Unplanned Procedures During Thoracoscopic Segmentectomies

Lateral Dorsal Basal Lung Resection Based on Functional Preserving Sublobectomy Method: Single-Center Experience

PURPOSE

Functional preserving sublobectomy (FPSL), a novel balancing strategy for segmentectomy and wedge resection, allows rapid and accurate removal of invisible nodules without the use of any preoperative localization markers. This study aimed to share single-center experience of lateral dorsal basal lung resection based on FPSL, so as to provide new surgical options for thoracic surgeons.

METHODS

A retrospective analysis was performed on 13 patients who underwent thoracoscopic basal lung resection after FPSL at XX hospital from January 2021 to August 2022.

RESULTS

The operation was successfully performed in 13 patients by using FPSL, including 12 patients with malignant tumors. The mean operating time was 107.5 ± 25.6 min. The mean postoperative hospital stay was 3.7 ± 2.4 days. None of the patients needed extended excision, such as an entire basal or inferior lobectomy.

CONCLUSION

Our single-center experience showed that the FPSL method only dealt with the target vessels, which greatly reduced the technical difficulty of surgery. In addition, both arteries and veins could be used as target vessels, and in particular cases such as undeveloped interlobar fissure, the operation could still be completed successfully. Lateral dorsal basal lung resection based on FPSL may be a new surgical option for surgeons.

Application of three-dimensional computed tomography bronchography and angiography in thoracoscopic anatomical segmentectomy of the right upper lobe: A cohort study

Objective

Three-dimensional computed tomography bronchography and angiography (3D-CTBA) can provide detailed imaging information for pulmonary segmentectomy. This study aimed to investigate the safety and effectiveness of 3D-CTBA guidance of anatomical segmentectomy of the right upper lobe (RUL).

Methods

This was a retrospective analysis of anatomical segmentectomy of the RUL at the Thoracic Surgery Department of the Fourth Hospital of Hebei Medical University from December 9, 2013, to June 2, 2021. Preoperatively, all patients underwent contrast-enhanced CT of the chest (to determine the size of the pulmonary nodule) and a lung function test. 3D-CTBA has been performed since 2018; patients with vs. without 3D-CTBA were compared. Segmentectomy was performed according to nodule location.

Results

Of 139 patients (46 males and 93 females, aged 21–81 years), 93 (66.9%) completed single segmentectomy, 3 (2.2%) completed single subsegmentectomy, 29 had combined subsegmentectomy, 7 had segmentectomy combined with subsegmentectomy, and 6 had combined resection of two segments. Eighty-five (61.2%) patients underwent 3D-CTBA. 3D-CTBA cases had decreased intraoperative blood loss (67.4 ± 17.6 vs. 73.1 ± 11.0, P = 0.021) and shorter operation time (143.0 ± 10.8 vs. 133.4 ± 20.9, P = 0.001). 3D-CTBA (Beta = −7.594, 95% CI: −12.877 to −2.311, P = 0.005) and surgical procedure (Beta = 9.352, 95% CI: 3.551–15.153, P = 0.002) were independently associated with intraoperative blood loss. 3D-CTBA (Beta = −13.027, 95% CI: −18.632 to 17.422, P < 0.001) and surgical procedure (Beta = 7.072, 95% CI: 0.864–13.280, P = 0.026) were also independent factors affecting the operation time.

Conclusion

Preoperative use of 3D-CTBA to evaluate the pulmonary vessels and bronchial branch patterns of the RUL decreased blood loss and procedure time and so would be expected to improve the safety and effectiveness of thoracoscopic segmentectomy.

Outcomes and experience of anatomical partial lobectomy

OBJECTIVE

The use of limited anatomic resection for early-stage lung cancer is widely practiced worldwide. However, most studies have focused on standard segmentectomy or subsegmentectomy, and data on the short-term outcomes after anatomic sublobar resection in China are lacking.

METHODS

In 2014, the use of anatomic partial lobectomy (APL), which is defined as lesion-centered resection of anatomical sublobular parts, was proposed by the National Cancer Center in China. We retrospectively evaluated all consecutive patients who underwent APL between November 2013 and October 2019 from our database, and the operative techniques and short-term outcomes were analyzed.

RESULTS

A total of 3336 patients with a median age of 56 years underwent APL during the study period. Benign lesions were present in 8.5% of all patients and decreased across time. The mean total operation time was 127.3 minutes, the mean overall number of nodal sampling/dissections was 13, and the mean number of stations sampled was 4. Postoperative complications (grade ≥2) developed in 359 patients (10.8%), and no mortality occurred in the 30 days after surgery. Multivariate analysis showed that smoking, surgeon's early experience, thoracotomy or unplanned conversion to thoracotomy, and complex cases were risk factors for the occurrence of postoperative complications.

CONCLUSIONS

Despite the increasing proportion of complex cases treated with APL, the incidence of postoperative complications decreased as our center accumulated surgical experience. APL procedures are safe and feasible when conducted in a specialized center.

Thoracoscopic anatomical individual basilar segmentectomy

OBJECTIVES

Thoracoscopic anatomical single or combined anatomical individual basilar segmentectomy, including subsegmentectomy, is technically challenging due to variations and the deep location of vessels and bronchi in the parenchyma. However, the long-term perioperative outcomes of various anatomical subsegmentectomy approaches have not been reported. Thus, we investigated the effectiveness of thoracoscopic basilar segmentectomy.

METHODS

We evaluated the records of 119 patients who underwent thoracoscopic single or complex basilar segmentectomy between January 2005 and December 2020 and compared the fissure and non-fissure approach for S9 and/or S10.

RESULTS

A total of 29 patients underwent single segmentectomy, and 90 patients underwent various combined anatomical segmentectomies via video-assisted thoracoscopic surgery and planning using three-dimensional simulation. There were 39 cases of S9 and/or S10 segmentectomy. The median chest tube in-dwell duration and postoperative hospital stay were 1 and 4 days, respectively. The postoperative morbidity (Clavien-Dindo grade II/IIIa) rate was 5.9% without perioperative mortality. Pathological examination revealed 83 cases of lung cancer, 21 cases of metastasis and 15 cases of benign lesions. The postoperative hospitalization duration showed significant differences in the perioperative outcomes between the fissure and non-fissure approaches for S9 and/or S10.

CONCLUSIONS

Thoracoscopic anatomical basilar individual segmentectomy has emerged as a safe and feasible procedure. The non-fissure approach enabled anatomic resection of a single segment or combined basal segments, helped avoid dissection of an incomplete fissure and facilitated surgical outcomes similar to the fissure approach.

Electromagnetic navigation bronchoscopy localization of lung nodules for thoracoscopic resection

Background

Thoracoscopic localization of small peripheral pulmonary nodules is a concern. Failure can lead to larger parenchymal resection or conversion to thoracotomy. This study evaluates our experience in preoperative electromagnetic navigation bronchoscopy-guided localization of small peripheral lung lesions.

Methods

From January 2017 to March 2020 clinical, radiographic, surgical, and pathological data of patients who underwent electromagnetic navigation bronchoscopy (ENB)-guided methylene blue pleural marking of highly suspected pulmonary lesions before a full thoracoscopic resection were evaluated. Localization was performed for solid or mixed subpleural nodules measuring <10 mm, solid nodules measuring <20 mm located at more than 1 cm from the pleura and any pure ground glass opacity. Successful localization was defined as successful identification and thoracoscopic resection of target lesions.

Results

Forty-eight patients were included: 30 solid nodules (63%), 12 pure GGO (25%) and 6 mixed (13%). The median largest diameter at CT-scan was 11 mm (IQR, 9-14 mm) while the median distance from the pleural surface was 12 mm (IQR, 6-16 mm). The median ENB length was 25 min (19-33 min). Localization procedure was successful in 45 cases (94%). No procedural-related complications were reported.

Conclusions

ENB is a safe and accurate preoperative procedure to localize small lung peripheral lesions. The high successful rate, the absence of related complications, the possibility of performing the procedure in the same operating room with a single general anesthesia, make ENB-guided dye marking an advantageous tool for thoracoscopic pulmonary resection.

Thoracoscopic complex basilar segmentectomies: an analysis of 63 procedures

Background

Thoracoscopic complex basilar segmentectomies are technically demanding and challenging. We review our experience to check whether this complexity can lead to specific surgical issues or increased post-operative morbidity.

Methods

Complex basilar segmentectomies were defined as the anatomical resection of at least one segment composing the basilar pyramid, excluding S⁶. Data of patients who had an intention-to-treat thoracoscopic complex basilar segmentectomy were retrospectively collected from 2007 to 2019: indications, preoperative assessment, clinical features, operative technical aspects and early post-operative outcome.

Results

Sixty-three patients, 26 men (41%) and 37 women (59%) with a median age of 66 years and a median body mass index (BMI) of 26 kg/m2 were included. Interventions performed were mostly S⁹⁺¹⁰ (n=32) and S⁸ (n=12) segmentectomies. Forty-five planned operations (71%) were completed. Extension to a larger resection was necessary in 17 patients (27%) and 4 patients underwent conversion to open surgery (6%). Median operative time was 168 minutes with a median intraoperative bleeding of 30 mL. Complications occurred in 11 patients (17%). There was no mortality. Median length of pleural drainage was 2 days (range, 1–2 days) and median hospital stay 4 days.

Conclusions

The extension rate of complex basilar segmentectomy is higher than that of other sublobar resections but their post-operative morbidity is identical.

Video-Assisted Thoracic Surgery Segmentectomy

Although lobectomy remains the gold-standard surgical treatment for non-small-cell lung cancer, the frequency of thoracoscopic segmentectomy is increasing. Multiple factors must be considered in the choice of the procedure, ranging from adequate surgical planning or simulation, tumor localization, and identification of the intersegmental plane to severing the intersegmental plane to achieve an oncologically safe surgical margin with no or minimal manual palpation and different landmarks. In this article, we present an overview of methods for each procedural step of thoracoscopic segmentectomy, from preoperative planning to division of the intersegmental plane.

Lobectomy versus sublobar resection in patients with non-small cell lung cancer: a systematic review

Surgery is the gold standard treatment of lung cancer. The minimally invasive technique does not only concern access to the chest but also the limits of parenchymal resection. The study debates on the safety and oncological adequacy of sublobar resections in bronchogenic carcinoma patients. A systematic analysis of the data in the literature was carried out, comparing the outcomes of patients with resectable non-small lung cancer (NSCLC) who underwent lobectomy or sublobar resection. These last interventions include both segmentectomies and wedge resections taking into consideration the following parameters: complications, relapse rate and overall survival. The complication rate is higher in patients underwent lobectomy compared to sublobar resection, especially in presence of high comorbidity index or octogenarian patients (overall values respectively between 0 and 48% and 0 and 46.6%). Contrarily, the relapse rate (6.2% to 32% vs. 3.6% to 53.4%) and overall survival (50.2% to 93.8% vs. 38.6% to 100%) are more favorable in patients undergoing lobectomy. Sublobar resections are particularly indicated in elderly patients and in patients with high comorbidity index or reduced respiratory functional reserve. However, pulmonary lobectomy still remains the safest and oncologically correct method in patients with good performance status or higher risk of recurrence.

Oncological results of full thoracoscopic major pulmonary resections for clinical Stage I non-small-cell lung cancer

OBJECTIVES

The full thoracoscopic approach to major pulmonary resections is considered challenging and controversial as it might compromise oncological outcomes. The aim of this work was to analyse the results of a full thoracoscopic technique in terms of nodal upstaging and survival in patients with non-small-cell lung carcinoma (NSCLC).

METHODS

All patients who underwent a full thoracoscopic major pulmonary resection for NSCLC between 2007 and August 2016 were analysed from an 'intent-to-treat' prospective database. Overall survival and disease-free survival were estimated using the Kaplan-Meier curves and comparisons in survival using the log-rank test.

RESULTS

A total of 648 patients met the inclusion criteria, of whom 621 patients had clinical Stage I and 27 had higher stages (16 oligometastatic patients were excluded from the analysis, 11 cT3 or cT4). The mean follow-up was 34.5 months. There were 40 conversions to thoracotomy (6.3%). Thirty-day or in-hospital mortality was 0.95%. Complications occurred in 29.3% of patients. On pathological examination, 22.5% of clinical Stage I patients were upstaged. Nodal upstaging to N1 or N2 was observed in 15.8% of clinical Stage I patients. Five-year overall survival of the whole cohort was 75% and was significantly different between clinical Stages IA (76%) and IB (70.9%). For tumours <2 cm, no significant difference in overall survival was found for the segmentectomy group compared to the lobectomy group: 74% versus 78.9% (P = 0.634).

CONCLUSIONS

Long-term survival is not compromised by a full thoracoscopic approach. Our results compared favourably with those of video-assisted techniques.

Three-dimensional printing in the preoperative planning of thoracoscopic pulmonary segmentectomy

Background

The purpose of this study is to explore whether 3D printing has a better clinical value for making a preoperative plan than three-dimensional computed tomography (3D-CT) in thoracoscopic pulmonary segmentectomy.

Methods

We collected a total of 124 patients' clinical data who underwent thoracoscopic pulmonary segmentectomy from October 2017 to August 2018. According to the preoperative examination, the patients were divided into three groups: general group, 3D-CT group, and 3D printing group. The clinical data of each group were analyzed and compared.

Results

Compared with the general group, intraoperative blood loss in 3D-CT group and 3D printing group decreased significantly (P<0.05). Operation time in 3D-CT group and 3D printing group was significantly shorter than in the general group (P<0.05). Between 3D-CT group and 3D printing group intraoperative blood loss and operation time had no significant differences (P>0.05). Postoperative chest tube duration and postoperative hospital stay had no significant differences between each group P>0.05). The incidence of postoperative hemoptysis in the general group occurred higher than in the 3D-CT group and 3D printing group, but the differences were not statistically significant (P>0.05). Postoperative complications of pneumonia, atelectasis, and pulmonary air leakage (>6 d) had no significant differences between each group (P>0.05).

Conclusions

3D printing and 3D-CT for making a preoperative plan have an equivalent effect in thoracoscopic pulmonary segmentectomy for experienced surgeons. Preoperative simulations using 3D printing for the assessment of pulmonary vessel and bronchi branching patterns is beneficial for the safe and efficient performance of thoracoscopic pulmonary segmentectomy.

Thoracoscopic segmentectomy assisted by three-dimensional computed tomography bronchography and angiography for lung cancer in a patient living with situs inversus totalis: A case report

BACKGROUND

Situs inversus totalis (SIT) is a rare congenital condition that is characterized by a complete mirror image of the typical arrangement of the thoracic and abdominal viscera. Performing thoracoscopic segmentectomy for a patient with lung cancer and SIT is an extremely skilled and challenging surgical procedure.

CASE SUMMARY

A 41-year old woman with a medical history of dextrocardia since childhood was admitted to our hospital with a mixed ground-glass opacity (mGGO) in her left lung field, discovered by computed tomography during her health checkup. In order to facilitate surgical orientation, three-dimensional computed tomography bronchography and angiography (3D-CTBA) was preoperatively carried out. The result of 3D-CTBA was consistent with the diagnosis of SIT and an mGGO in the posterior segment of the left upper lobe (LS²). Surgery was conducted in accordance with preoperative 3D-CTBA and designed surgical procedure, combined with intraoperative navigation. Final pathological examination revealed in situ adenocarcinoma. The patient’s postoperative condition was uneventful and no complications were observed.

CONCLUSION

We present the first case of lung cancer in a patient with SIT who successfully underwent thoracoscopic segmentectomy assisted by 3D-CTBA. This is a new technique that covers precise confirmation and dissection of targeted structures and intersegmental demarcation, and can help achieve a meticulous anatomical segmentectomy.

Concepts and techniques: how to determine and identify the appropriate target segment in anatomical pulmonary segmentectomy?

Anatomical segmentectomy is gathering increasing interest among thoracic surgeons because of increased detection of pulmonary nodules with ground-glass opacity (GGO) as well as an increase in the number of compromised patients. Accurate determination of intersegmental planes is a challenge in anatomical segmentectomy, and multiple methods have been proposed including developing inflation/deflation lines and injecting indocyanine green either intravenously or intrabronchially. Considering resection margins, adding a localization technique to conventional methods, or conducting virtual-assisted lung mapping (bronchoscopic multi-spot dye marking) may be an optional approach for optimal anatomical segmentectomy to identify intersegmental planes and obtain adequate resection margins. To determine optimal resection lines in anatomical segmentectomy, surgeons must also consider oncological validity such as venous and lymph drainage, resection margins, and lung anatomy to avoid complications such as venous congestion, infarction, and air leakage. Although anatomical segmentectomy is an attractive approach to resect small early-stage lung cancer and some metastatic lung tumors, caution is needed to optimally perform this technically demanding surgery.

[Pulmonary intralobar sequestration in adults: Evolution of surgical treatment]

BACKGROUND

Until now, the traditional procedure to treat intralobar pulmonary sequestration (ILS) in adults has been a lobectomy performed by open thoracotomy. We have reviewed our data to observe if the surgical management of these lesions has evolved over the last years.

METHODS

We retrospectively reviewed the records of the patients who were operated for an ILS either by posterolateral thoracotomy (PLT group), or by thoracoscopy (TS group) between 2000 and 2016.

RESULTS

Eighteen patients were operated for a SIL during this period. Prior to 2011, all resections were performed by thoracotomy (n=6) and after 2011 the surgical approach was either a thoracotomy (n=5) or a thoracoscopy (n=7). There was one conversion because of dense pleural adhesions and this patient was integrated in the PLT group for further analysis. ILS were more frequently encountered on the left side (n=12, 66.6 %) than on the right one (n=6, 33.3 %) and exclusively in the lower lobes. All patients of the PLT group underwent a lobectomy. In the TS group, 5 patients underwent a sublobar resection (2 segmentectomiesS⁹⁺¹⁰, 1 basilar segmentectomy and 2 atypical resections). There was no mortality. In the PLT group, 5 patients (45 %) had complications versus one patient (14 %) in the TS group. The mean hospital stay was 7.4 days in the PLT group versus 5.4 days in the TS group.

CONCLUSIONS

These data confirm that ILS can be safely treated by a sublobar resection that should be performed, whenever possible, thoracoscopically.

Planning and marking for thoracoscopic anatomical segmentectomies

Although sublobar resection (SLR) for treating non-small cell lung carcinoma (NSCLC) is still controversial, thoracoscopic segmentectomy is rising. Performing it by closed chest surgery is complex as it means confirming the location of the lesion, identifying vascular and bronchial structures, preserving venous drainage of adjacent segments, severing the intersegmental plane and ensuring an oncological safety margin with no manual palpation and different landmarks. Accurate planning is mandatory. We discuss in this article the interest of 3D reconstruction and mapping technics to enhance safety and reliability of these procedures.