special instruments for segmentectomy. (a) Curved suction tube; (b) Double joint separation forceps (head bent 15°); (c) Double joint separation forceps (head bent 90°); (d) Double joint tissue forceps

4.2.2 Selection of Surgical Instruments Segmentectomy may be more meticulous than lobectomy, and special instruments for segmentectomy are often chosen (Fig. 4.4) with finer graspers or multiple angles to facilitate dissection around distal vasculature or segmental airways.

4.2.3 Operational Skills 4.2.3.1 “From the Shallower to the Deeper” to Dissect the Targeted Segmental Structures Three-dimensional (3D) reconstruction provides an understanding of the adjacent relationships between vessels and bronchus within the targeted segment before operation, helping determine the surgical approaches and dissecting sequence. Segmentectomy by 3D navigation can be undertaken according to the principle of “From the shallower to the deeper,” that is, after the superficial structures have been dissected, the deeper structures then become superficial. For most upper lobe segmentectomy, the approach can be taken from the membrane-like structure of the anterior hilum moving posteriorly. For RS2b  +  RS3a segmentectomy, the approach can be chosen from the interlobular fissure cranially. For S6 segmentectomy, the approach can be performed from interlobular fissure caudally. For lower lobe S9 or S10, the approach can be chosen from the inferior pulmonary ligament moving cephalad. All these approaches follow “from the shallower to the deeper.”

4.2.3.2 “Wang’s Technique” The “Wang’s technique” (Fig. 4.5) is a practical and instructable maneuver proposed by Dr. Jun Wang, using the hook electrocautery (typically right hand) and curved suction (typically left hand), allowing sharp and blunt dissection simultaneously while aspirating shed blood from the operative field. The operating space is the shape of a thin cylinder, which is suitable for the procedure of segmentectomy. 4.2.3.3 Dissection of Segmental Vessels and Bronchus 1. Dissection of arteries: The targeted lobar artery and its segmental branches are dissected first and then compared with the 3D reconstruction diagram. The targeted segmental arteries should be dissected distally while the untargeted segmental arteries should be visualized but not fully dissected to avoid damage when mobilizing the targeted segmental structures from the retained segmental hilar structures. The segmental artery has a vascular sheath on its surface, which should be opened and dissected distally along its longitudinal axis. The direction of the arterial branches and their proximity to the surrounding veins and bronchi can be confirmed according to 3D reconstruction to prevent inadvertent injury. Small arteries can be ligated with 4-0 silk sutures (Fig.  4.6); larger arteries can be divided using an articulating surgical stapler. 2. Dissection to veins: Ligation is more suitable for control of vein branches that have thinner walls, since division with even narrow tissue depth staple cartridges may result in ongoing bleeding. The intrasegmental veins are dissected in the same way as the segmental arteries; intersegmental veins are important markers of the resected extent of lung segment and need to be adequately dissected. The intrasegmental vein collects many small

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Fig. 4.6  Ligating the small artery with silk thread Fig. 4.8  Dissecting bronchus with fine forceps

Small vein

Fig. 4.7  Dissecting fine venous branches with an ultrasonic scalpel Fig. 4.9  Dividing and closing the bronchus with the surgical stapler

branches along its course, which are more likely to cause vascular damage and bleeding when dissected with hook electrocautery. Dissecting veins with an ultrasonic scalpel is safe (Fig. 4.7). 3. Dissection to Bronchus: Segmental bronchus surrounded by intrasegmental or intersegmental vessels can be dissected using blunt-tipped forceps, especially 15° forceps, in close proximity to the targeted bronchus (Fig. 4.8) to avoid vessels injury. Segmental or subsegmental bronchi are sometimes sufficiently thin that these can be divided and sealed with a narrow thickness (white) stapler cartridge (Fig. 4.9).

4.2.3.4 Vessel-Dissected Inflation-Deflation Method At present, the boundary of the lung segment is mainly determined by inflation-deflation method, in which the lung is inflated with 100% pure oxygen after dividing the blood vessels and bronchi of the targeted segment, so the targeted lung

segment is inflated, and the remaining lung is deflated about 10 min later to determine the intersegmental interface. This method has two problems: first, prolonged waiting time, worse in patients with emphysema; second, the pressure usually requires 25–30  cm H2O to allow the oxygen to pass through Koch’s orifice to expand the targeted segment that has no bronchus. Sometimes such pressure may lead to lung injury. We have attempted the “Vessel-dissected inflation and deflation method” based on the principle that oxygen in the deflating lung is mainly carried out by blood, not bronchus. The segmental interface of inflating and deflating after only dividing the vessels of the targeted segment is consistent with the interface obtained by dividing the segmental vessels and bronchus (Figs.  4.10 and 4.11). The pressure which expands targeted segments completely is usually below 20 cm H2O. During the waiting time taken to visualize this interface, dissection of the targeted bronchus can reduce the operating time.

4  Indications and Technical Details of Segmentectomy for Lung Cancer

27

Fig. 4.12  Relationship between the safe margin of nodule and the segmental interface of the RUL (Lateral view)

Fig. 4.10  The intersegmental plane is defined by dividing only the targeted artery

Fig. 4.11  The intersegmental plane defined after dividing both the segmental artery and segmental bronchus

Fig. 4.13  When the RS1 segmentectomy is undergone, V1b and V2a which are intersegmental veins need to be preserved

4.2.3.5 Definition of Targeted Segments or Subsegments The extent of the operation is delimited according to the estimated sphere representing a safe surgical margin of 2 cm as determined by the preoperative 3D-CTBA reconstruction (Fig. 4.12). Operation between intersegmental veins will not cause accidental injury to the structures of the untargeted segments (Figs. 4.13 and 4.14). 4.2.3.6 Segmental Gate Dissection When the interface of inflation-deflation is clear, the intersegmental planes can be dissected with hook electrocautery in the cut mode to define the interface. The intersegmental

Fig. 4.14  When the RS1 segmentectomy is undertaken, V1b and V2a which are intersegmental veins should be preserved

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Fig. 4.15  Wave opening to LS6

plane is not flat but resembles the wave of the sea, so the operative approach is also named as “Wave Opening” (Fig. 4.15). That means the interface without intersegmental veins is first opened to form a deep “wave” and then a shallow “wave” including tubular structures is dissected later. In this way, the dissected interface is clear and usually leakage free. After the targeted hilar structure is fully dissected, “Dimensional reduction tailoring” can be undertaken to make the intersegmental plane unfold after operation. After dividing the targeted segmental vessels and bronchi, the segmental hilum can be dissected in an “Inward Opening” fashion, i.e., by dissecting the severed bronchus as far as possible to be away from the preserved structure. The thin anvil of the stapler is inserted into the intersegmental space gently and fired to reduce the intersegmental air leak. However, care should be taken to position the cartridge anvil between the intersegmental plane in situ and then bring the lung tissue into the suture jaws with oval forceps to avoid bleeding.

Suggested Reading 1. Yan TD, Black D, Bannon PG, et al. Systematic review and meta-­ analysis of randomized and nonrandomized trials on safety and efficacy of video assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer. J Clin Oncol. 2009;27(15):2553–62. 2. Okada M, Koike T, Higashiyama M, et al. Radical sublobar resection for small-sized non-small cell lung cancer: a multicenter study. J Thorac Cardiovasc Surg. 2006;132(4):769–75.

J. Liu and G. Mao 3. Okada M. Radical sublobar resection for small diameter lung cancers. Thorac Surg Clin. 2013;23(3):301–11. 4. Schuchert MJ, Abbas G, Awais O, et al. Anatomic segmentectomy for the solitary pulmonary nodule and early-stage lung cancer. Ann Thorac Surg. 2012;93(6):1780–5. [discussion: 6–7] 5. Mitchell JD, Yu JA, Bishop A, et  al. Thoracoscopic lobectomy and segmentectomy for infectious lung disease. Ann Thorac Surg. 2012;93(4):1033–9. [discussion: 9–40] 6. Jones DR, Stiles BM, Denlinger CE, et al. Pulmonary segmentectomy: results and complications. Ann Thorac Surg. 2003;76(2):343– 8. [discussion: 8–9] 7. Tsutani Y, Miyata Y, Nakayama H, et  al. Oncologic outcomes of segmentectomy compared with lobectomy for clinical stage IA lung adenocarcinoma: propensity score-matched analysis in a multicenter study. J Thorac Cardiovasc Surg. 2013;146(2):358–64. 8. Pedersen JH, Ashraf H, Dirksen A, et al. The Danish randomized lung cancer CT screening trial–overall design and results of the prevalence round. J Thorac Oncol. 2009;4(5):608–14. 9. National Lung Screening Trial Research Team, Aberle DR, Adams AM, Berg CD, et  al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011;365(5):395–409. 10. Ginsberg RJ, Rubinstein LV.  Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg. 1995;60(3):615–22. [discussion: 22–3] 11. Martin-Ucar AE, Nakas A, Pilling JE, et al. A case matched study of anatomical segmentectomy versus lobectomy for stage I lung cancer in high risk patients. Eur J Cardiothorac Surg. 2005;27(4):675–9. 12. Koike T, Yamato Y, Yoshiya K, et al. Intentional limited pulmonary resection for peripheral T1N0M0 small-sized lung cancer. J Thorac Cardiovasc Surg. 2003;125(4):924–8. 13. Smith CB, Swanson SJ, Mhango G, et al. Survival after segmentectomy and wedge resection in stage I non-small-cell lung cancer. J Thorac Oncol. 2013;8(1):73–8. 14. Yim AP. VATS major pulmonary resection revisited–controversies, techniques, and results. Ann Thorac Surg. 2002;74(2):615–23. 15. Yang CF, D’Amico TA.  Thoracoscopic segmentectomy for lung cancer. Ann Thorac Surg. 2012;94(2):668–81. 16. Shiraishi T, Shirakusa T, Iwasaki A, et  al. Video-assisted thoracoscopic surgery (VATS) segmentectomy for small peripheral lung cancer tumors: intermediate results. Surg Endosc. 2004;18(11):1657–62. 17. Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg. 2004;77(2):726–8. 18. Gonzalez-Rivas D, Paradela M, Fernandez R, et  al. Uniportal video-assisted thoracoscopic lobectomy: two years of experience. Ann Thorac Surg. 2013;95(2):426–32. 19. Gonzalez-Rivas D, Paradela M, Fieira E, et  al. Single incision video-assisted thoracoscopic lobectomy: initial results. J Thorac Cardiovasc Surg. 2012;143(3):745–7. 20. Rocco G.  One-port (uniportal) video-assisted thoracic surgical resections–a clear advance. J Thorac Cardiovasc Surg. 2012;144(3):S27–31.

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LS1 + 2 + LS3 Segmentectomy by 3D Navigation Jixian Liu, He Wang, and Xuxing Peng

5.1 Summary of Medical Records

5.1.1 Indications and Contraindications

A female, 57 years old, with irritating dry cough for more than 2 months, underwent a CT chest examination (Figs. 5.1, 5.2, and 5.3) and found a mixed ground glass nodule (mGGN) with a diameter of about 25 mm × 13 mm in the S1 + 2 + S3 of the left upper lobe (LUL). It was treated with antibiotic, with no significant change on re-examination CT 2 months later.

(a) The size of the nodule of the Left Upper lobe (LUL) is less than 3 cm in diameter, which C/T (Consolidation/ Tumor) value is less than 50%. (b) The nodule had no change 2 months later after being treated with antibiotics for 2 weeks, raising the possibility of early lung cancer.

Fig. 5.1  Chest CT (Horizontal view) showing the nodule (Arrow) located between LS1  +  2 and LS3. The yellow circle: identifies a 2-cm margin

Fig. 5.2  Chest CT (Coronal view) showing the nodule (Arrow) located between LS1 + 2and LS3. The yellow circle: identifies a 2-cm margin

J. Liu (*) · H. Wang · X. Peng Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 J. Liu, D. Wu (eds.), Segmentectomy for Early-Stage Lung Cancer, https://doi.org/10.1007/978-981-99-0143-2_5

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Fig. 5.3  Chest CT (Sagittal view) showing the nodule (Arrow) located between LS1 + 2 and LS3. The yellow circle: identifies a 2-cm margin

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Fig. 5.4  Relationship between the safe margin of nodule and the lung segment interface of the LUL (Anterior view)

(c) With the planning of the preoperative 3D-CTBA reconstruction, the distance of incision margin to the nodule is greater than 2  cm after LS1  +  2  +  LS3 segmentectomy. (d) The patient was in good physical condition, no contraindications to the surgery procedure.

5.2 Preoperative 3D-CTBA Reconstruction The safety margin of this pulmonary nodule (bounded by 2 cm around the nodule) shows the margin is located within S1 + 2 + S3 of the LUL (Fig. 5.4), so the LS1 + 2 + LS3 segmentectomy is required to satisfy the safe surgical margins.

5.2.1 Anatomical Features Fig. 5.5  Bronchial branch of LUL (Anterior view)

The left upper lobe bronchus (Fig.  5.5) is divided into B1 + 2 + B3 and B4 + 5, where the B1 + 2 + B3 are divided into B1 + 2 and B3. The LUL arteries (Figs. 5.6 and 5.7): The two branches (A1 + 2a + b and A1 + 2ci) of the A1 + 2 branch off from the pulmonary trunk with common trunk; A3 emanate alone from the root of the left pulmonary artery trunk; the A4 + 5 includes two parts; one is mediastinal type, with A4b and A5 branching off from the root of the pulmonary artery, directing between the superior pulmonary vein and upper lobe bronchus toward the lingual segment, the another is A4a branching off from the interlobular artery.

Note: The fine artery A1 + 2cii branching to S1 + 2cii found intraoperatively was not reconstructed preoperatively. The LUL vein (Fig.  5.8) branches into the V1  +  2  +  3 and V4 + 5, with V1 + 2 traveling below B3 and branching between B3 and B1 + 2. The operation can be undergone from interlobar fissure cephalad, needing to dissect A1  +  2cii, A1  +  2a  +  b  +  ci, A3, V1  +  2  +  V3a  +  V3c, and B1  +  2  +  B3, preserving V3b (Intersegmental vein between S3 and S4).

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5.3 Surgery Planning and Procedure 5.3.1 Surgical Planning A1  +  2cii  →  A1  +  2a  +  b  +  ci  →  A3  →  V1  +  2  +  V3a  +  V3c  → B1 + 2 + B3 → LS1 + 2 + LS3.

5.3.2 Surgical Procedure

Fig. 5.6  Relationship between arteries and bronchi of LUL (Anterior view)

1. Probe to locate the nodule, located between LS1 + 2 + LS3. 2. The upper lung is drawn cephalad, the pleura of oblique fissure is opened. Then the poorly differentiated fissure is incised, the L11 lymph node is removed (Fig.  5.9) and sent for pathology; the A1 + 2cii are dissected, ligated, and divided (Figs. 5.10 and 5.11). 3. Pull the upper lung tissue ventrally to reveal the pulmonary trunk, dissect A1 + 2a + b + ci (Fig. 5.12), and divide it with Stapler (Fig. 5.13). 4. Continue cephalad to dissect A3 (Fig. 5.14) and divide it with the stapler (Fig. 5.15). 5. The upper lung is retracted dorsally to reveal the left superior pulmonary vein, and V1  +  2  +  V3a  +  V3c is dissected above V3b (Fig. 5.16) and divide with a stapler. 6. Dissect B1 + 2 + B3 (Figs. 5.17 and 5.18) and divide them with a stapler.

Fig. 5.7  Relationship between arteries and bronchi of LUL (Posterior view)

Fig. 5.9  Opening the oblique fissure and dissecting of the 11L lymph node (LUL left upper lobe, LLL left lower lobe)

Fig. 5.8  Relationship among arteries, veins, and bronchi of LUL (Anterior view)

Fig. 5.10  Dissecting A1 + 2cii

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Fig. 5.11  Ligating and dividing A1 + 2cii (PA Pulmonary Artery)

Fig. 5.15  Dividing A3 with the stapler

Fig. 5.12  Dissecting A1 + 2a + b + ci

Fig. 5.16  Dissecting V1 + 2 + V3a + V3c from the anterior of the hilum

Fig. 5.13  Dividing A1 + 2a + b + ci with the stapler

Fig. 5.17  Dissecting B1 + 2 + B3 from the anterior of the hilar after cutting V1 + 2 + V3a + V3c

7. Inflate the lung with pure oxygen having a pressure of 20–30 mmHg to full inflation. About 10 min later, a clear interface of inflation and deflation is seen, i.e., LS1 + 2 + LS3 inflated and LS4 + 5deflated. 8. The lung is divided along the interface of inflation and deflation and LS1  +  2  +  LS3 is resected (Figs.  5.19 and 5.20). The final pathological diagnosis was adenocarcinoma (pT1cN0M0). Fig. 5.14  Pulling the left upper lung ventrally and dissecting A3

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Fig. 5.18  Dissecting B1 + 2 + B3 from interlobular fissure and dividing it with the stapler

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Fig. 5.19  Tailoring the lung along the interface of inflating and deflating

Fig. 5.20  The labeled figure of segmental stump of postoperative LS1 + 2 + LS3 segmentectomy

5.3.3 Key Points of the Surgical Procedure (a) A1 + 2cii in the patient is a very small branch emanating from the interlobar artery, which was too thin to be reconstructed from 3D-CTDA. It needed careful dissection to prevent damage. It was reinforced with titanium

clips after ligation, and the distal end was divided with an ultrasonic knife. (b) The artery of the lingula segment is mediastinal type and travels between the upper pulmonary vein and the left upper bronchus; the operator needs to notice it when V1 + 2 + V3a + V3c is dissected.

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5.4 Schematic Diagram of the Surgical Procedure

LLL

Schematic diagram of the surgical procedure for LS1 + 2 + LS3 segmentectomy (Figs.  5.21, 5.22, 5.23, 5.24, 5.25, 5.26, 5.27, 5.28, 5.29, 5.30, 5.31, 5.32, 5.33, and 5.34).

LUL

Fig. 5.23  Dissecting A1 + 2cii

LLL

Fig. 5.21  Figure of descending dimension of LS1 + 2 + LS3 segmentectomy (The shadow is the range of excision: Red circles represent arteries, Green circles represent bronchi)

LUL

Fig. 5.24  Dividing A1 + 2cii LLL

LLL

LUL

Fig. 5.22  Figure of panoramic anatomy of LUL (From interlobular view)

LUL

Fig. 5.25  Dissecting A1 + 2a + b + ci

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LLL

LUL

LLL

LUL

Fig. 5.29  Panoramic Anatomy of LUL (anterior view) Fig. 5.26  Dividing A1 + 2a + b + ci LUL LLL

LUL

Fig. 5.27  Dissecting A3

Fig. 5.30  Dissecting V1 + 2 + V3a + V3c

LLL

LUL

LUL

Fig. 5.31  Dividing V1 + 2 + V3a + V3c Fig. 5.28  Dividing A

3

LLL

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LLL

LUL

Fig. 5.32  Dissecting B1 + 2 + B3 from interlobular fissure

Fig. 5.34  The labeled figure of segmental stumps

Suggested Reading 1. Subramanian M, McMurry T, Meyers BF, et al. Long- term results for clinical stage IA lung cancer- comparing lobectomy and sublobar resection. Ann Thorac Surg. 2018;106:375–81. 2. Cao J, Yuan P, Wang Y, et al. Survival rates after lobectomy, segmentectomy, and wedge resection for non-small cell lung cancer. Ann Thorac Surg. 2018;105:1483–91.

LUL

Fig. 5.33  Dividing B1 + 2 + B3

6

LS4 + 5Segmentectomy by 3D Navigation Jixian Liu and Junbin Wang

6.1 Summary of Medical Records A lung nodule was discovered on chest CT in a 54-year-old man. Following a short course of antibiotics, no significant change in the nodule was noted on re-examination CT 6 months later. The CT scan (Figs. 6.1, 6.2, and 6.3) showed a 1.8 cm × 1.6 cm mGGO in LS4 + 5.

6.1.1 Indications and Contraindications (a) The size of the nodule of the left upper lobe (LUL) is less than 2  cm in diameter, with C/T (Consolidation/ Tumor) value of less than 50%.

Fig. 6.2  Chest CT (Coronal view) showing the nodule (arrow) located within LS4 + 5. The yellow circle: identifies a 2-cm margin

Fig. 6.1  Chest CT (Axial view) showing the left upper lobe lung nodule (arrow) located within LS4 + 5. The yellow circle: identifies a 2-cm margin

J. Liu (*) · J. Wang Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China

Fig. 6.3  Chest CT (Sagittal view) showing the nodule (arrow) located within LS4 + 5. The yellow circle: identifies a 2-cm margin

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 J. Liu, D. Wu (eds.), Segmentectomy for Early-Stage Lung Cancer, https://doi.org/10.1007/978-981-99-0143-2_6

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(b) The nodule demonstrated no resolution after being treated with antibiotics for 2 weeks, raising the possibility of early lung cancer. (c) With preoperative 3D-CTBA reconstruction, the estimated surgical margin will be over 2  cm with LS4  +  5 segmentectomy. (d) The patient demonstrated good physical condition, without contraindications to operation.

6.2 Preoperative 3D-CTBA Reconstruction The estimated 2 cm margin of this nodule (Fig. 6.4) indicates that LS4 + 5segmentectomy is required.

6.2.1 Anatomical Features

Fig. 6.5  Bronchial branches of the left upper lobe (Anterior view)

The LUL bronchus (Fig. 6.5) is divided into B1 + 2 + 3 and B4 + 5 and B4 + 5 is divided into three branches: namely B4, B5a, and B5b. A4 + 5 (Fig. 6.6) has three branches: A4 and A5a which emanate from the root of the left superior pulmonary artery

Fig. 6.6  Relationship between arteries and bronchi of LS4 + 5 (Lateral view)

Fig. 6.4  Relationship between the 2-cm margin and the segmental interface of the LUL (Anterior view)

together are mediastinal type arteries (Med.A4 & Med.A5a), while A5b emanates from the interlobar artery and accompanies the corresponding bronchus. V4 + 5 (Fig. 6.7) emanates from the lowermost branch of the left superior pulmonary vein. Dissection of V4 + 5, A5b, B4 + 5, and Med.A4 & Med.A5a is required for segmentectomy.

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Oblique Fissure LUL LLL

Fig. 6.8  Dissecting the oblique fissure

Fig. 6.7  Relationship among arteries, veins and bronchi of LS4  +  5 (Anterior view)

6.3 Surgery Planning and Procedure According to CT and preoperative 3D reconstruction, LS4 + 5 segmentectomy is outlined. Dissection is completed from the anterior hilum of LUL posteriorly and oblique fissure cephalad. Fig. 6.9  Dissecting 11L lymph node

6.3.1 Surgical Planning V4 + 5 → A5b → B4 + 5 → Med.A4 & Med.A5a → LS4 + 5.

6.3.2 Surgical Procedures 1. The patient underwent double lumen endotracheal intubation and was placed in the right lateral decubitus position. The procedure uses a dual-port approach, with the left fourth intercostal space between the anterior and mid-axillary lines as the main operating port and for the thoracoscope, approximately 3  cm long, and the sixth intercostal space in the left posterior axillary line for assistant instruments. 2. Probe to locate the nodule within LS4 + 5. 3. The left upper lobe is drawn posteriorly and superiorly, the pleura of oblique fissure and anterior hilar is opened (Fig. 6.8). An incomplete fissure is incised, a 11L lymph node is dissected (Fig.  6.9) for intraoperative frozen pathology. 4. The lowermost branch of the left superior pulmonary vein is V4 + 5, dissected (Fig. 6.10) and divided with the Stapler.

Fig. 6.10  Dissecting V4 + 5

5. A5b is the most anterior branch of the interlobar artery trunk, dissected and divided with the endoGIA stapler (Fig. 6.11). 6. Along V4  +  5 and A5b upward, LB4  +  5 is dissected and divided with the Stapler (Fig. 6.12). 7. LB4 + 5 is retracted upward to dissect Med.A4 & Med.A5a along the inferior border of V1 + 2 + 3 (Fig. 6.13). 8. Inflate the lung with 100% pure oxygen having a pressure of 20–30  mmHg to full inflation. About 10  min

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Fig. 6.11  Dividing A5b (LUB left upper bronchus)

J. Liu and J. Wang

Fig. 6.14  The completed LS4 + 5 segmentectomy

later, a clear interface of inflation and deflation is seen, i.e., LS4 + 5 inflating and LS1 + 2 + 3 deflating. 9. The segmental plane is developed along the interface of inflation and deflation and LS4 + 5 is resected. 10. Show the stumps of segmental surface postoperative (Fig. 6.14). The postoperative pathological diagnosis: Invasive adenocarcinoma (pT1bN0M0) with the 11L lymph node negative for carcinoma.

Fig. 6.12  Dividing B4 + 5

6.3.3 Key Operation Points A4 and A5a are arteries of mediastinal type, which can only be exposed after dividing B4 + 5.

6.4 Schematic Diagram of the Surgical Procedure Schematic diagram of the surgical procedure for LS4 + 5 segmentectomy (Figs.  6.15, 6.16, 6.17, 6.18, 6.19, 6.20, 6.21, 6.22, 6.23, 6.24, 6.25, 6.26, 6.27, and 6.28).

Fig. 6.13  Dissecting Med.A4 & Med.A5a

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LUL

Interlobar Artery Left Lower Bronchus LLL

Fig. 6.18  Panoramic anatomy of LUL (Anterior view) Fig. 6.15  Figure of descending dimension of LS4 + 5 segmentectomy (The shadow is the range of excision: Red circles represent arteries; Green circles represent bronchi)

LUL

LLL

Fig. 6.19  Dissecting V4 + 5

Fig. 6.16  Panoramic anatomy of the interlobular left pulmonary artery (Interlobular view)

Fig. 6.20  Dividing V4 + 5

Fig. 6.17  Dissecting the 11L lymph node

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Fig. 6.24  Dividing B4 + 5 Fig. 6.21  Dissecting A5b

Fig. 6.25  Dissecting Med.A4 & Med.A5a

Fig. 6.22  Dividing A5b

Fig. 6.26  Dividing Med.A4 & Med.A5a Fig. 6.23  Dissecting B4 + 5

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Suggested Reading

Margin

Nodules

Fig. 6.27  Locating the node and delineating the resected area

Inerlobar Artery Left Lower Bronchus

Fig. 6.28  Segmental stumps after LS4 + 5.segmentectomy

1. Dai C, Shen J, Ren Y, et al. Choice of surgical procedure for patients with non-small-cell lung cancer ≤ 1 cm or > 1 to 2 cm among lobectomy, segmentectomy, and wedge resection: a population-based study. J Clin Oncol. 2016;34(26):3175–82. 2. Khullar OV, Liu Y, Gillespie T, Higgins KA, et  al. Survival after sublobar resection versus lobectomy for clinical stage IA lung cancer: an analysis from the national cancer data base. J Thorac Oncol. 2015;10(11):1625–33.

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Extended LS3 Segmentectomy by 3D Navigation Jixian Liu and Wei Yue

7.1 Summary of Medical Records A 56-year-old asymptomatic woman was found to have a left upper lobe (LUL) lung nodule on a CT scan that enlarged during 4-month interval surveillance. Chest CT (Figs.  7.1, 7.2, and 7.3) showed a mixed ground glass opacity (mGGO) of about 22 mm × 16 mm in size located in LS3.

7.1.1 Indications and Contraindications (a) The diameter of the nodule in the LUL is about 2 cm, with C/T (Consolidation/Tumor) value of less than 50%. (b) The nodule has been observed for 4 months. Results of the review showed that the nodule enlarged, being considered the possibility of early lung cancer. Fig. 7.2  Chest CT (Coronal view) showing the nodule (arrow) located in the LS3. The yellow circle: Identifies a 2-cm margin

Fig. 7.1  Chest CT (Axial view) showing the nodule (arrow) located in the LS3. The yellow circle: Identifies a 2-cm margin

J. Liu (*) · W. Yue Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China

Fig. 7.3  Chest CT (Sagittal view) showing the nodule (arrow) located in the LS3. The yellow circle: identifies a 2-cm margin

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 J. Liu, D. Wu (eds.), Segmentectomy for Early-Stage Lung Cancer, https://doi.org/10.1007/978-981-99-0143-2_7

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(c) With the planning of the preoperative 3D-CTBA reconstruction, the incisional margin to the nodule is more than 2  cm after the procedure of extended LS3 segmentectomy. (d) The patient demonstrates excellent performance status without contraindications to resection.

7.2 Preoperative 3D-CTBA Reconstruction The marginal ball of this pulmonary nodule (nodule and its 2 cm margin) shows the margin is mainly located in LS3 and partially extends into S1 + 2 (Fig. 7.4), indicating that extended LS3 segmentectomy is required to achieve a satisfactory surgical margin.

7.2.1 Anatomical Features

Fig. 7.5  Bronchial branch of the LUL (Lateral view)

The left upper lobe bronchus (Fig.  7.5) is divided into B1 + 2 + B3 and B4 + 5, B1 + 2 + B3 is divided into B1 + 2 and B3. The left superior pulmonary arteries (LSPA) (Fig.  7.6): A1  +  2a  +  b and A1  +  2c emanate from the trunk of LSPA, respectively; the two branches (A3b and A3a + c) of the A3 also branch off from the trunk of LSPA, respectively. A4b is a mediastinal type artery emanating from the root of LSPA alone, A4a and A5 are co-trunks emanating from the interlobular artery.

Fig. 7.6 Relationship between arteries and bronchi of the LUL (Anterior view)

Fig. 7.4  Relationship between the safe margin of nodule and the segmental interface of the LUL (Lateral view)

V1 + 2 + 3 and V4 + 5 emanate from the left superior pulmonary vein (LSPV) respectively (Figs. 7.7 and 7.18), the trunk of V1 + 2 + 3 travels under B3 to the LSPV, not on the surface of anterior hilum. V3c and V3a + b emanate from the V1 + 2 + 3 trunk, respectively; the intrasegmental vein of S3, V3c, will be divided; V3b is the intersegmental vein between S3 and S4. For this resection, V3a  +  b should be divided together to ensure adequate margins.

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Fig. 7.8  Mark the nodule close to LS1 + 2 with a suture

Fig. 7.7  Relationship among arteries, veins, and bronchi of the LUL (Anterior view)

The operation will dissect V3c, A3b, A3a + c, V3a + b, and B following the principle of proceeding “from the shallower to the deeper.” 3

7.3 Surgery Planning and Procedure

Fig. 7.9  Dissecting 11L

According to CT and preoperative 3D reconstruction, the extended LS3 segmentectomy is undertaken, dissecting from the anterior hilum posteriorly.

7.3.1 Surgical Planning V3c → A3b → A3a + c → V3a + b → B3 → Extended LS3.

7.3.2 Surgical Procedures 1. The patient undergoes double-lumen endotracheal intubation, positioned right lateral decubitus. The procedure is completed with two ports: The fourth intercostal in left axillary midline as main operating port and for the video thoracoscope; the sixth intercostal port in posterior axillary line for retraction and assistance. 2. Probe to locate the nodule which is mainly located within LS3, mark the nodule with a suture close to LS1 + 2 (Fig. 7.8) to facilitate identification of the 2-cm surgical margin. 3. The LUL is retracted posteriorly and the pleura is incised anterior to the hilum, with dissection of the 11L lymph node (Fig.  7.9) to send for intraoperative frozen pathology.

Fig. 7.10  Dissecting V3c

4. V3c is dissected (Fig. 7.10) and divided. 5. Dissect A3b (Fig.  7.11) and A3a  +  c (Fig.  7.12) at the superior border of V3c stumps, ligating and dividing them individually. 6. Separate V3a  +  b along the surface of the V1  +  2  +  3 (Fig. 7.13), ligate and divide. 7. Dissect B3 between V1 + 2 and A1 + 2a + b (Figs. 7.14 and 7.27), and divide the segmental bronchus with a surgical stapler.

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Fig. 7.14  Dissecting B3 Fig. 7.11  Dissecting A3b

Fig. 7.12  Dissecting A a + c 3

Fig. 7.15  Tailoring along the interface of inflated LS3 and only partially deflated LS1 + 2

8. Inflate the lung with 100% pure oxygen to a peak inspiratory pressure of 20–30 mmHg to the full inflation of the upper lung. About 10 min later, a clear interface of inflation and deflation is seen, i.e., LS3 inflating and residual lung deflating. 9. The lung is tailored along the interface of the inflated LS3 and partially deflated LS1 + 2 (Fig. 7.15) because the nodule is very close to LS1 + 2, so LS3 and part of LS1 + 2 are resected. Fig. 7.13  Dissecting V3a + b

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Fig. 7.16  Segmental stumps after Extended LS3 segmentectomy

10. Show the stumps of the segmental surface postoperatively (Fig. 7.16). The postoperative pathology of this patient was microinvasive adenocarcinoma (MIA) with no involvement of the 11L lymph node.

Fig. 7.17  Figure of descending dimension of LS3 segmentectomy (The shadow is the range of excision: Red circles represent arteries; Green circles represent bronchi)

LUL

7.3.3 Key Points of the Surgical Procedure 1. The V1  +  2  +  3 is an anatomical variant which converges between S1 and S2 and drains into the left superior pulmonary vein from below B3 instead of the usual V1 + 2 traveling in front of the hilum. 2. B3 which is surrounded by vessels can only be approached when the arteries and the veins of S3 are dissected from the anterior hilar. Dissection between V1 + 2 and A1 + 2 can avoid inadvertent injury to the segmental airway and vessels of LS1 + 2.

Fig. 7.18  Panoramic figure of the LUL (Anterior view)

7.4 Schematic Diagram of the Surgical Procedure Schematic diagram of the surgical procedure for Extended LS3 segmentectomy (Figs. 7.17, 7.18, 7.19, 7.20, 7.21, 7.22, 7.23, 7.24, 7.25, 7.26, 7.27, 7.28, 7.29, and 7.30).

Fig. 7.19  Dissecting V3c

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Fig. 7.20  Dividing V3c

Fig. 7.23  Dissecting A3a + c

Fig. 7.21  Dissecting A3b

Fig. 7.24  Dividing A3a + c

Fig. 7.22  Dividing A3b

Fig. 7.25  Dissecting V3a + b

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Fig. 7.26  Dividing V3a + b

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Fig. 7.29  Locating the node and delineating the resected area

Fig. 7.30  The labeled figure of segmental stumps after Extended LS3 segmentectomy Fig. 7.27  Dissecting B3

Suggested Reading 1. Cao J, Yuan P, Wang Y, et al. Survival rates after lobectomy, segmentectomy, and wedge resection for non-small cell lung cancer. Ann Thorac Surg. 2018;105:1483–91. 2. Subramanian M, McMurry T, Meyers BF, et al. Long- term results for clinical stage IA lung cancer- comparing lobectomy and sublobar resection. Ann Thorac Surg. 2018;106:375–81.

Fig. 7.28  Dividing B3

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RS1 Segmentectomy by 3D Navigation Jixian Liu and Xiaoqiang Li

8.1 Summary of Medical Records A 43-year-old asymptomatic woman was found to have a right upper lobe (RUL) lung nodule on a CT scan. She was treated with antibiotics for 2 weeks, with no significant change of the nodule on re-examination. Her chest CT (Figs. 8.1, 8.2, and 8.3) showed an 8-mm pure ground glass opacity (pGGO) located in the RS1.

Fig. 8.2  Chest CT (coronal view) showing the nodule located in the RS1 (Yellow circle: nodule and its 2 cm margin)

Fig. 8.1  Chest CT (axial view) showing the nodule located in the RS1 (Yellow circle: nodule and its 2 cm margin) Fig. 8.3  Chest CT (sagittal view) showing the nodule located in the RS1 (Yellow circle: nodule and its 2 cm margin)

J. Liu (*) · X. Li Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 J. Liu, D. Wu (eds.), Segmentectomy for Early-Stage Lung Cancer, https://doi.org/10.1007/978-981-99-0143-2_8

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Fig. 8.4  Relationship between the safe margin of nodule and the RUL segmental interfaces (Anterior view)

8.1.1 Indications and Contraindications (a) This 8 mm pure GGO located in the center of RS1 would not be amenable to non-anatomic wedge resection with adequate surgical margin. (b) Despite a short course of antibiotic therapy, persistence of the nodule is suspicious for early lung cancer. (c) With the use of preoperative 3D-CTBA reconstruction, the prospective incisional margin is more than 2 cm after RS1 segmentectomy (Fig. 8.4). (d) The patient has good performance status, without contraindications to operation.

Fig. 8.5  Segmental bronchi of the RUL (Lateral view)

8.2 Preoperative 3D-CTBA Reconstruction The marginal ball of this nodule (nodule and its 2 cm margin) shows the margin is completely located in RS1 (Fig. 8.4), so the RS1 segmentectomy is required to satisfy the safe surgical margin.

Fig. 8.6  Relationship between segmental arteries and bronchi of the RUL (Lateral view)

8.2.1 Anatomical Features The right upper lobe bronchus (Fig. 8.5) is divided into B , B2, and B3, B1 and B2 emanating from the common trunk. The RA1 (Fig. 8.6) divides into A1b which emanates separately from the upper trunk of the right superior pulmonary artery and A1a emanating from the upper trunk in form of co-trunk with Rec A2. 1

V1a, an intrasegmental vein (Fig.  8.7), will be divided. V b which is the intersegmental vein of S1 and S3 will be preserved. V2a, which travels between B1 and B3 to right superior pulmonary vein (RSPV) above which is the boundary of RS1 (Fig. 8.8). The operation needs to dissect V1a, A1b, A1a, and B1. 1

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8.3.2 Surgical Procedures 1. The patient undergoes double-lumen endotracheal intubation and is placed in the left lateral decubitus position. Two ports are placed: The third intercostal in right axillary midline as main operating port and for thoracoscope placement; the port in the fifth intercostal space in the posterior axillary line for retraction (Fig. 8.9). 2. Probe to locate the nodule within RS1. 3. Retract the upper lung posteriorly and incise the anterior hilar pleura to expose V1a, A1b, and A1a  +  Rec. A2 (Fig.  8.10) and dissect the station 12R lymph node for intraoperative frozen pathological examination (Fig. 8.11). 4. Following the 3D navigation, dissect the V1a, superficial intrasegmental vein (Fig.  8.12), ligating and dividing between 4 and 0 silk ties (Fig. 8.13). Fig. 8.7  Relationship between segmental veins and bronchi of the RUL (Lateral view)

Main operating port

Assistant port

Fig. 8.9  Layout of incision

Fig. 8.8  Relationship among segmental arteries, veins, and bronchi of the RS1 (Lateral view)

8.3 Surgery Planning and Procedure According to CT and preoperative 3D reconstruction, RS1 segmentectomy is undertaken, dissecting from superior hilum posteriorly.

8.3.1 Surgical Planning V1a → A1b → A1a → RB1 → RS1

Fig. 8.10  Demonstration of V1a, A1b and A1a + Rec.A2

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Fig. 8.14  Dissecting A1b Fig. 8.11  Dissecting the station 12R lymph node

Fig. 8.15  Dissecting A1a and ligating it with a 4-0 silk thread Fig. 8.12  Dissecting V1a

Fig. 8.16  Demonstrating B1

Fig. 8.13  Ligating V1a with 4-0 silk thread

5. At the upper edge of V1a, dissect A1b separately (Fig. 8.14) and A1a from co-trunk of A1a + Rec.A2 (Fig. 8.15), taking care to protect Rec.A2. Ligate and divide these, respectively.

6. Dissect B1 ventral to the Rec.A2 and above the V2a (Fig. 8.16) and divide using the stapler (Fig. 8.17). 7. Inflate lung with 100% pure oxygen to peak airway pressure of 20–30 mmHg to insufflate the upper lobe. About 10 min later, a clear interface of inflation and deflation is seen, i.e., RS1 inflating and the remaining parenchyma deflating (Fig. 8.18).

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Fig. 8.17  Dividing B1

Fig. 8.19  Opening the interface between S1 and S2, S3

Fig. 8.18  Showing the interface of inflating and deflating

Fig. 8.20 Postoperative stumps of segmental surface after RS1 segmentectomy

8. The membrane-like structure between the inflating RS1 and the deflating RS2  +  RS3 is opened by means of “Inward Opening” fashion (Fig. 8.19). 9. The lung is tailored along the interface of inflating and deflating (Fig. 8.20). The postoperative pathology of this patient was microinvasive adenocarcinoma (MIA) with the station 12R lymph node negative for malignancy.

8.3.3 Key Points of the Surgical Procedure 1. V2a which travels between B1 and B3 to the right superior pulmonary vein, instead of the usual route below B3 toward the central vein. V2a is exposed for a long route in the operative area and needs careful protection. 2. A1a and Rec.A2 originate from the common trunk, and more attention should be taken to protect Rec.A2 when dissecting A1a. B1 traverses ventrally close to Rec.A2.

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8.4 Schematic Diagram of the Surgical Procedure Schematic diagram of the surgical procedure for RS1 segmentectomy (Figs.  8.21, 8.22, 8.23, 8.24, 8.25, 8.26, 8.27, 8.28, 8.29, 8.30, and 8.31).

Fig. 8.24  Dividing V1a

RUL

Fig. 8.21  Figure of descending dimension of RS1 segmentectomy (The shadow is the range of excision: Red circles represent arteries; Green circles represent bronchi)

Fig. 8.25  Dissecting A1b RUL

RUL

RML

Fig. 8.22  RUL anterior hilum (Anterior view) Fig. 8.26  Dividing A1b, dissecting A1a

Fig. 8.23  Dissecting V1a

Fig. 8.27  Dividing A1a

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Fig. 8.28  Dissecting B

1

Fig. 8.31 The labeled figure of segmental stumps after RS1 segmentectomy

Suggested Reading 1. Cao C, D’Amico T, Demmy T, Dunning J, Gossot D, Hansen H, et al. Less is more: a shift in the surgical approach to non-small-cell lung cancer. Lancet Respir Med. 2016;4:e11–2. 2. Wang J, Xu XF, Wen W, Wu WB, Zhu Q, Chen L. Modified method for distinguishing the intersegmental border for lung segmentectomy. Thorac Cancer. 2018;9:330–3. Fig. 8.29  Dividing B1

Fig. 8.30  Locating the nodule and delineating the resection planes

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Extended RS2 Segmentectomy by 3D Navigation Jixian Liu and Xiaoqiang Li

9.1 Summary of Medical Records A 65-year-old asymptomatic woman was found to have a right upper lobe (RUL) lung nodule that persisted despite empiric antibiotic therapy. Her chest CT (Figs.  9.1, 9.2, and 9.3) showed an 11  mm  ×  15  mm mixed ground glass opacity (mGGO) located in the RS 2 adjacent to RS 3.

Fig. 9.2  Chest CT (Coronal view) showing the nodule located in the RS2 adjacent to RS3 (Yellow circle: nodule and its 2 cm margin)

Fig. 9.1  Chest CT (Axial view) showing the nodule located in the RS2 adjacent to RS3 (Yellow circle: nodule and 2 cm margin)

J. Liu (*) · X. Li Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China

Fig. 9.3  Chest CT (Sagittal view) showing the nodule located in the RS2 adjacent to RS3 (Yellow circle: nodule and its 2 cm margin)

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 J. Liu, D. Wu (eds.), Segmentectomy for Early-Stage Lung Cancer, https://doi.org/10.1007/978-981-99-0143-2_9

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9.1.1 Indications and Contraindications ( a) The nodule is an 11  mm  ×  15  mm mixed GGO located in the center of RUL, difficult to obtain an adequate surgical margin by non-anatomic wedge resection. (b) The nodule persisted despite antibiotic therapy, raising the possibility of early lung cancer. (c) Preoperative 3D-CTBA reconstruction demonstrates that the planned surgical margin would be greater than 2 cm for an extended RS2 segmentectomy. (d) The patient demonstrates good physical condition, with no contraindications to operation.

9.2 Preoperative 3D-CTBA Reconstruction

Fig. 9.5  Bronchial branches of the RUL (Posterior view)

The estimated resection sphere (nodule and its 2 cm margin) shows the margin is located in RS2 very close to RS3 (Fig. 9.4), leading to the decision to proceed with extended RS2 segmentectomy.

9.2.1 Anatomical Features The right upper lobe bronchus (Fig. 9.5) is divided into B1, B2, and B3 separately.

Fig. 9.6 Relationship between arteries and bronchi of the RUL (Posterior view)

The upper trunk of the right pulmonary artery (Fig. 9.6) includes A3, A1, and Rec A2, while the Asc A2 branches off from the interlobar trunk of the right pulmonary artery distributing S2b and S2aii. V1a, V2a, V2b, and V2c converge as the central vein (CV) (Fig. 9.7). V2b is an intrasegment vein of S2 that needs to be divided. Since the planned surgical margin for this nodule is close to S3, V2c needs to be divided. The operation needs to dissect Rec A2, Asc A2, V2b, V2c, and B2, protecting V2a.

Fig. 9.4  Relationship between the estimated surgical margin and the RUL segmental interface (Anterior view)

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Fig. 9.7  Relationship among arteries, veins, and bronchi of the RS2 (Posterior view)

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Fig. 9.8  Dissecting the 11R lymph node and Asc.A2 (RUL right upper lobe, RLL right lower lobe)

9.3 Surgery Planning and Procedure According to CT and preoperative 3D reconstruction, the extended RS2 segmentectomy is initiated, dissecting from the interlobar fissure cephalad.

9.3.1 Surgical Planning Asc.A2 → B2 → Rec.A2 → V2c → V2b → RS2

9.3.2 Surgical Procedures 1. The patient undergoes double-lumen tracheal intubation and is placed in left lateral decubitus. The procedure is completed with two ports: The fourth intercostal space in right axillary midline serves as the main operating port and for thoracoscope placement; the seventh intercostal space in the posterior axillary line is used for placement of retraction. 2. Probe to locate the nodule within RS2 adjacent to RS3. 3. The posterior part of the oblique fissure is opened, submitting the 11R lymph node for intraoperative frozen pathology (Fig.  9.8). Dissect and divide Asc.A2 (Fig. 9.9). 4. The 12R lymph node between B2 and B3 is dissected (Fig. 9.10), with attention to preserving A3. 5. The central vein (CV) is located between B2 and B3, B2 is dissected and divided dorsal to the CV (Fig. 9.11). 6. Retracting the upper lobe anteriorly and inferiorly, the most dorsal branch of the upper trunk of the right pulmonary artery is Rec. A2 (Fig. 9.12), and is divided.

Fig. 9.9  Dividing Asc.A2

7. Dissect and divide V2c from the interlobar fissure (Fig. 9.13) to expand the resected range. 8. Dissect along the CV distally to identify V2b (Fig. 9.14), dissect and divide it, taking care to preserve V2a. 9. Inflate lung with 100% oxygen to peak airway pressure of 20–30 mmHg to inflate the upper lung. About 10 min later, a clear interface of inflation and deflation is noted, i.e., RS2 + part of RS3 remains inflated while the remaining parenchyma deflates (Fig. 9.15). 10. The segmentectomy is tailored along the interface of aerated and deflated lungs. 11. The divided stumps following segmentectomy (Fig. 9.16). The postoperative pathology indicated microinvasive adenocarcinoma (MIA) with 11R and 12R lymph nodes negative for malignancy.

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Fig. 9.10  Dissecting 12R lymph node(s) (RUB right upper bronchus)

Fig. 9.11  Dissecting B2

J. Liu and X. Li

Fig. 9.13  Dissecting V2c

Fig. 9.14  Dissecting V2b

Fig. 9.15  Interface of inflation and deflation after the division of B2

Fig. 9.12  Dissecting Rec.A2 (RUL right upper lobe)

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Fig. 9.16  Resection bed demonstrating divided stumps of segmental structures after an extended RS2 segmentectomy

9.3.3 Key Points of the Surgical Procedure 1. Rec.A2 and A1 are co-trunk, and care is taken to protect A1 when dissecting Rec.A2. 2. The dorsal side of the CV is B2, the ventral side is B3, and the dissection of B2 behind the CV will not accidentally injure B3.

Fig. 9.17  Figure of descending dimension of extended RS2 segmentectomy (The shadow is the range of excision: Red circles represent arteries; Green circles represent bronchi)

RUL

9.4 Schematic Diagram of the Surgical Procedure

RUL

Schematic diagram of the surgical procedure for extended RS2 segmentectomy (Figs. 9.17, 9.18, 9.19, 9.20, 9.21, 9.22, 9.23, 9.24, 9.25, 9.26, 9.27, 9.28, and 9.29). RML

RLL

Fig. 9.18  Panoramic figure of the RUL (Interlobal view)

Fig. 9.19  Dissecting Asc.A2

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RUL

Fig. 9.20  Dividing Asc.A2; Dissecting B2

Fig. 9.23  Dissecting Rec.A2

RUL RLL

RML

Fig. 9.24  Dividing Rec.A2

Fig. 9.21  Dividing B2

RUL

RUL RLL

RML

Fig. 9.22  Relationship of arteries and veins of RUL (Anterior hilar view)

Fig. 9.25  Dissecting V2c

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RUL

RUL

RML RLL

Fig. 9.29  The labeled figure of segmental stumps after extended RS2 segmentectomy

Fig. 9.26  Dividing V2c

RUL

Suggested Reading 1. Cao C, D’Amico T, Demmy T, Dunning J, Gossot D, Hansen H, et al. Less is more: a shift in the surgical approach to non-small-cell lung cancer. Lancet Respir Med. 2016;4:e11–2. 2. Schuchert M, Pettiford B, Keeley S, D’Amato T, Kilic A, Close J, et al. Anatomic segmentectomy in the treatment of stage I non-small cell lung cancer. Ann Thorac Surg. 2007;84:926–33.

Fig. 9.27  Dissecting V2b

Fig. 9.28  Dividing V2b

RS3 Segmentectomy by 3D Navigation

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Jixian Liu and Lei Yang

10.1 Summary of Medical Records A 49-year-old asymptomatic woman was found to have a right upper lobe (RUL) lung nodule that persisted despite antibiotic therapy. Her chest CT (Figs. 10.1, 10.2, and 10.3) showed an 11  mm  ×  15  mm mixed ground glass opacity (mGGO) located in the RS3.

10.1.1 Indications and Contraindications (a) The lesion, located deep in the RS3 is less than 2 cm in diameter, with C/T (Consolidation/Tumor) ratio less than 25%.

Fig. 10.2  Chest CT (Coronal view) showing the nodule located in the RS3 (Yellow circle: nodule with 2 cm margin)

Fig. 10.1  Chest CT (Axial view) showing the nodule located in the RS3 (Yellow circle: nodule with 2 cm margin)

J. Liu (*) · L. Yang Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China

Fig. 10.3  Chest CT (Sagittal view) showing the nodule located in the RS3 (Yellow circle: nodule with 2 cm margin)

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 J. Liu, D. Wu (eds.), Segmentectomy for Early-Stage Lung Cancer, https://doi.org/10.1007/978-981-99-0143-2_10

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(b) The nodule was unchanged in size despite antibiotic therapy, raising the possibility of early lung cancer. (c) With preoperative 3D-CTBA reconstruction, the surgical margin is estimated to be more than 2 cm after RS3 segmentectomy. (d) The patient was in good physical condition, no contraindications to the surgery procedure.

J. Liu and L. Yang

Right superior pulmonary vein (RSPV) (Figs.  10.7 and 10.8): V3c that runs in front of the hilum is the intra-segment vein of S3b. V3a is the intersegmental vein of S3a and S3b. These two veins should be divided. V3b which runs below S3 and is the intersegmental vein between S3 and the right middle lobe needs to be retained. The central vein

10.2 Preoperative 3D-CTBA Reconstruction The estimated spherical 2 cm margin of this nodule is contained within RS3 (Fig. 10.4), indicating that RS3 segmentectomy would yield an adequate surgical margin.

10.2.1 Anatomical Features The right upper bronchus (RUB) (Fig. 10.5) is divided into a common trunk of B1 + B2 and a dominant B3, with B3 divided into a common trunk of B3a + B3bi and B3bii. The branch of the right superior pulmonary artery (RSPA) (Fig. 10.6): A1 branches separately from the upper trunk of the RSPA; A2 branches separately from the interlobar artery; A3 is divided into 2 branches, one of which is A3a + A3bi with co-trunk out, another of which is A3bii separately. Fig. 10.5  Bronchial branches of the RUL (Anterior view)

Fig. 10.4  Relationship between the resection margin and the segmental interface of the RUL (Lateral view)

Fig. 10.6  Relationship between arteries and bronchi of the RUL (Anterior view)

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Fig. 10.9  Relationship among arteries, veins, and bronchi of the RS3 (Anterior view) Fig. 10.7 Relationship between veins and bronchi of the RUL (Anterior view)

10.3 Surgery Planning and Procedure According to CT and preoperative 3D reconstruction, RS3 segmentectomy is pursued. Dissect from the anterior hilum dorsally.

10.3.1 Surgical Planning V3c → A3a + A3bi&A3bii → V3a → B3 → RS3.

10.3.2 Surgical Procedures

Fig. 10.8  Relationship among arteries, veins, and bronchi of the RS3 (Anterior view)

(V1a  +  V1b  +  V2a  –  c  +  V3a) meets between B1 and B2, courses below B3 to RSPV, and drains Venous blood of S1 + S2 and part of S3. The operation needs to dissect V3c, co-trunk of A3a + A3bi, 3 A bii, V3a and B3 (Fig. 10.9).

1. The patient has Left lateral position and double-lumen tracheal intubation. The procedure is carried out with two ports: The fourth intercostal space in right axillary midline as main operating port and for thoracoscope placement; the sixth intercostal port in posterior axillary line for tractive instruments. 2. Probe to locate the nodule within RS3. 3. Pull the upper lung dorsally and incise the pleura in front of the hilum. 4. V3c is dissected at the anterior hilum (Fig. 10.10). Ligate and divide V3c (Fig. 10.11). 5. Dissect A3a  +  A3bi and A3bii below the V3c stumps (Fig. 10.12), dividing it to expose A1. 6. 12R lymph node (Fig. 10.13) is dissected for intraoperative frozen pathology.

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Fig. 10.10  Dissecting V3c

Fig. 10.13  Dissecting a 12R lymph node

Fig. 10.11  Ligating and dividing V3c

Fig. 10.14  Ligating V3a (CV: central vein)

Fig. 10.12  Dissecting A3a + A3bi and A3bii

Fig. 10.15  Dissecting B3

7. Dissect V3a on the surface of the central vein (CV) (Fig. 10.14), ligate and divide. 8. Continue to dissect B3 along the CV surface (Fig. 10.15) and divide. 9. Inflate lung with 100% pure oxygen to a peak pressure of 20–30  mmHg to obtain full inflation of the upper lung. About 10  min later, a clear interface of inflation and deflation is seen, i.e., RS3 inflated and residual lungs deflating (Fig. 10.16). Fig. 10.16  Showing the inflation interface

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10. The lung is tailored along the interface of inflating and deflating (Fig. 10.17). 11. The completed segmentectomy (Fig. 10.18). The postoperative pathology of this patient was microinvasive adenocarcinoma (MIA) with No. 12 lymph node negative.

(b) Dissecting the 12R lymph node after A2 and V2 are divided facilitates exposure and division of B3. Dissect B3 on the surface of CV.

10.3.3 Key Points of the Surgical Procedure

Schematic diagram of the surgical procedure for RS3 segmentectomy (Figs. 10.19, 10.20, 10.21, 10.22, 10.23, 10.24, 10.25, 10.26, 10.27, 10.28, 10.29, and 10.30).

(a) RV1 runs below B1 and drains into CV, rather than its usual course running on the surface of the anterior hilum, which makes RS3 segmentectomy simple and has less chance to damage RV1.

10.4 Schematic Diagram of the Surgical Procedure

Fig. 10.17  Tailoring S3 along the interface

Fig. 10.19  Figure of descending dimension of RS3 segmentectomy (The shadow is the range of excision: Red circles represent arteries; Green circles represent bronchi)

RLL

Fig. 10.18 Postoperative stumps of segmental surface after RS3 segmentectomy

Fig. 10.20  Panoramic figure of the RUL (Anterior view)

RUL

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RUL

RUL

Fig. 10.24  Dividing A3a + A3bi, A3bii Fig. 10.21  Dissecting V c 3

RLL

RUL

RUL

RML

RML

Fig. 10.22  Dividing V3c Fig. 10.25  Dissecting V3a

RUL RUL

RML

Fig. 10.26  Dividing V3a Fig. 10.23  Dissecting A3a + A3bi, A3bii

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RUL

RLL

RUL

RML RML

Fig. 10.30 The labeled figure of segmental stumps after RS3 segmentectomy

Fig. 10.27  Dissecting B

3

RUL

Suggested Reading 1. Gu Y, Duan R, Lv X, Song J.  Airway Management of the Right Anterior Segmentectomy through Uniportal video-assisted thoracoscopic surgery (VATS) after left pneumonectomy by an adapted double-lumen endobronchial tube (DLT): a case report. BMC Anesthesiol. 2019;19(1):82. 2. Stamenovic D, Messerschmidt A. Uniportal video-assisted thoracoscopic resection of anterior segment of the left upper lobe. Multimed Man Cardiothorac Surg. 2018;2018 https://doi.org/10.1510/ mmcts.2018.002.

RML

Fig. 10.28  Dividing B3

Node interface

Fig. 10.29  Locating the node and delineating the resected area

RS2b + RS3a Segmentectomy by 3D Navigation

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Jixian Liu and Yiwang Ye

11.1 Summary of Medical Records A 35-year-old asymptomatic man was found to have a right upper lobe (RUL) lung nodule that persisted despite antibiotic therapy. Chest CT (Figs. 11.1, 11.2, and 11.3) showed an 8 mm × 9 mm mixed ground glass opacity (mGGO) located between RS2 and RS3.

11.1.1 Indications and Contraindications (a) The lesion located deep in the RUL is less than 2 cm in diameter, with C/T (Consolidation/Tumor) ratio less than 50%.

Fig. 11.2  Chest CT (Coronal view) showing the nodule located between the RS2b and RS3a (Yellow circle: nodule and its 2  cm margin)

Fig. 11.1  Chest CT (Axial view) showing the nodule located between RS2b and RS3a (Yellow circle: nodule and its 2 cm margin)

J. Liu (*) · Y. Ye Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China

Fig. 11.3 Chest CT (Sagittal view) showing the nodule located between RS2b and RS3a (Yellow circle: nodule and its 2 cm margin)

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 J. Liu, D. Wu (eds.), Segmentectomy for Early-Stage Lung Cancer, https://doi.org/10.1007/978-981-99-0143-2_11

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(b) The nodule was found to persist on serial chest CT imaging despite antibiotic therapy, raising the possibility of early lung cancer. (c) With the planning by 3D-CTDA reconstruction, the distance from the planned resection margin to the nodule would be more than 2  cm after RS2b  +  RS3a segmentectomy. (d) The patient demonstrated good performance status, without contraindications to operation.

11.2 Preoperative 3D-CTBA Reconstruction

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A1 and A3 are co-trunk separated from the upper trunk of right superior pulmonary artery (RSPA), and A3a (Fig. 11.6) is located anteriorly and superiorly of B3a. A2 branches alone from the interlobular artery and divides into A2a and A2b, with A2b located below B2b. The right superior pulmonary vein (RSPV) (Fig. 11.7) is divided into V1b, a central vein (V1a, V2a, V2b, and V2c), and V3a (separated from the root of the RSPV). V2c, the intersegmental vein between S2b and S3a will be resected. The operation needs to dissect V2c, A2b, B2b, B3a, and A3a (Fig. 11.8).

The projected resection sphere (including the nodule and a 2-cm margin) shows the margin located in RS2b  +  RS3a (Fig. 11.4), amenable to RS2b + RS3a segmentectomy.

11.2.1 Anatomical Features The right upper bronchus (RUB) (Fig. 11.5) is divided into B1, B2 and B3 separately. B2 branches into B2a and B2b, B3 branches into B3a and B3b. The nodule is located between B2b and B3a.

Fig. 11.5  Bronchial branches of the RUL (Lateral view)

Fig. 11.4  Relationship between the nodule and 2 cm margin and the segmental interface of the RUL (Lateral view)

Fig. 11.6  Relationship between arteries and bronchi of the RS2b + RS3a (Lateral view)

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The fourth intercostal space, right axillary midline

The sixth intercostal space, posterior axillary line

Fig. 11.7  Relationship between veins and bronchi of RS2b  +  RS3a (Lateral view) CV: (Central Vein) Fig. 11.9  Incision layout

11.3.2 Surgical Procedures

Fig. 11.8  Relationship among arteries, veins, and bronchi of the RS2b + RS3a (Lower lateral view)

11.3 Surgery Planning and Procedure According to CT and preoperative 3D reconstruction, RS2b + RS3a segmentectomy is undertaken, dissecting from the junction of oblique fissure and horizontal fissure to the cranial side.

11.3.1 Surgical Planning A2b → B2b → V2c → B3a → A3a → RS2b + RS3a.

1. The patient undergoes double-lumen endotracheal intubation and is positioned in the left lateral position. The procedure requires two ports: The fourth intercostal in the right axillary midline as the main operating port and through thoracoscope; the sixth intercostal port in posterior axillary line for tractive instruments (Fig. 11.9). 2. Probe to locate the nodule between RS2 + RS3. 3. Retract the upper lung cranially and incise the pleura of the interlobar fissure. 4. Expose the interlobar artery of right pulmonary artery, dissecting A2 (Fig. 11.10) distal to A2a and A2b, dissecting A2b (Fig. 11.11), and dividing A2b. 5. Dissect B2 posterior to A2b and along the lateral edge of the central vein. Dissect B2 distally until encountering B2a and B2b (Fig. 11.12), dividing B2b. 6. Lift the distal end of B2b, dissecting V2c (Fig.  11.13) medial to the central vein, ligating and dividing V2c. A 12R lymph node is dissected for intraoperative frozen pathology. 7. Dissect B3a ventrally at the level of the V2c stump (Fig. 11.14) and divide. According to 3D reconstruction, the root of B3a is surrounded by several small branches of A3a. 8. A3a is cranial, closely adjacent to B3a, and is mobilized and divided (Fig. 11.15). 9. Inflate lung with 100% pure oxygen to an airway pressure of 20–30 mmHg in order to inflate the parenchyma

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Fig. 11.13  Dissecting V2c

Fig. 11.10  Dissecting A2

Fig. 11.11  Dissecting A2b

Fig. 11.12  Dissecting B2b

of the upper lung. About 10 min later, a clear interface between inflation and deflation is seen, i.e., RS2b + RS3a inflating and Residual lungs deflating (Fig. 11.16). 10. The lung is tailored along the interface of inflation and deflation (Fig. 11.17).

Fig. 11.14  Dissecting B3a

Fig. 11.15  Dissecting A3a in front of B3a

11. Demonstrating the stumps of the adjacent segmental surface (Fig. 11.18). The postoperative pathology of this patient indicated microinvasive adenocarcinoma (MIA) with a 12R lymph node negative.

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11.3.3 Key Points of the Surgical Procedure

Fig. 11.16  Showing the interface of inflation and deflation

(a) CV and V2c have thin walls with no vascular sheaths and require an assistant to pull lung moderately around them to form a micro-tension plane which will help to dissect them. (b) B3a and A3a are located on the deep surface of the interlobar fissure, and the surface lung tissue needs to be dissected carefully to avoid bleeding which can influence view; B3a is surrounded by branches of A3a and needs to be dissected carefully.

11.4 Schematic Diagram of the Surgical Procedure Schematic diagram of the surgical procedure for RS2b + RS3a segmentectomy (Figs.  11.19, 11.20, 11.21, 11.22, 11.23, 11.24, 11.25, 11.26, 11.27, 11.28, 11.29, 11.30, 11.31, and 11.32).

Fig. 11.17 Tailoring lung along the interface of inflating and deflating

Fig. 11.19  Figure of descending dimension of RS2b + RS3a segmentectomy (The shadow is the range of excision: Red circles represent arteries; Green circles represent bronchi)

Fig. 11.18 Stumps of segmental surface after RS2b  +  RS3a segmentectomy

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RUL

Middle lower lobe bronchi Interlobar artery

RML

Fig. 11.20  Panoramic figure of the RUL (Interlobular view)

Fig. 11.23  Dissecting B2b

RUL

Fig. 11.21  Dissecting A2b

Fig. 11.24  Dividing B2b

Fig. 11.22  Dividing A2b

Fig. 11.25  Dissecting V2c

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Fig. 11.26  Dividing V2c

Fig. 11.27  Dissecting B3a

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Fig. 11.29  Dissecting A3a

Fig. 11.30  Dividing A3a

Fig. 11.28  Dividing B3a Fig. 11.31  Locating the node and delineating the resected area

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Suggested Reading 1. Okada M, Mimura T, Ikegaki J, Katoh H, Itoh H, Tsubota N.  A novel video-assisted anatomic segmentectomy technique: selective segmental inflation via bronchofiberoptic jet followed by cautery cutting. J Thorac Cardiovasc Surg. 2007;133:753–8. 2. Kamiyoshihara M, Kakegawa S, Ibe T, Takeyoshi I.  Butterfly-­ needle video-assisted thoracoscopic segmentectomy: a retrospective review and technique in detail. Innovations. 2009;4:326–30.

Fig. 11.32  The labeled figure of segmental stumps after RS2b + RS3a segmentectomy

RS1 + RS2 + RS3c Segmentectomy by 3D Navigation

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Jixian Liu and Zichun Wei

12.1 Summary of Medical Record A 53-year-old female was found to have a nodule located in the right upper lobe (RUL) on CT scan 3 months ago without any physical sickness. She was treated with antibiotics for 2 weeks, with no significant change of the nodule on re-­ examination CT 3 months later. Chest CT (Figs. 12.1, 12.2, and 12.3) showed a 12  mm  ×  9  mm mixed ground glass opacity (mGGO) located in the middle of Right Upper Lobe (RUL).

Fig. 12.2  Chest CT (Coronal view) showing the nodule (Arrow) located in the middle of RUL The yellow circle: identifies a 2-cm margin

Fig. 12.1  Chest CT (Axial view) showing the nodule (Arrow) located in the middle of RUL The yellow circle: identifies a 2-cm margin

J. Liu (*) · Z. Wei Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China

Fig. 12.3  Chest CT (Sagittal view) showing the nodule (Arrow) located in the middle of RUL The yellow circle: identifies a 2-cm margin

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 J. Liu, D. Wu (eds.), Segmentectomy for Early-Stage Lung Cancer, https://doi.org/10.1007/978-981-99-0143-2_12

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12.1.1 Indications and Contraindications

12.2.1 Anatomical Features

(a) The lesion located deep in the RUL is less than 2 cm in diameter, which C/T (Consolidation/Tumor) ratio is less than 50%. (b) The nodule had no change 3 months later after being treated with antibiotics for 2 weeks, raising the possibility of early lung cancer. (c) With the planning of the preoperative 3D-CTBA reconstruction, the distance of incisional margin to the nodule is more than 2 cm after the procedure of RS1 + RS2 + RS3c segmentectomy. (d) The patient was in good physical condition, with no contraindications to the planned surgical procedure.

The right upper bronchus (RUB) (Fig. 12.5) is divided into a common trunk of B1 + B2 and a dominant B3, with B3 divided into B3a + B3b and B3c. Notice: B3c is B2bi here, and because it is the dominant segment, it is named B3c here. A1 and A2 (Fig. 12.6) is co-trunk artery emanating from the upper trunk of the right superior pulmonary artery, with-

12.2 Preoperative 3D-CTBA Reconstruction The marginal ball of this nodule (nodule and its 2 cm margin) shows the margin is located in RS1  +  RS2  +  RS3c (Fig. 12.4), so RS1 + RS2 + RS3c segmentectomy is required to satisfy the safe surgical margin.

Fig. 12.5  Bronchial branch of the RUL (Anterior view)

2 cm safe margin

Fig. 12.4  Relationship between the safe margin of nodule and the segmental interface of the RUL (Lateral view) Fig. 12.6  Relationship between arteries and bronchi of the RUL (Posterior view)

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out Asc.A2 emanating from the interlobar artery. A3 branches into A3a, A3b, and A3c. The right superior pulmonary Vein (RSPV) (Fig. 12.7) is divided into V1a + b that runs anteriorly to the hilar; central venous (V2a + V2b + V2c + V3a) that converges among S1 and S2, running below B3 to the RSPV. The operation needs to dissect co-trunk of A1 + A2, A3c, 1 V a + b, V2a + b, and co-trunk of B1 + B2, B3c (Fig. 12.8).

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12.3 Surgery Planning and Procedure According to CT and preoperative 3D reconstruction, RS1  +  RS2  +  RS3c segmentectomy is undergone. Dissect from the anterior hilar dorsally.

12.3.1 Surgical Planning V1a + b → A1 + 2 + A3c → B1 + B2 → V2a + b → B3c → RS1  + RS2 + RS3c.

12.3.2 Surgical Procedures

Fig. 12.7  Relationship between veins and bronchi of the RUL (Lateral posterior view)

Fig. 12.8  Relationship among arteries, veins, and bronchi of the RUL (Anterior view)

1. The patient in left lateral position and has double-lumen tracheal intubation. The procedure undergone with single port: The fourth intercostal space at the right axillary midline was a main operating port, through which the thoracoscope and other instruments passed. 2. Probe to locate the nodule within RS1 + RS2 + RS3c. 3. Pull the upper lung dorsally and incise the pleura in front of the hilum (Fig. 12.9). 10R lymph node (Fig. 12.10) is dissected for intraoperative frozen pathology. 4. Dissect V1a + b (Fig. 12.11), ligating and dividing it. 5. Dissect A1 + A2 + A3c together behind V1a + b stumps (Fig. 12.12), dividing them with the Stapler. 6. Pull the RUL ventrally and cephalad, after opening the interlobular fissure, dissect bluntly B1 + B2 (Fig. 12.13). Notice the distal branches of CV which is closely adjacent to the root of B1 + B2, dividing it with the Stapler. 7. Dissect V2a + b behind the B1 + B2 stumps (Fig. 12.14), paying attention to protect V2c which is in front of it. Dividing V2a + b with the Stapler.

Fig. 12.9  Dissecting the hilum

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Fig. 12.10  Dissecting No.10 lymph node

Fig. 12.13  Dissecting B1 + B2

Fig. 12.11  Dissecting V1a + b

Fig. 12.14  Dissecting V2a + b (Interlobar view)

9. Inflate lung with 100% pure oxygen having a pressure of 20–30  mmHg to fully inflate the RUL.  About 10  min later, a clear interface of inflation and deflation is seen, i.e., RS1  +  RS2  +  RS3c inflating and residual lungs deflating. 10. The lung is tailored along the interface of inflation and deflation (Fig. 12.16). 11. Show the stumps of the segmental surface postoperatively (Fig. 12.17). The postoperative pathology of this patient was microinvasive adenocarcinoma (MIA) with 10R lymph node negative. Fig. 12.12  Dissecting A1 + A2 + A3c

12.3.3 Key Points of the Surgical Procedure

8. The RUL is drawn dorsally, dissecting B3c (Fig.  12.15), dividing it with the Stapler. Protect B3a and B3b below B3c.

(a) It is necessary to dissect B1 + B2 bluntly because V2a + b is very closely adjacent to it.

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(b) Care should be taken to protect V2c when dissecting V2a  +  b, as V2c is an important anatomical marker of surgical boundaries.

12.4 Schematic Diagram of the Surgical Procedure Schematic diagram of the surgical procedure for RS1 + RS2 + RS3c segmentectomy (Figs. 12.18, 12.19, 12.20, 12.21, 12.22, 12.23, 12.24, 12.25, 12.26, 12.27, 12.28, 12.29, 12.30, 12.31, and 12.32).

Fig. 12.15  Dissecting B3c (Anterior view)

Fig. 12.16 Tailoring lung along the interface of inflating and deflating

Fig. 12.18  Figure of descending dimension of RS1 + RS2 + RS3c segmentectomy (The shadow is the range of excision: Red circles represent arteries; Green circles represent bronchi)

RUL

RML

Fig. 12.17  Stumps of segmental surface after RS1  +  RS2  +  RS3c segmentectomy

Fig. 12.19  Panoramic figure of the RUL (Anterior view)

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Fig. 12.23  Dividing A1 + A2 + A3c Fig. 12.20  Dissecting V1a + b RUL

RML

RLL

Fig. 12.21  Dividing V1a + b Fig. 12.24  Panoramic figure of the RUL (Interlobar view)

RUL

Fig. 12.22  Dissecting A1 + A2 + A3c

Fig. 12.25  Dissecting B1 + B2 from Interlobar fissure

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RUL

Fig. 12.26  Dividing B1 + B2

Fig. 12.29  Dissecting B3c anteriorly

Fig. 12.30  Dividing B3c

Fig. 12.27  Dissecting V2a + b

Fig. 12.31  Locating the nodes and delineating the resected area

Fig. 12.28  Dividing V2a + b

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Suggested Reading 1. Saji H, Okada M, Tsuboi M, et al. Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/ WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial. Lancet. 2022;399:1607–17. 2. Dell’Amore A, Lomangino I, Cannone G, et  al. Comparison of operative and postoperative characteristics and outcomes between thoracoscopic segmentectomy and lobectomy for non-small-cell lung cancer: a propensity score matching study from the Italian VATS Group Registry. Eur J Cardiothorac Surg. 2022;61:533–42.

Fig. 12.32 The labeled figure RS1 + RS2 + RS3c segmentectomy

of

segmental

stumps

after

LS6 Segmentectomy by 3D Navigation

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Jixian Liu and Feihu Long

13.1 Summary of Medical Records A 35-year-old female was found to have a nodule located in the left lower lobe (LLL) on CT scan 2 months ago without any physical sickness. She was treated with antibiotics for 2 weeks, with no significant change of the nodule on re-­ examination CT 2 months later. Chest CT (Figs. 13.1, 13.2, and 13.3) showed a 10  mm  ×  9  mm mixed ground glass opacity (mGGO) located in the middle of LS6.

Fig. 13.2  Chest CT (Coronal view) showing the nodule (Arrow) located in the middle of LS6. The yellow circle: identifies a 2-cm margin

Fig. 13.1  Chest CT (Axial view) showing the nodule (Arrow) located in the middle of LS6. The yellow circle: identifies a 2-cm margin

J. Liu (*) · F. Long Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China

Fig. 13.3  Chest CT (Sagittal view) showing the nodule (Arrow) located in the middle of LS6. The yellow circle: identifies a 2-cm margin

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 J. Liu, D. Wu (eds.), Segmentectomy for Early-Stage Lung Cancer, https://doi.org/10.1007/978-981-99-0143-2_13

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13.1.1 Indications and Contraindications (a) The lesion located deep in the LLL is less than 2 cm in diameter, which C/T (Consolidation/Tumor) ratio of less than 50%. (b) The nodule had no change 2 months later after being treated with antibiotics for 2 weeks, raising the possibility of early lung cancer. (c) With the plan of the preoperative 3D-CTBA reconstruction, the distance of incisional margin to the nodule is more than 2  cm after the procedure of LS6 segmentectomy. (d) The patient was in good physical condition, with no contraindications to the surgery procedure.

J. Liu and F. Long

A6 (Fig. 13.6) is divided from the interlobar artery that is divided into A6a, A6b, and A6c. The left inferior pulmonary vein (LIPV) (Fig.  13.7) divides into V6 and V7–10. V6 divides into V6a, V6b, and V6c, with V6a and V6b divided from a common trunk. The operation needs to dissect A6, B6, and V6a (Figs. 13.8 and 13.9).

13.2 Preoperative 3D-CTBA Reconstruction The marginal ball of this nodule (nodule and its 2 cm margin) shows the margin is located in LS6 (Fig. 13.4), and LS6 segmentectomy is required to satisfy the safe surgical margin.

13.2.1 Anatomical Features The left lower bronchus (LLB) (Fig.  13.5) divides into B6 and B7–10, with B6 dividing into B6a, B6b, and B6c. Fig. 13.5  Bronchial branch of the LLL (Posterior view)

Fig. 13.4  Relationship between the safe margin of nodule and the segmental interface of the LLL (Posterior view)

Fig. 13.6  Relationship between arteries and bronchi of LS6 (Posterior view)

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Fig. 13.9  Relationship among arteries, veins, and bronchi of the LS6 (Posterior view)

Fig. 13.7  Relationship between veins and bronchi of LS6 (Posterior view)

13.3 Surgery Planning and Procedure According to CT and preoperative 3D reconstruction, LS6 segmentectomy was performed. Dissect from the interlobar fissure caudally.

13.3.1 Surgical Planning A6 → B6 → V6a → LS6.

13.3.2 Surgical Procedures

Fig. 13.8  Relationship among arteries, veins, and bronchi of the LS6 (Posterior view)

1. The patient in right lateral position and double-lumen tracheal intubation. The procedure is performed with a single port: The fifth intercostal space of left axillary midine is main operating port through which thoracoscope and other instruments passed together. 2. Probe to locate the nodule within LS6. 3. Pull the LLL ventrally and incise the pleura behind the hilum, 10L lymph node (Fig. 13.10) is dissected for intraoperative frozen pathology. 4 . Dissect the interlobar fissure and cut the poorly formed part with the stapler (Fig. 13.11), 12L lymph node (Fig. 13.12) is dissected for intraoperatively fro-

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Fig. 13.10  Dissecting No.10 lymph node

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zen pathology. Dividing A 6 with the stapler (Fig. 13.13). 5. Dissect B6 from both the interlobar fissure and the posterior hilum (Fig. 13.14), dividing it with the stapler above V6. 6. Lift the B6 stump and dissect V6 behind it. Dissect V6 distal to V6a, and divide it. Take care to protect V6b and V6c (Fig. 13.15). 7. Inflate lung with 100% pure oxygen having a pressure of 20–30 mmHg to full inflation of the LLL. About 10 min later, a clear interface of inflation and deflation is seen, i.e., LS6 inflating and Residual lungs deflating (Fig. 13.16). 8. The lung is tailored along the interface of inflation and deflation. Show the nodule located in the center of LS6 (Fig. 13.17). 9. Show the stumps of segmental surface postoperatively (Fig. 13.18).

Fig. 13.11  Dividing the oblique fissure with the Stapler (LUL: left upper lobe; LLL: left lower lobe) Fig. 13.13  Dividing A6

Fig. 13.14  Dissecting B6 Fig. 13.12  Dissecting 12L lymph node

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Fig. 13.18  Stumps of segmental surface after LS6 segmentectomy

Fig. 13.15  Dissecting V6a

The postoperative pathology of this patient was microinvasive adenocarcinoma (MIA) with 10L, 12L lymph nodes negative.

13.3.3 Key Points of the Surgical Procedure

Fig. 13.16  Showing the interface of inflation and deflation

(a) Because the main operating area is in the posterior part of the oblique fissure, the incision is selected in the fifth intercostal of the axillary midline, and the straight view of the single port VATS (Video-Assisted Thoracoscopic Surgery) is in the operative area. (b) It is safer to expose V6 from the dorsal mediastinum first and then to dissect bluntly B6 from the front, which can avoid to damage V6. (c) V6b and V6c are intersegmental veins that need to be preserved. When dissecting V6a, care should be taken not to damage them.

13.4 Schematic Diagram of the Surgical Procedure Schematic diagram of the surgical procedure for LS6 segmentectomy (Figs. 13.19, 13.20, 13.21, 13.22, 13.23, 13.24, 13.25, 13.26, and 13.27).

Fig. 13.17  Showing the nodule located within LS6

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Fig. 13.21  Dissecting A6

LUL

Fig. 13.19  Figure of descending dimension of LS6 segmentectomy (The shadow is the range of excision: Red circles represent arteries; Green circles represent bronchi)

LLL

Fig. 13.22  Dividing A6

LLL LUL LLL

LUL

Fig. 13.20  Panoramic figure of the LLL (Interlobar view)

Fig. 13.23  Dissecting B6

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LUL LUL LLL Interlobar artery

LLL

Fig. 13.24  Dividing B6 Fig. 13.27 The labeled figure of segmental stumps after LS6 segmentectomy

LLL LUL

1. Nakamura K, Okada M, Asamura H, et al. A phase III randomized trial of lobectomy versus limited resection for small-sized peripheral non-small cell lung cancer (JCOG0802/WJOG4607L). Jpn J Clin Oncol. 2010;40(3):271–4. 2. Okada M, Tsutani Y, Ikeda T, et al. Radical hybrid video-assisted thoracic segmentectomy: long- term results of minimally invasive anatomical sublobar resection for treating lung cancer. Interact Cardiovasc Thorac Surg. 2012;14(1):5–11.

Fig. 13.25  Dissecting V6a

LLL LUL

Fig. 13.26  Dividing V6a

Suggested Reading

RS8a Segmentectomy by 3D Navigation

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Jixian Liu and Xinyu Luan

14.1 Summary of Medical Records

(b) The nodule observed for 4 months became a little larger, raising the possibility of early lung cancer. A 35-year-old female was found to have a nodule located in (c) With the planning of the preoperative 3D-CTBA reconthe right lower lobe (RLL) on CT scan 4 months ago without struction, the distance of incisional margin to the nodule any physical sickness. The nodule was a little larger on re-­ is more than 2  cm after the procedure of RS8a examination CT 4 months later. Chest CT (Figs. 14.1, 14.2, segmentectomy. and 14.3) showed a diameter of 18 mm mixed ground glass (d) The patient was in good physical condition, with no conopacity (mGGO) located in the RS8a. traindications to the surgery procedure.

14.1.1 Indications and Contraindications (a) The lesion located deep in the RLL is less than 2 cm in diameter, which C/T (Consolidation/Tumor) ratio is less than 50%.

Fig. 14.2  Chest CT (Coronal view) showing the nodule (Arrow) located in the middle of RS8a. The yellow circle: identifies a 2-cm margin

Fig. 14.1  Chest CT (Axial view) showing the nodule (Arrow) located in the middle of RS8a. The yellow circle: identifies a 2-cm margin

J. Liu (*) · X. Luan Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 J. Liu, D. Wu (eds.), Segmentectomy for Early-Stage Lung Cancer, https://doi.org/10.1007/978-981-99-0143-2_14

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Fig. 14.3  Chest CT (Sagittal view) showing the nodule (Arrow) located in the middle of RS8a. The yellow circle: identifies a 2-cm margin

J. Liu and X. Luan

Fig. 14.4  Relationship between the safe margin of nodule and the segmental interface of the RLL (Anterior view)

14.2 Preoperative 3D-CTBA Reconstruction The marginal ball of this nodule (nodule and its 2 cm margin) shows the margin is located in RS8a (Fig. 14.4), so RS8a segmentectomy is required to satisfy the safe surgical margin.

14.2.1 Anatomical Features The right lower bronchus (RLB) (Fig. 14.5) divides into B6 and B7–10, B8 divides into B8a and B8b. A8a (Fig. 14.6) emanates from A9, A8b from the interlobar artery. S8a segmentectomy does not need to dissect the vein. The operation needs to dissect A8a and B8a (Fig. 14.7).

Fig. 14.5  Bronchial branch of the RLL (Anterior view)

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14.3.1 Surgical Planning A8a → B8a → S8a.

14.3.2 Surgical Procedures

Fig. 14.6  Relationship between arteries and bronchi of RLL (Anterior view)

1. The patient is in left lateral position with double-lumen tracheal intubation. The procedure is performed with a single port: The fifth intercostal of right axillary midline is main operating port, through which the thoracoscope and retractive instruments pass through. 2. Probe to locate the nodule within RS8a. 3. The poorly differentiated oblique fissure is dissected (Fig. 14.8); dissect A6 and A9–10. 12R lymph node (Fig. 14.9) is dissected for intraoperative frozen pathology.

Fig. 14.8  Dissecting oblique fissure (RLL right lower lobe of lung, RML right middle lobe)

Fig. 14.7  Relationship among arteries, veins, and bronchi of the RS8a (Anterior view)

14.3 Surgery Planning and Procedure According to CT and preoperative 3D reconstruction, RS8a segmentectomy is performed. Dissect from interlobar fissure caudally.

Fig. 14.9  Dissecting 12R lymph node

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4. Following the 3D navigation, A8a which is on the surface of A9 is dissected and ligated with 3-0 silk thread and cut off with an Ultrasonic knife (Fig. 14.10). 5. Dissect B8a just behind A8a stump (Fig. 14.11), and divide it with a stapler. 6. Inflate lung with 100% pure oxygen having a pressure of 20–30  mmHg to the full inflation of the RLL.  About 10 min later, a clear interface of inflation and deflation is seen, i.e., RS8a inflating and residual lung deflating (Fig. 14.12). 7. The lung is tailored along the interface of inflation and deflation (Fig. 14.13). 8. Show the stumps of segmental surface postoperatively (Fig. 14.14). The postoperative pathology of this patient was microinvasive adenocarcinoma (MIA) with 12R lymph node negative.

J. Liu and X. Luan

Node

Fig. 14.12  Showing the interface of inflation and deflation

Node

Fig. 14.10  Dividing A8a

Fig. 14.13 Tailoring lung along the interface of inflation and deflation

Fig. 14.14  Stumps of segmental surface after RS8a segmentectomy

Fig. 14.11  Dissecting B8a bluntly

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14.3.3 Key Points of the Surgical Procedure RLL

RUL

(a) The procedure proceeded mainly inside the oblique fissure. If the interlobar fissure is poor differentiated, it will bring difficulty to the surgical procedure, so more care should be needed to dissect the fissure. (b) A8a which emanates from A9 needs to be identified after exposing A6 and A9 + 10.

Interlobar artery

14.4 Schematic Diagram of the Surgical Procedure Schematic diagram of the surgical procedure for RS8a segmentectomy (Figs. 14.15, 14.16, 14.17, 14.18, 14.19, 14.20, 14.21, and 14.22).

Fig. 14.16  Panoramic figure of the RLL (Interlobar view)

RLL

RUL

Interlobar artery

Fig. 14.17  Dissecting A8a

RLL

Interlobar artery

Fig. 14.18  Dividing A8a

Fig. 14.15  Figure of descending dimension of RS8a segmentectomy. (The shadow is the range of excision: Red circles represent arteries; Green circles represent bronchi)

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RLL RLL

RUL

RUL Interlobar artery

Fig. 14.22 The labeled figure of segmental stumps after RS8a segmentectomy Fig. 14.19  Dissecting B8a

Suggested Reading 1. Saji H, Okada M, Tsuboi M, et al. Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/ WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial. Lancet. 2022;399(10335):1607–17. 2. Suzuki K, Watanabe SI, Wakabayashi M, et al. A single-arm study of sublobar resection for ground-glass opacity dominant peripheral lung cancer. J Thorac Cardiovasc Surg. 2020;S0022–5223(20):33043–9. 3. Ito H, Suzuki K, Mizutani T, et al. Long-term survival outcome after lobectomy in patients with clinical T1 N0 lung cancer. J Thorac Cardiovasc Surg. 2020;S0022–5223(20):30054.

RLL

Fig. 14.20  Dividing B8a

RLL

RUL

Fig. 14.21  Locating the node and delineating the resected area

LS9 + LS10 Segmentectomy by 3D Navigation

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Jixian Liu and Xinyu Luan

15.1 Summary of Medical Records

15.1.1 Indications and Contraindications

A 42-year-old male was found to have a nodule located in the (a) The lesion located deep in the LLL is less than 2 cm in left lower lobe (LLL) on CT scan 2 months ago without any diameter, and C/T (Consolidation/Tumor) ratio is less physical sickness. He was treated with antibiotics for 2 than 50%. weeks, with no significant change of the nodule on re-­ (b) The nodule had no change 2 months later after being examination CT 2 months later. Chest CT (Figs. 15.1, 15.2, treated with antibiotics for 2 weeks, raising the possibiland 15.3) showed a 13  mm  ×  8  mm mixed ground glass ity of early lung cancer. opacity (mGGO) located in the middle of LS9 + LS10. (c) With the planning of the preoperative 3D-CTBA reconstruction, the distance of incisional margin to the nodule

Fig. 15.1  Chest CT (Axial view) showing the nodule (Arrow) located in the middle of LS9  +  LS10. The yellow circle: identifies a 2-cm margin

Fig. 15.2  Chest CT (Coronal view) showing the nodule (Arrow) located in the middle of LS9 + LS10. The yellow circle: identifies a 2-cm margin

J. Liu (*) · X. Luan Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China

© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 J. Liu, D. Wu (eds.), Segmentectomy for Early-Stage Lung Cancer, https://doi.org/10.1007/978-981-99-0143-2_15

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Fig. 15.3  Chest CT (Sagittal view) showing the nodule (Arrow) located in the middle of LS9 + LS10. The yellow circle: identifies a 2-cm margin

J. Liu and X. Luan

Fig. 15.4  Relationship between the safe margin of nodule and the segmental interface of the LLL (Posterior view)

is more than 2  cm after the procedure of LS9  +  LS10 segmentectomy. (d) The patient was in good physical condition, with no contraindications to the surgery procedure.

15.2 Preoperative 3D-CTBA Reconstruction The marginal ball of this nodule (nodule and its 2 cm margin) shows the margin is located in the middle of LS9 + LS10 (Figs. 15.4), so LS9 + LS10 segmentectomy is required to satisfy the safe surgical margin.

15.2.1 Anatomical Features

Fig. 15.5  Bronchial branches of the LLL (Lateral view)

The left lower bronchus (LLB) (Fig. 15.5) is divided into B6, B7 + 8, B9, and B10 with B9 and B10 emanating from the common trunk. A9 and A10 also emanate in the common trunk from interlobar artery (Fig. 15.6). The left inferior pulmonary vein (LIPV) is observed from the view of lower lobe ligament (Fig. 15.7): V10b + c which is the lowest branch of the LIPV is the intra-segmental vein of S10; V10a which is located on the cranial side of V10b + c and emanates from the surface of V8 + V9 is also an intra-­ segmental vein of S10 that needs to be divided. V9 which is the inter-segmental veins of S8 and S9 needs to be protected. V9b which is the inter-segmental vein between S9b and S10b needs to be divided. V9b can be exposed by pulling B9 stump upward after dividing it. The operation needs to dissect V10b + c, V10a, B9 + B10, Fig. 15.6  Relationship between arteries and bronchi of LLL (Lateral 9 view) A  + A10, and V9b.

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V9

A9

Inferior pulmonary ligament A10 B9 B10 V10a

V10b+

V8+9

Fig. 15.8  Dissecting inferior pulmonary ligament V6

Fig. 15.7  Relationship among arteries, veins, and bronchi of the LLL (Inferior view)

15.3 Surgery Planning and Procedure According to CT and preoperative 3D reconstruction, LS9  +  LS10 segmentectomy is performed. Dissect from the left inferior pulmonary vein cephalad.

15.3.1 Surgical Planning

Fig. 15.9  Dissecting 9L lymph node

V10b  +  c  →  V10a  →  B9  +  B10  →  A9  +  A10  →  V9b  →  LS9  + LS10

15.3.2 Surgical Procedures 1. The patient is in the right lateral position and has double-­ lumen tracheal intubation. The procedure is performed with two ports: The fifth intercostal of left axillary ­midline as main operating port and insertion of the thoracoscope; the seventh intercostal port in posterior axillary line for retractive instruments. 2. Probe to locate the nodule within LS9 + LS10. 3. Pull the left lower lobe cephalad and dissect the inferior pulmonary ligament (Fig.  15.8), the 9L lymph node is dissected (Fig.  15.9) for intraoperative frozen pathology. 4. Dissect the LIPV (Fig. 15.10) to the distal side to find the lowest branch, that is V10b + c (Fig. 15.11) which can be divided by the stapler. Along V8 + V9 to dissect the first branch that is V10a, ligating with 4-0 silk thread (Fig. 15.12) and dividing it with an ultrasound knife. 5. Dissect bluntly co-trunk of B9 + B10 (Fig. 15.13) between V8 + V9 and V6, dividing them with the stapler.

Fig. 15.10  Dissecting LIPV

6. Lift the B9 + B10 stumps and dissect co-trunk of A9 + A10 bluntly (Fig. 15.14) behind them, dividing them with the stapler. 7. Lift the A9 + A10 stump to dissect V9b (Fig. 15.15) which distributes between S9b and S10b, ligating it with silk thread and dividing it. 8. Inflate lung with 100% pure oxygen having a pressure of 20–30 mmHg to the full inflation of the LLL. About 10 min later, a clear interface of inflation and deflation is seen, i.e., LS9 + LS10 inflating and Residual lung deflating (Fig. 15.16).

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Fig. 15.11  Dissecting V10b + c

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Fig. 15.14  Dissecting co-trunk of A9 + A10 Bluntly

Fig. 15.15  Dissecting V9b

Fig. 15.12  Ligating V10a with silk thread

Fig. 15.16  Showing the interface of inflating and deflating

Fig. 15.13  Dissecting co-trunk of B9 + B10 Bluntly

9. The lung is tailored along the interface of inflation and deflation (Figs. 15.17 and 15.18). 10. Show the stumps of segmental surface postoperatively (Fig. 15.19).

The postoperative pathology was microinvasive adenocarcinoma (MIA) with 9L lymph node negative.

15.3.3 Key Points of the Surgical Procedure (a) When LS9 + LS10 segmentectomy is performed, the process from the lower pulmonary vein cephalad makes the

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operation simple, but this process requires the operator to adapt to the change of the surgical approach. First, dissect the inferior pulmonary vein, then the inferior lobar bronchus, and finally the inferior pulmonary artery. (b) V9 is an important surgical margin, and operating between V9 and V6 will not injure the structure of S8.

15.4 Schematic Diagram of the Surgical Procedure Fig. 15.17  Tailoring lung along the interface of inflation and deflation (From caudal to cephalad)

Schematic diagram of the surgical procedure for LS9 + LS10 segmentectomy (Figs.  15.20, 15.21, 15.22, 15.23, 15.24, 15.25, 15.26, 15.27, 15.28, 15.29, 15.30, 15.31, 15.32, and 15.33).

Fig. 15.18  Tailoring lung along the interface of inflation and deflation (From ventral to dorsal)

Fig. 15.19 Stumps of segmental surface after LS9  +  LS10 segmentectomy

Fig. 15.20  Figure of descending dimension of LS9 + LS10 segmentectomy (The shadow is the range of excision: Red circles represent arteries; Green circles represent bronchi)

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LUL

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LLL

LUL

LLL

Fig. 15.21  Panoramic figure of the LLL (Inferior view) Fig. 15.24  Dissecting V10a LUL

LLL LUL

LLL

Fig. 15.25  Dividing V10a Fig. 15.22  Dissecting V10b + c LUL LUL

LLL

Fig. 15.23  Dividing V10b + c Fig. 15.26  Dissecting B9 + B10

LLL

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LUL

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LLL

LUL

LLL

Fig. 15.27  Dividing B9 + B10 Fig. 15.30  Dissecting V9b

LUL

LLL

LUL

LLL

Fig. 15.31  Dividing V9b Fig. 15.28  Dissecting co-trunk of A9 + A10

LUL

Fig. 15.29  Dividing A9 + A10

LLL

LUL

LLL

Fig. 15.32  Locating the node and delineating the resected area

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Suggested Reading LUL

LLL

Fig. 15.33  The labeled figure of segmental stumps after LS9  +  LS10 segmentectomy

1. Suzuki K, Watanabe SI, Wakabayashi M, et al. A single-arm study of sublobar resection for ground-glass opacity dominant peripheral lung cancer. J Thorac Cardiovasc Surg. 2020;S0022–5223(20):33043–9. 2. Ito H, Suzuki K, Mizutani T, et al. Long-term survival outcome after lobectomy in patients with clinical T1 N0 lung cancer. J Thorac Cardiovasc Surg. 2020;S0022–5223(20):30054.

LS10b + c Segmentectomy by 3D Navigation

16

Jixian Liu and Dan Ma

16.1 Summary of Medical Records

16.1.1 Indications and Contraindications

A 60-year-old female was found to have a nodule located in (a) The lesion located deep in the LLL is less than 2 cm in the left lower lobe (LLL) on CT scan 2 months ago without diameter, with C/T (Consolidation/Tumor) ratio less any physical sickness. She was treated with antibiotics for 2 than 50%. weeks, with no significant change of the nodule on re-­ (b) The nodule had no change 2 months after being treated examination CT 2 months later. Chest CT (Figs. 16.1, 16.2, with antibiotics for 2 weeks, raising the possibility of and 16.3) showed a 12.6 mm × 9.6 mm mixed ground glass early lung cancer. opacity (mGGO) located in the middle of LS10b + c. (c) With the planning of the preoperative 3D-CTBA reconstruction, the distance of incisional margin to the nodule is more than 2  cm after the procedure of LS10b  +  c segmentectomy.

Fig. 16.1  Chest CT (Axial view) showing the nodule (Arrow) located in the middle of LS10b + c. The yellow circle: identifies a 2-cm margin

Fig. 16.2  Chest CT (Coronal view) showing the nodule (Arrow) located in the middle of LS10b + c. The yellow circle: identifies a 2-cm margin

J. Liu (*) Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China D. Ma Johnson & Johnson Medical Shanghai Ltd., Shanghai, China © The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023 J. Liu, D. Wu (eds.), Segmentectomy for Early-Stage Lung Cancer, https://doi.org/10.1007/978-981-99-0143-2_16

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LS10

Fig. 16.3  Chest CT (Sagittal view) showing the nodule (Arrow) located in the middle of LS10b + c. The yellow circle: identifies a 2-cm margin

b+c

Fig. 16.4  Relationship between the safe margin of nodule and the segmental interface of the LLL (Lateral view)

(d) The patient was in good physical condition, with no contraindications to the surgery procedure.

16.2 Preoperative 3D-CTBA Reconstruction The marginal ball of this nodule (nodule and its 2 cm margin) is completely located in the LS10b  +  c (Fig.  16.4), so LS10b + c segmentectomy is required to satisfy the safe surgical margin.

16.2.1 Anatomical Features Left lower lobar bronchus (Fig. 16.5) divides into B6, B7 + 8, B9 and B10, with B10 dividing into proximal B10a and distal B10b + c. Left inferior pulmonary artery: A6 is the uppermost branch of the interlobar artery; A7 + 8 is the most anterior branch of

Fig. 16.5  Bronchial branch of the LLL (Posterior view)

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Fig. 16.8  Relationship among arteries, veins, and bronchi of the LLL (Inferior view)

Fig. 16.6  Relationship between arteries and bronchi of LLL (Lateral view)

16.3 Surgery Planning and Procedure According to CT and preoperative 3D reconstruction, LS10b  +  c segmentectomy is performed. Dissect from left inferior pulmonary vein cephalad.

16.3.1 Surgical Planning V10b + c → B10b + c → A10b + c → LS10b + c.

16.3.2 Surgical Procedures

Fig. 16.7  Relationship between veins and bronchi of LLL (Inferior view)

the interlobar artery. A9 + A10b (Fig. 16.6) is divided in the common trunk from the interlobar artery and A10a and A10c divided in the common trunk from the interlobar artery. From the view of inferior pulmonary ligament cephalad, left inferior pulmonary vein (LIPV) (Fig.  16.7) is divided into V7 + 8, V9 + V10a in co-trunk, V10b + c, and V6. The operation needs to dissect V10b  +  c, B10b  +  c, and 10 A b + c (Fig. 16.8).

1. The patient is in the right lateral position and has double-­ lumen tracheal intubation. The procedure is performed with two ports: The fifth intercostal space of left axillary midline as main operating port and where the thoracoscope enters, and the seventh intercostal port in posterior axillary line for retractive instruments. 2. Probe to locate the nodule within LS10b + c. 3. Pull the left lower lobe cephalad and dissect the inferior pulmonary ligament (Fig. 16.9), the 9L lymph node is dissected (Fig. 16.10) for the intraoperative frozen pathology. 4. Dissect the LIPV (Fig. 16.11) to the distal side to find the lowest branch V10b + c. On its surface, there are usually several small branches, ligating and dividing them (Fig. 16.12). 5. Dissect V10b  +  c (Fig.  16.13), identify V9 which is in front of it and V10a which is above it. Dividing V10b + c with the stapler.

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Left inferior pulmonary vein

Fig. 16.9  Dissecting inferior pulmonary ligament

Fig. 16.10  Dissecting station 9L lymph node

Fig. 16.12  Dividing small branches on V10b + c

Fig. 16.13  Dissecting V10b + c

Left inferior pulmonary vein

Fig. 16.11  Dissecting the left inferior pulmonary vein Fig. 16.14  Dissecting B10b + c bluntly

6. Dissect B10b + c (Fig. 16.14) beside the V10a and divide it with the stapler. 7. Draw the B10b  +  c cephalad to show A10b and A10c (Fig.  16.15) which is located beside the V10a, cutting them off together with the stapler (Fig. 16.16). 8. Inflate lung with 100% pure oxygen having a pressure of 20–30  mmHg to the full inflation of the LLL.  About 10 min later, a clear interface of inflation and deflation is seen, i.e., LS10b + c inflating and Residual lungs deflating.

9. The lung is tailored along the interface of inflating and deflating (Fig. 16.17). 10. Show the stumps of segmental surface postoperatively (Fig. 16.18). The postoperative pathology of this patient was microinvasive adenocarcinoma (MIA) with 9L lymph node negative.

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Fig. 16.15  Dissecting A10b + c Fig. 16.18 Stumps of segmental surface after LS10b  +  c segmentectomy

16.3.3 Key Points of the Surgical Procedure

Fig. 16.16  Dividing A10b + c with the stapler

(a) There are many small branches on the inferior surface of LIPV which should be carefully dissected to avoid bleeding. (b) LS10b  +  c segmentectomy is a combined sub-­ segmentectomy that is relatively simple to proceed from the inferior pulmonary ligament cephalad. From the 3D reconstruction image, the key point of the operation is the full dissection of the basal segment vein of LIPV to the distal to expose V10a. V10a is an important boundary marker between LS10a and LS10b + c and dissecting vessels below V10a can avoid damaging the vessels of other segments.

16.4 Schematic Diagram of the Surgical Procedure Schematic diagram of the surgical procedure for LS10b + c segmentectomy (Figs.  16.19, 16.20, 16.21, 16.22, 16.23, 16.24, 16.25, 16.26, 16.27, 16.28, 16.29, and 16.30). Fig. 16.17 Tailoring lung along the interface of inflating and deflating

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Fig. 16.19  Figure of descending dimension of LS10b + c segmentectomy (The shadow is the range of excision: Red circles represent arteries; Green circles represent bronchi)

LLL

Small branches Small branches

Fig. 16.20  Panoramic figure of the LLL (Inferior view) Fig. 16.21  Dissecting V10b + c small branches

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Small branches

Fig. 16.22  Dividing V10b + c small branches Fig. 16.25  Dissecting B10b + c

Fig. 16.23  Dissecting V10b + c

Fig. 16.26  Dividing B10b + c

Fig. 16.24  Dividing V10b + c Fig. 16.27  Dissecting A10b + c

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Fig. 16.28  Dividing A10b + c Fig. 16.30  The labeled figure of segmental stumps after LS10b  +  c segmentectomy

Suggested Reading 1. Winckelmans T, Decaluwé H, De Leyn P, Van Raemdonck D. Segmentectomy or lobectomy for early-stage non-small-cell lung cancer: a systematic review and meta-analysis. Eur J Cardiothorac Surg. 2020;57(6):1051–60. 2. Chen L, Fang W. [A review on comparison of lobectomy and segmentectomy in the treatment of early stage non-small cell lung cancer]. Zhongguo Fei Ai Za Zhi. 2019;22(8):526–31. Fig. 16.29  Locating the node and delineating the resected area