Thoracoscopic Pulmonary Sub-Subsegmentectomy Based on Three-Dimensional Images

Unveiling the synergetic benefits of the tunneling technique using stapler tractor in precise resection of lung segments: a retrospective cohort study

Background

Tunneling technique has shown preliminary promise in lung segmentectomy which requires the use of staplers in specific procedures. However, the obstacle when staples pass is the most obvious factor hindering the implementation and development of this technique. This study investigated whether the obstacle of the technology could be addressed by using an innovative self-designed stapler tractor and analyzed the combined and respective advantages of them.

Methods

The clinical data of patients with lung nodules located near anatomical sites with potential tunnel creation treated by segmentectomy were analyzed in this retrospective case-control study. The data were divided into four groups according to four distinct surgical strategies: In Group A, the tunneling technique was performed with a stapler tractor; in Group B, the tunneling technique was performed without a stapler tractor; in Group C, didn't perform the tunneling technique but using stapler tractor in a normal approach; and in Group D, neither performed the technique nor used the stapler tractor. The general linear data, operation times, intraoperative adverse events, postoperative recovery and complications were compared.

Results

Compared with other groups, Group A exhibited the best surgical outcomes in comprehensive aspects. Separately, the tunnel groups (Group A&B) had better outcomes in the macro implementation of operation, including resection margin, the number of sampled intrapulmonary lymph nodes and resected subsegments, while the staple tractor groups (Group A&C) performed better on details of the procedure, including operation time, conversion to thoracotomy, and intraoperative bleeding (p < 0.05). Both of them were beneficial for shorter hospital stay, and the tunnel group was more advantageous.

Conclusion

The tunneling technique is an advanced and beneficial surgical strategy for performing precise resection of lung segments while a stapler tractor can promote and facilitate it as a supplementary instrument. They show more combined benefits in effectively minimizing the occurrence of erroneous injuries and enhancing the operational efficacy.

Identification of anatomical types of segmental bronchi in left superior and lingular lobes using multi-slice CT

PURPOSE

The objectives of this study were to evaluate various branching patterns of segmental bronchi in the left superior and lingular lobes and to survey the anatomical diversity and sex-related differences of these branches in a large sample of the study population.

MATERIALS AND METHODS

Overall, 10,000 participants (5428 males, and 4572 females, mean age 50 ± 13.5 years [SD] years; age range: 3-91 years) who underwent multi-slice CT (MSCT) scans between September 2019 and December 2021 were retrospectively included. Using the syngo.via post-processing workstation, the data were applied to generate three-dimensional (3D) and virtual bronchoscopy (VB) simulations of a bronchial tree. The reconstructed images were then interpreted to identify and categorize distinct bronchial patterns in the left superior and lingular lobes. Cross-tabulation analysis and the Pearson Chi-square (χ2) test were used to calculate the constituent ratios of bronchial branch types and determine their significance between male and female groups.

RESULTS

Our results revealed mainly four distinct types for the left superior lobe (LSL) bronchial tree, i.e., (B1 + 2, B3, 76.13%); (B1 + 2 + 3, 17.32%); (B1 + 3, B2, 5.74%); (B1a + B3, B1b + B2, 0.81%) and two types for the left lingular lobe (LLL) bronchial tree, i.e., (B4, B5, 91.05%); (B4, B5, B*, 8.95%). There were no significant sex-related differences in the proportion of bronchial branches in LLL (P > 0.05). However, sex-related differences were significant in the proportion of bronchial branches in LSL (P < 0.05).

CONCLUSION

The current study has validated the presence of segmental bronchial variations in the left superior and lingular lobes. These findings may have a crucial effect on the diagnosis of symptomatic patients, as well as in carrying out procedures such as lung resections, endotracheal intubation, and bronchoscopies.

Identification of anatomical types of segmental bronchi in right middle lobe using multi-slice CT

PURPOSE

The objectives of this study were to evaluate the various branching patterns of segmental bronchi in the right middle lobe (RML) and to survey the anatomical diversity and sex-related differences of these branches in a large sample of the study population.

MATERIALS AND METHODS

In this retrospective board-approved study with informed consent, 10,000 participants (5428 males and 4,572 females, mean age 50 ± 13.5 years [SD]; age range: 3-91 years) who underwent multi-slice CT (MSCT) scans from September 2019 to December 2021 were retrospectively included. The data were applied to generate three-dimensional (3D) and virtual bronchoscopy (VB) simulations of a bronchial tree using the syngo.via post-processing workstation. The reconstructed images were then interpreted to locate and classify distinct bronchial patterns in the RML. Cross-tabulation analysis and the Pearson chi-square test were used to calculate the constituent ratios of bronchial branch types and determine their significance between male and female groups.

RESULTS

Our results revealed that the segmental bronchial ramifications of the RML were classified into two types mainly, i.e., bifurcation (B4, B5, 91.42%) and trifurcation (B4, B5, B*, 8.58%). There were no significant sex-related differences in the proportion of bronchial branches in the RML (P > 0.05).

CONCLUSION

The current study has confirmed the presence of segmental bronchial variations in the RML lobe using 3D reconstruction and virtual bronchoscopy. These findings may have significant implications for the diagnosis of symptomatic patients and for carrying out specific procedures like bronchoscopy, endotracheal intubation, and lung resection.

Prevalence and anatomical characteristics of subsuperior segment in lung lower lobe

OBJECTIVE

The subsuperior segment is an atypical pulmonary segment of the lung lower lobe. With the increased application of segmentectomy, it has received increased attention from thoracic surgeons. Studies of the subsuperior segment are scarce and mostly on the basis of small-sample autopsy studies, whose described characteristics are inconsistent with intraoperative observations. Our objective was to accurately define the subsuperior segment and elucidate its prevalence and anatomical characteristics in detail.

METHODS

A total of 2194 chest computed tomography images were obtained using separate random sampling on the basis of the amount of data available to each of the 6 thoracic surgery institutions in different provinces covering various regions of China. All of the images were reconstructed in 3 dimensions. Subsuperior segments were screened according to their new definition and statistically analyzed for their prevalence and anatomical characteristics.

RESULTS

The prevalence of subsuperior segments was 32.04%, with 413 on the right (18.79%); the value was higher than that on the left (347; 15.81%). The average volume of the subsuperior segment was 52.81 ± 21.96 cm3. Only 1 bronchus was detected in the unilateral subsuperior segment, with an average diameter of 2.53 ± 0.61 mm. Only 1 pulmonary artery was observed in most of the subsuperior segments (89.34%), but 81 cases (10.66%) had 2 in our study. One intersegmental vein of the subsuperior segment was the most common situation on both sides.

CONCLUSIONS

Using a multicenter large-sample study, we calculated a 32.04% prevalence and systematically detailed the anatomical characteristics of the subsuperior segment in the lung lower lobe, corrected previous reports, and supplemented pulmonary anatomical studies.

The intersegmental pulmonary vein is not always located on the intersegmental plane of the lung: Evaluation with 3-dimensional volume-rendering image reconstruction

Objective

To clarify whether intersegmental pulmonary veins are always located on the intersegmental plane and determine the division from which blood flows into them.

Methods

We analyzed representative intersegmental veins located between the upper/lingular and superior/basal division of the lungs using preoperative chest computed tomography (CT) DICOM data from 22 patients who underwent lobectomy or segmentectomy during 2020. The location and blood flow of V³a+b and V⁶b+c were assessed using REVORAS (Ziosoft), a novel volume-rendering 3-dimensional (3D) image reconstruction software dedicated to lung segmentectomy.

Results

The V³a+b was in the upper division and on the intersegmental plane between the upper and lingular divisions of the left lung in 11 patients (50%) each. A main root of V³a+b was not found in the lingular division, but some peripheral flow in the V³a+b was derived from it in 14 patients (64%). The V⁶b+c was found in the superior division of the right lower lobe in 13 patients (59%) and the left lower lobe in 10 patients (45%), and on the intersegmental plane between the superior and basal division of the right lower lobe in 6 patients (27%) and the left lower lobe in 10 patients (45%). A main root of V⁶b+c was imperceptible in the basal division. Some peripheral blood flow was derived from the basal division in 6 patients (27%) with V⁶b+c veins located in the right lower lobe and in 8 patients (36%) with V⁶b+c veins located in the left lower lobe.

Conclusions

Precise evaluation of intersegmental veins using preoperative volume-rendering 3D reconstructed CT images provides useful anatomic information for separating intersegmental pulmonary parenchyma.

Computed Tomography-Guided Localization and Extended Segmentectomy for Non-Small Cell Lung Cancer

Background: Lung cancer is one of the most devastating cancers. Low-dose computed tomography (LDCT) can detect lung cancer at an early stage of the disease when a minimally invasive surgical procedure using video-assisted thoracoscopic surgery is the best strategy. Herein, we discuss the treatment of deep lung tumors between segments or lesions located near the margin of a segment. Patients and Methods: This was a retrospective study conducted from January 2013 to January 2020 using the National Taiwan University Hospital data bank. We included early-stage non-small cell lung cancer (NSCLC) patients who underwent lung surgery and screened out those who received CT-guided localization for extended segmentectomy. Outcome measurements were safety margin, complication rate, and postoperative course. Results: During the study period, 68 patients with early-stage NSCLC received CT-guided localization followed by extended segmentectomy. The mean surgery time was 92.1 ± 30.3 min, and the mean blood loss was 32.8 mL. Mean drainage time was 2.3 ± 1 days, and the total hospital stay was 4.9 ± 1.1 days. Pathological reports showed tumor-free resection margins >2 cm. Sixty-one patients had adenocarcinoma at stage IA and two patients at stage IB. One patient had squamous cell carcinoma at stage IA. Conclusion: CT-guided localization followed by extended segmentectomy allows lung volume preservation with clean safety margins and good clinical outcomes.

Technical aspects and early results of uniportal video-assisted thoracoscopic complex segmentectomy: a 30 case-series study

Background

With the advantages of better cosmetic incision and faster recovery, uniportal video-assisted thoracoscopic surgery (UP-VATS) has developed rapidly worldwide in recent decades, and indications for UP-VATS have been further expanded to those for conventional VATS. Complex segmentectomy that makes several or intricate intersegmental planes, with more complex procedures, continues to be difficult in minimally invasive techniques. However, there are few reports on UP-VATS complex segmentectomy. In this report, we describe the perioperative clinical data and operative techniques and present our early results of UP-VATS complex segmentectomy in our hospital.

Methods

The records of a total of 30 patients who underwent UP-VATS complex segmentectomy by a single surgeon between January 2021 and June 2021 were retrospectively reviewed. We defined cases as complex segmentectomy if they required resection of segments 9 and 10, combined segmentectomy, segmentectomy + subsegmentectomy, subsegmentectomy, or combined subsegmentectomy.

Results

The mean age was 52.8 ± 9.9 years old; the mean nodule size was 0.84 ± 0.36 cm; the mean margin width was 2.307 ± 0.309 cm; the median operative time was 229.0 ± 58.06 min; the mean operative hemorrhage was 56.60 ± 17.95 mL; 5.58 ± 1.74 lymph nodes dissected had not metastasized; the mean duration of postoperative chest tube drainage was 4.7 ± 1.4 days; and the mean postoperative hospital stay was 6.5 ± 3.0 days. Although 1 patient experienced a prolonged air leak, the other 29 recovered uneventfully. Another patient failed to reach the 2-cm safe margins and subsequently underwent completion lobectomy.

Conclusions

UP-VATS complex segmentectomy is a safe and effective procedure in the treatment of lung cancers, sparing more pulmonary parenchyma and ensuring safe margins, with the disadvantage being the lengthy operative times during early skill acquisition.

Pulmonary vessels and bronchus anatomy of the left upper lobe

PURPOSES

The bronchopulmonary vascular bifurcation patterns in the upper lobe of the left lung are diverse. Therefore, it is important for general thoracic surgeons to understand the detailed anatomy of the pulmonary segments when performing thoracoscopic anatomical pulmonary resection. This study aimed to analyze the bronchovascular patterns of the left upper lobe and summarize the anatomical information associated with pulmonary anatomical pulmonary resection.

METHODS

We reviewed the anatomical patterns of pulmonary vessels and the left lung bronchus of 539 patients using computed tomography imaging data including those obtained using three-dimensional computed tomography. We herein report the anatomic structure in the left upper lobe.

RESULTS

Regarding the superior division bronchi, a pattern of trifurcation into B¹⁺², B³, lingular division bronchus was observed in nine patients (1.7%). A pattern of proximal bifurcation of B⁴ was found in eight patients (1.5%). Regarding the lingular veins (LV), patterns of LV drainage into the left lower pulmonary vein were observed in 22 patients (4.1%). Regarding the pulmonary artery, mediastinal lingular arteries (MLA) were found in 161 patients (29.9%).

CONCLUSION

The bifurcation patterns of the bronchovascular region in the upper lobe of the left lung were clarified. These results should be carefully noted when performing anatomical pulmonary resection.

Intersegmental plane simulation based on the bronchus-vein-artery triad in pulmonary segmentectomy

Background

Few reliable methods to simulate and evaluate the intersegmental plane have been reported. We introduce intersegmental plane simulation based on the bronchus-vein-artery triad in three-dimensionally reconstructed images from patients who underwent segmentectomy for early lung cancer.

Methods

We collected clinical data of consecutive patients with early-stage lung cancer who underwent three-dimensional imaging-guided single-port thoracoscopic segmentectomy at Department No. 1 of Thoracic Surgery at Fujian Medical University Fujian Union Hospital from January 2019 to July 2019. Patients were divided into two groups according to the application of intersegmental plane simulation and nodule analysis: the intersegmental plane group and the non-intersegmental plane group. General clinical characteristics, operation status, and postoperative recovery were compared between groups. The three-dimensional reconstruction results in the intersegmental plane group were analyzed and summarized.

Results

A total of 120 patients were included (61 in the intersegmental plane group and 59 in the non-intersegmental plane group). There were no significant differences between the two groups in general characteristics (all P>0.05). All target lesions were resected in both groups. There were no significant differences between groups in operation characteristics or postoperative recovery, with the exception of the duration of chest drainage and the rate of gross margin insufficiency. There were five cases of gross margin insufficiency in the non-intersegmental plane group. With three-dimensional imaging reconstruction, a total of 131 intersegmental veins could be used to evaluate the simulated intersegmental plane in 61 patients, with an average of 2.1±0.5 veins per patient. Two patients (3.3%) had one vein that could be used to evaluate the intersegmental plane, 50 patients (82.3%) had two, seven patients (11.3%) had three, and two patients (3.3%) had four. The total number of intersegmental veins located on the simulated intersegmental plane was 124 (94.7%), with an average of 2.0±0.6 veins per patient. The accuracy of intersegmental plane simulation was 91.8% (56/61).

Conclusions

The bronchus-vein-artery triad in intersegmental plane simulation can assist surgeons in preoperative planning and can facilitate complete resection of early lung cancer with sufficient surgical margins.

Anatomy of the left subsuperior segment for segmentectomy

PURPOSE

The subsuperior segmental bronchi (B*) forms the subsuperior segment (S*) between the superior (S⁶) and basal segment (S⁷, S⁸, S⁹, S¹⁰) of the lung. However, the anatomical planes of S* remains undefined. The present study clarified the anatomical features of S*.

METHODS

We reviewed the anatomical patterns of pulmonary vessels and the left lung bronchus in 539 patients using three-dimensional computed tomography. We report the anatomic structure in S*.

RESULTS

A total of 537 patients were analyzed. B* was observed in 129 (24.0%) patients. The intersegmental vein between S⁶ and S* was complete in all cases. The absence of intersegmental veins of S* was observed in 77 (14.3%) patients, reaching 59.7% of B* cases. Twenty-two (4.1%) cases of B* diverged from the trunk of the basal bronchus, and about half of the B* branched to the dorsolateral (n = 77, 14.3%) or dorsal (n = 2, 0.37%) direction.

CONCLUSION

Our study revealed the branching patterns of B* and anatomical intersegmental veins of S*. Our results provide useful information regarding anatomical segmentectomy including or adjusting to the left S*.

A modified system for classifying the bilateral superior pulmonary veins using three-dimensional computed tomography bronchography and angiography images

Background

Identifying the distribution of pulmonary veins with three-dimensional reconstruction images is of great significance for surgical guidance. Existing models neglect the consistency of the bilateral superior pulmonary veins (SPVs) and lack a simple unified classification pattern. This study aimed to analyze the distributional features of bilateral SPVs, based on a cohort of patients undergoing CT examination.

Methods

The three-dimensional computed tomography bronchography and angiography (3D-CTBA) images of 1,520 cases were retrospectively analyzed. The reconstructed images of the right upper lobes were read in 715 cases, and left upper lobes in 805 cases. Through symmetrical analysis, the circulation of main venous branches and the spatial relationships of confluences with adjacent bronchus were compared.

Results

The SPVs of bilateral upper lobes showed common distributional features and were divided into three main types. The central vein type, the semi-central vein type, and the non-central vein type accounted for 83.35% [596], 7.84% [56], 8.11% [58] of the 715 cases with right scanning, and 25.71% [207], 62.61% [504], 10.81% [87] of the 805 cases with left scanning, respectively. There were 5 (0.70%) cases with rare variations in the right upper lobe and 7 (0.87%) in the left upper lobe. The attribution of intersubsegmental vein in the posterior segment (V²b) and its position relative to the anterior segmental bronchus (B³) was the basis of classification in the right upper lobe, and the attribution of intersubsegmental vein in the apicoposterior segment (V¹⁺²c) and its position relative to B³ was the basis of classification in the left upper lobe. In this classification system, the branching pattern of the intersegmental vein between the apical segment and the anterior segment (V¹b) in the right upper lobe, and the intersegmental vein between the apicoposterior segment and the anterior segment (V^{1+ 2}a) in the left upper lobe were used for subdivision.

Conclusions

Our modified system had a high degree of consistency in classifying SPVs in bilateral upper lobes, thus providing guidance for preoperative and intraoperative procedures.

Analysis of bronchial and vascular patterns in left upper lobes to explore the genesis of mediastinal lingular artery and its influence on pulmonary anatomical variation

BACKGROUND

For thoracic surgeons, three-dimensional computed tomography bronchography and angiography (3-DCTBA) is a convenient way to analyze pulmonary variations before segmentectomy. Mediastinal lingular artery (MLA) is one of the representative variations.

METHODS

The 3-DCTBA data of left upper lobe (LUL) were collected from patients who underwent pulmonary surgery from January 2018 to December 2019. We reviewed the patterns of bronchi and pulmonary vessels and grouped them according to different classifications.

RESULTS

Among all the 404 cases of 3-DCTBA, mediastinal lingular artery (MLA) was found in 107 cases (26.49%). The patterns of B³ and the vein in left upper division (LUD) are distinct between mediastinal (M-type) group and interlobar (IL-type) group. The patterns of bronchi and veins in lingular division, as well as the pattern of pulmonary artery in LUD, have no differences between M-type and IL-type groups.

CONCLUSIONS

Mediastinal lingular artery is speculated to originate from the variation of B³, and the MLA independently influences the venous pattern in LUD in turn.

Preoperative non-invasive visual localization of synchronous multiple lung cancers using three-dimensional computed tomography lung reconstruction

BACKGROUND

Synchronous multiple primary lung cancers are becoming more common with increasing use of computed tomography for screening. Intraoperative localization and resection of ill-defined pulmonary ground-glass opacities during thoracoscopic resection is challenging. This study aimed to determine the clinical feasibility of non-invasive visual localization of these nodules by three-dimensional computed tomography lung reconstruction before sublobar resection.

METHODS

Forty-four patients with synchronous multiple primary lung cancers underwent thoracoscopic pulmonary resection at our institution between June 2017 and August 2019. Preadmission computed tomography images were downloaded and reconstructed into a three-dimensional model. Small nodules (< 15 mm) were localized non-invasively by three-dimensional computed tomography lung reconstruction before surgery. Patient demographics, nodule characteristics, procedural details, pathological data, and outcomes were obtained from the medical records.

RESULTS

One hundred and twenty-one pulmonary nodules from the 44 patients were scheduled for video-assisted thoracic surgery; 54 (44.6%) were pure ground-glass opacities and 57 (47.1%) were mixed ground-glass opacities. One hundred and seventeen nodules were localized preoperatively. The mean nodule diameter was 7.67 ± 3.87 mm. The mean distance from the nodule to the pleura was 14.84 ± 14.43 mm. All nodules were removed successfully by wedge resection (27 patients), lobectomy (26 patients), or segmentectomy (25 patients). Most lesions (85.1%) were malignant. Paraffin pathology revealed 12 cases of atypical adenomatous hyperplasia (9.92%), 13 of adenocarcinoma in situ (10.74%), 16 of minimally invasive adenocarcinoma (13.22%), and 73 of invasive adenocarcinoma (60.33%).

CONCLUSIONS

Three-dimensional computed tomography lung reconstruction is a feasible and alternative method of visual localization for small lung nodules before sublobar resection in some suitable patients.

Benefit of three-dimensional image simulation in surgical resection of early stage lung cancer

BACKGROUND

The present study investigated the oncological outcomes of clinical stage IA2 non-small cell lung cancer that was treated using preoperative simulation and surgical resection.

METHODS

The data of patients who underwent surgical resection for clinical stage IA2 non-small cell lung cancer between January 2002 and June 2018 were reviewed. Preoperative simulations were indicated for patients with centrally located tumors who can undergo anatomic resection. The clinical features, imaging characteristics of the tumors, surgical approaches and outcomes were analyzed.

RESULTS

Of the 1086 identified patients, 281 patients with clinical stage IA2 non-small cell lung were enrolled and categorized into 2 groups, with and without preoperative simulation. The tumor location, maximum standard uptake value, histological grade, disease-free survival and disease recurrence were significantly different between the 2 groups. For the group with preoperative simulations, 70.7% of the patients underwent anatomic resection, and 79.7% of the patients without preoperative simulations underwent anatomic resection (P <0.001). Patients with preoperative simulations had fewer relapses (2%) than patients without preoperative simulations (11.5%, P < 0.01).

CONCLUSIONS

Preoperative simulation confirmed the relationship between the tumor and surrounding blood vessels and bronchus and ensured an oncological safety margin. 3D simulations are a useful and feasible tool for planar operative procedures, satisfy the requirements for early-stage NSCLC. These results are promising but preliminary and more extended follow-up is needed.

VATS right posterior segmentectomy with anomalous bronchi and pulmonary vessels: a case report and literature review

Background

Anatomic variation may increase the difficulty and risk of anatomic segmentectomy. The preoperative three-dimensional computed tomography bronchography and angiography (3D-CTBA) can provide a detailed model of the segmental structure, and contribute to precise and safe segmentectomy.

Case presentation

This is a case of anomalous bronchi and pulmonary vessels in the right upper posterior segment (RS²). Under the guidance of 3D-CTBA, anatomic RS² segmentectomy was performed accurately and safely. The postoperative condition was uneventful.

Conclusions

This rare case highlights the importance of 3D-CTBA to guild accurate segmentectomy with anatomic variation.

Thoracoscopic Pulmonary Segmentectomy With Collateral Ventilation Method

BACKGROUND

Despite its popularity in recent years, segmentectomy still faces a challenge: the accurate delineation of the intersegmental plane, especially in complex segmentectomy. In this study, we describe a method using collateral ventilation to create an inflation-deflation line for video-assisted thoracoscopic surgery (VATS) segmentectomy and evaluated its efficacy in complex segmentectomy by comparing it with simple segmentectomy.

METHODS

Enrolled in the study were 264 patients who underwent VATS segmentectomy from January 2017 to September 2018. We classified the clarity of the inflation-deflation line into 4 grades, and the procedures of grade 3 or 4 were considered successful. Meanwhile, we performed a propensity score matching analysis to compare complex and simple segmentectomy.

RESULTS

Complete resection with free margins was achieved in all patients. In inflation-deflation line clarity evaluation, 245 patients were classified as grade 4 (92.8%), 10 as grade 3 (3.8%), 8 as grade 2 (3.0%), and 1 as grade 1 (0.4%). Procedural success (grade 3 or 4) was achieved in 255 patients (96.6%). Prolonged air leak (>5 days) was observed in 11 patients (4.2%). Propensity matching generated 83 pairs of well-matched patients. The proportion of procedural success and the incidence of prolonged air leak (>5 days) were similar in both groups. However, compared with simple segmentectomy, complex segmentectomy was associated with a longer median operative time (159 versus 135 minutes; P < .001).

CONCLUSIONS

Collateral ventilation method is simple, safe, and effective in VATS segmentectomy to identify the intersegmental plane, and also well-adapted for complex segmentectomy.

Pulmonary vessels and bronchial anatomy of the left lower lobe

PURPOSE

To identify and clarify the comprehensive anatomic patterns in the left lower lobe (LLL).

METHODS

Using computed tomography (CT) imaging data, including that obtained using three-dimensional CT, we reviewed the anatomic patterns of the pulmonary vessels and bronchi in the left lungs of 539 patients, focusing on the LLL.

RESULTS

The two-stem type in A⁶ was observed in 131 (24.7%) patients and the three-stem type in A⁶ was observed in 11 (2.1%) patients. The independent two-stem type in B⁶ was observed in four (0.75%) patients. The B⁷ with independent branching from the basal bronchi was observed in 42 (7.9%) patients. B* was observed in 129 (24.0%) patients and B* was accompanied by A* in all patients. An extrapericardial common trunk of the left pulmonary veins was identified in five patients (0.93%).

CONCLUSION

We identified various bronchovascular patterns in the LLL of a large number of patients. Our results provide useful information for anatomic pulmonary resection, especially segmentectomy.

Single-port video-assisted thoracoscopic surgery subsegmentectomy: The learning curve and initial outcome

BACKGROUND

We report initial surgical results and learning process of single-port video-assisted thoracoscopic surgery (VATS) subsegmentectomy in comparison with segmentectomy in our institution as the presentative of minimal invasiveness and precise resection for early stage lung cancer.

METHODS

All patients undergoing single-port VATS sublobar anatomic resection between January 2014 and December 2018 for clinical diagnosis of lung cancer were included. The learning curve was analyzed using the cumulative summation (CUSUM) method. Comparisons were done between those who underwent single-port VATS subsegmentectomy and segmentectomy.

RESULTS

A total of 364 patients underwent single-port VATS segmentectomy and 91 patients underwent single-port VATS subsegmentectomy were included. Lung adenocarcinoma was the most common (61.1%) diagnosis. The operative time and blood loss in the subsegmentectomy group were less than the segmentectomy group. The incidence of intraoperative complication was also lower in the subsegmentectomy group. The surgical proficiency was reached at 28 cases in single-port VATS subsegmentectomy. For primary lung cancer, the tumor size in subsegmentectomy group was smaller than segmentectomy group (1.1 cm versus 1.4 cm, p = 0.026). The resection margin was smaller in subsegmentectomy group, and both groups reached adequate margin without significant difference (94.7% versus 95.5%, p = 0.737). During the follow-up period, 2 (3.5%) patients in subsegmentectomy group and 9 (4.1%) patients in segmentectomy group developed distant metastasis.

CONCLUSION

Single-port VATS subsegmentectomy is safe and feasible for small-sized lung lesion, providing the benefit of minimal invasiveness, preservation of pulmonary function, and clearance of lymphatic drainage at the intersegmental plane. The surgical proficiency could be achieved based on the experiences in single-port VATS segmentectomy.

Application of the IQQA-3D imaging interpretation and analysis system in uniportal video-assisted thoracoscopic anatomical segmentectomy: a series study

Background

This study's objective was to evaluate and summarize the application of the IQQA-3D imaging interpretation and analysis system in uniportal video-assisted thoracoscopic anatomical segmentectomy.

Methods

We collected the clinical data of consecutive patients who underwent uniportal video-assisted thoracoscopic anatomical segmentectomy for single or multiple pulmonary nodules at Department No. 1 of Thoracic Surgery at Fujian Medical University, Fujian Union Hospital from July 2017 to November 2018. Patients were divided into two groups according to the use of IQQA: the IQQA group and non-IQQA group. General clinical characteristics, operation status, and postoperative recovery were compared between groups. Variations in the segmental bronchi, arteries, and veins of patients in the IQQA group were summarized.

Results

This study included 133 cases, 96 in the IQQA group and 37 in the non-IQQA group. There were no significant differences between groups in patient sex, age, preoperative smoking, pulmonary function, maximum lesion diameter, or pathological type (all P>0.05). The proportion of segmentectomies that were moderately difficult or complex was significantly higher in the IQQA group than in the non-IQQA group (28.1% vs. 16.2% and 29.2% vs. 13.5%, respectively; P=0.017). Despite having a higher percentage of more complicated operations, the IQQA group did not have longer operation times or increased postoperative complications. Fifty-five cases (57.3%) in the IQQA group had segmental structure variations, with a total of 73 variations. Among patients who underwent IQQA, 27 (65.9%) in the general segmentectomy group, 13 (48.1%) in the moderate segmentectomy group, and 15 (53.6%) in the complex segmentectomy group had anatomic variations; these differences were not significant.

Conclusions

Preoperative 3D reconstruction is necessary before segmentectomy, especially for patients undergoing moderate or complex segmentectomy. IQQA was safe and feasible for preoperative localization of lesions, surgical planning, and intraoperative navigation in uniportal video-assisted thoracoscopic anatomical segmentectomy and can facilitate complicated segmentectomy.

Three-dimensional navigation-guided thoracoscopic combined subsegmentectomy for intersegmental pulmonary nodules

Background

Extended or combined segmentectomies are usually adapted for intersegmental pulmonary nodules. This study explored precise combined subsegmentectomy (CSS) under the guidance of three‐dimensional computed tomography bronchography and angiography (3D‐CTBA).

Methods

The definition of a pulmonary intersegmental nodule was based on a minimum distance between the nodule and the involved intersegmental veins in the preoperative 3D‐CTBA being less than the size of the nodule. Centering on the involved intersegmental vein, two adjacent subsegments belonging to the different segments were combined as a resected unit.

Results

We retrospectively reviewed the records of 47 patients (mean age 53.6 ± 12.3, range: 26–81 years) who underwent CSS. Thirty‐nine (83.0%) nodules were involved in most intersegmental locations of the upper lobes; the remainder in the lower lobes. The mean nodule size was 0.86 ± 0.32 cm; the mean margin width was 2.20 ± 0.38 cm. Pathological stages included: Tis (8 cases), T1mi (16), IA1 (T1aN0M0, 13), and IA2 (T1bN0M0, 5). Pathological diagnoses included: invasive adenocarcinoma (18 cases), minimally invasive adenocarcinoma (16), adenocarcinoma in situ (8), atypical adenomatous hyperplasia (3), and benign (2). The average operative duration was 190.8 ± 54.9 minutes; operative hemorrhage was 42.7 ± 23.0 mL; 5.8 ± 2.8 lymph nodes dissected had not metastasized; the duration of postoperative chest tube drainage was 3.0 ± 1.8 days; and the postoperative hospital stay was 5.3 ± 2.4 days.

Conclusions

Under 3D navigation, thoracoscopic CSS is a safe technique for intersegmental nodules, sparing more pulmonary parenchyma and ensuring safe margins to achieve anatomical resection.