Combined subsegmentectomy: postoperative pulmonary function compared to multiple segmental resection

Compensatory expansion of the right middle lobe: volumetric and functional analysis of the changes after right upper or lower lobectomy

The right middle lobe often poorly expands after right upper lobectomy. Postoperative pulmonary function may be inferior after right upper lobectomy than after right lower lobectomy due to poor expansion of the middle lobe. This study examined the difference in the postoperative right middle lobe expansion and pulmonary function between right upper and right lower lobectomy. Patients who underwent right upper or right lower lobectomy through video-assisted thoracic surgery (n = 82) were enrolled in this retrospective study. Pulmonary function tests and computed tomography were performed preoperatively and at 1 year postoperatively. Using three-dimensional computed tomography volumetry, the preoperative and postoperative lung volumes were measured, and the predicted postoperative forced expiratory volume in 1 s was calculated. Middle lobe volume ratio (i.e., ratio of the postoperative to the preoperative middle lobe volume) and the postoperative forced expiratory volume in 1 s ratio (i.e., ratio of the measured to the predicted postoperative forced expiratory volume in 1 s) were compared between right upper and right lower lobectomy. Compared with the patients who underwent right upper lobectomy (n = 50), those who underwent right lower lobectomy (n = 32) had significantly higher middle lobe volume ratio (1.15 ± 0.32 vs. 1.63 ± 0.52, p < 0.001) and postoperative forced expiratory volume in 1 s ratio (1.12 ± 0.12 vs. 1.19 ± 0.13, p = 0.010). The right middle lobe showed more expansion and better recovery of postoperative pulmonary function after right lower lobectomy than after right upper lobectomy.

Thoracoscopic Anatomical Sublobar Resection Including Subsegmentectomy for Non-Small Cell Lung Cancer

BACKGROUND

Among anatomical sublobar resection techniques for non-small cell lung cancer (NSCLC), the clinical benefit of subsegmentectomy remains unclear. We investigated whether anatomical sublobar resection including subsegmentectomy-segmental resection with subsegmental additional resection or subsegmental resection alone-is an effective and feasible surgical procedure for NSCLC.

METHODS

We retrospectively reviewed data of 285 patients with clinical stage I NSCLC who underwent anatomical sublobar resection at our institution from January 2013 to March 2021 and compared surgical outcomes between patients who underwent anatomical sublobar resection including (IS; n = 50) and excluding (ES; n = 235) subsegmentectomy.

RESULTS

No significant intergroup differences were noted in terms of age, sex, smoking, comorbidities, tumor size or location, consolidation tumor ratio, and preoperative pulmonary function. The IS group had more preoperative computed tomography-guided markings (34 vs. 15%; p = .004) and smaller resected lung volumes converted to the total subsegment number [3 (2-4) vs. 3 (3-6); p = .02] than the ES group. No significant differences in margin distance [mm, 20 (15-20) vs. 20 (20-20); p = .93], readmission rate (2% vs. 3%; p > .99), and intraoperative (8% vs. 7%; p = .77) or postoperative (8% vs. 10%; p = .80) complication rates were observed, and the 5-year local recurrence-free survival (91% vs. 90%; p = .92) or postoperative pulmonary function change were comparable between both groups.

CONCLUSIONS

Although further investigations are required, anatomical sublobar resection including subsegmentectomy for clinical stage I NSCLC could be an acceptable therapeutic option.

Learning curve analysis of single-port thoracoscopic combined subsegmental resections

Background

Combined subsegmental surgery (CSS) is considered to be a safe and effective resection modality for early-stage lung cancer. However, there is a lack of a clear definition of the technical difficulty classification of this surgical case, as well as a lack of reported analyzes of the learning curve of this technically demanding surgical approach.

Methods

We performed a retrospective study of single-port thoracoscopic CSS performed by the same surgeon between April 2016 and September 2019. The combined subsegmental resections were divided into simple and complex groups according to the difference in the number of arteries or bronchi which need to be dissected. The operative time, bleeding and complications were analyzed in both groups. Learning curves were obtained using the cumulative sum (CUSUM) method and divided into different phases to assess changes in the surgical characteristics of the entire case cohort at each phase.

Results

The study included 149 cases, including 79 in the simple group and 70 in the complex group. The median operative time in the two groups was 179 min (IQR, 159-209) and 235 min (IQR, 219-247) p < 0.001, respectively. And the median postoperative drainage was 435 mL (IQR, 279-573) and 476 mL (IQR, 330-750), respectively, with significant differences in postoperative extubation time and postoperative length of stay. According to the CUSUM analysis, the learning curve for the simple group was divided by the inflection point into 3 phases: Phase I, learning phase (1st to 13th operation); Phase II, consolidation phase (14th to 27th operation), and Phase III, experience phase (28th to 79th operation), with differences in operative time, intraoperative bleeding, and length of hospital stay in each phase. The curve inflection points of the learning curve for the complex group were located in the 17th and 44th cases, with significant differences in operative time and postoperative drainage between the stages.

Conclusion

The technical difficulties of the simple group of single-port thoracoscopic CSS could be overcome after 27 cases, while the technical ability of the complex group of CSS to ensure feasible perioperative outcomes was achieved after 44 operations.

Subsegmentectomy versus segmentectomy resection for the treatment of operable patients with stage IA non-small cell lung cancer: A meta-analysis

Background

There were new points of interest in performing subsegmentectomy and segmentectomy for patients with early stage non-small cell lung cancer (NSCLC). However, whether patients who underwent subsegmentectomy could obtain satisfactory clinical outcomes remains unclear. The present study aimed to compare the clinical outcomes and security of surgical procedures between subsegmentectomy and segmentectomy.

Methods

A systematic review and meta-analysis was performed through five online databases to identify the included literatures which presented intact clinical outcome data among different surgical procedures. The included studies were evaluated based on precise and predefined inclusion criteria.

Results

There were 4 published studies identified in this meta-analysis. A total of 325 patients who underwent subsegmentectomy and 904 patients who underwent segmentectomy were involved in this analysis. The duration of drainage [MD -0.19; 95%CI (-0.36, -0.02), p = 0.03] and postoperative hospital stay [MD -0.30; 95%CI (-0.58, -0.02), p = 0.009] of subsegmentectomy were significantly less than that of segmentectomy. There was no statistically significant difference among recurrence rate [OR 0.85; 95%CI (0.21, 3.42), p = 0.82], operation time, blood loss, incidence of complications [OR 0.83; 95%CI (0.58, 1.20), p = 0.33] between subsegmentectomy and segmentectomy in patients with stage IA NSCLC.

Conclusion

The meta-analysis was firstly performed to compare perioperative outcomes among surgical procedures. The perioperative outcomes were comparable between subsegmentectomy and segmentectomy. Subsegmentectomy might be an alternative treatment for the deep tumor with size less than 1.5 cm and mainly composed of Ground Glass Opacity (GGO).

Surgical outcomes of anatomical sublobar resections of left upper lobe and a technique of subsegmentectomy based on bronchovascular patterns

BACKGROUND

Anatomical sublobar resection was widely performed for small-sized nodule located in the deep field of the lung. In this study, we compared surgical outcomes between anatomical sublobar resection in left upper lobe including segmentectomy and subsegmentectomy. We also applied a technique based on bronchovascular patterns for subsegmentectomy.

PATIENTS AND METHODS

A hundred and fifty-one patients underwent anatomical sublobar resection of left upper lobe in our hospital in the period from January 2018 to December 2019 and they were retrospectively reviewed. Patients' characteristics and surgical outcome of the subsegmentectomy group (n = 71) were analyzed and compared to those of patients of the segmentectomy group (n = 80). The bronchovascular patterns of left upper lobe in these patients were also classified, and a technique of subsegmentectomy was introduced by cases description.

RESULTS

Compared to segmentectomy, the subsegmentectomy group had longer operative time [141min, interquartile range (IQR): 125-161 vs. 127.5 min, interquartile range (IQR): 114.75-148.25; P = 0.001] and more estimated blood loss [50 mL, IQR: 30-50 vs. 30 mL, IQR: 20-50; P = 0.02]. Branching pattern of bronchus was classified into 3 types in left upper division, and 2 types in lingular division. Branching pattern of pulmonary artery was classified into 7 types in left upper division and 2 types in lingular division. Branching pattern of pulmonary vein was classified into 3 types in left upper division and V³ b was classified into 4 types.

CONCLUSION

Subsegmentectomy is a safe procedure with surgical outcome comparable to the one of segmentectomy except operative time and estimated blood loss. Subsegmentectomy based on bronchovascular patterns in left upper lobe is feasible.

"Separated" precise subsegmentectomy: Single-port thoracoscopic noncombined subsegmentectomy in one lung lobe

BACKGROUND

In clinical practice, combined segmental resection (CSS) can avoid resection of multiple segments to preserve lung function. When two or more distant lung segments or subsegments of the same lobe present with a ground glass opacity (GGO) that meets the indications for sublobar resection, conventional CSS or wedge resection could not remove all the nodules, and lobectomy is performed in most of these patients. For these particular types of nodules, we perform a single lobe noncombined subsegmental resection, or "separated" precise subsegmentectomy, to preserve more lung tissue. This study was designed to initially assess the feasibility and safety of "separated" precise subsegmentectomy.

METHODS

Selected cases of specific GGO were subjected to "separated" precise subsegmentectomy and the results of general clinical data, perioperative operative time, bleeding, length of stay, computed tomography (CT) review, lung function and its dynamic changes were collected and analyzed in these patients.

RESULTS

"Separated" precise subsegmentectomy was performed in 12 patients and successfully completed. The median operation time, bleeding amount, and length of hospital stay were 96 min, 50 ml and 4 days, respectively. There was one case of pulmonary infection and one case of persistent air leakage, no death or pulmonary torsion, bronchopleural fistula and other pulmonary complications occurred. After 3 months, the median percentage of lung function retention was 91.7%, and the CT scan showed that the reserved lung tissue of 12 patients was well inflated and there was no obvious imaging manifestation of atelectasis.

CONCLUSION

"Separated" precise subsegmentectomy is a novel and safe surgical method that provides a more optimized way for patients with specific multiple nodules to preserve lung function. Further prospective large studies are needed to verify this finding.

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.

Comparison of surgical outcomes between thoracoscopic anatomical sublobar resection including and excluding subsegmentectomy

OBJECTIVES

Despite the ubiquitous utilization of anatomical sublobar resection for malignant lung tumors, the effectiveness and feasibility of subsegmentectomy remains unclear. This study therefore compared the perioperative outcomes between anatomical sublobar resection including (IS) and excluding (ES) subsegmentectomy.

METHODS

Patients who had undergone anatomical sublobar resection at our institution from January 2013 to March 2019 were retrospectively reviewed. Clinicopathologic characteristics and perioperative outcomes of the IS group (n = 58) were then analyzed the compared to those of the ES group (n = 203).

RESULTS

No statistically significant differences in age, sex, comorbidities, tumor location, preoperative pulmonary function, or tumor size on imaging were found between both groups. The IS group had significantly higher preoperative computed tomography-guided marking rates (40% vs. 18%; p < 0.01) and used significantly more staplers for intersegmental dissection than the ES group [4, interquartile range (IQR): 3-4 vs. 3, IQR: 3-4; p = 0.03]. Both groups had comparable 30-day mortality (0% vs. 0%; p > 0.99), intraoperative complications (7% vs. 10%; p = 0.61), and postoperative complications (5% vs. 8%; p = 0.58). After propensity score matching, the IS group experienced significantly lesser blood loss than the ES group (5 mL, IQR: 1-10 vs. 5 mL, IQR: 5-20; p = 0.03). Both groups experienced no local recurrence and demonstrated similar postoperative pulmonary functions after surgery.

CONCLUSIONS

IS may be a feasible and acceptable therapeutic option for malignant lung tumors. Nonetheless, future investigations are required to further validate the current findings.

Extent of Segmentectomy That Achieves Greater Lung Preservation Than Lobectomy

BACKGROUND

This study sought to clarify the extent of segmentectomy that achieves greater lung preservation than lobectomy.

METHODS

This was a single-center retrospective cohort study involving 374 patients with lung cancer who were treated with either lobectomy or segmentectomy between 2013 and 2018. The percentage of preserved pulmonary function (%PPF) after surgery was compared among patients who underwent lobectomy (n = 164), segmentectomy of 2 or more segments (Seg ≥2S; n = 42), and segmentectomy of less than 2 segments (Seg <2S; n = 168). Using perfusion scintigraphy, forced expiratory volume in 1 second of the preserved target lobe was measured to examine its effect on the %PPF. The number of resected subsegments (SSs) in segmentectomy that made the %PPF higher than that observed with lobectomy was also examined.

RESULTS

Mean %PPF was lowest in those patients who underwent lobectomy (86%), followed by Seg ≥2S (89%) and Seg <2S (95%) (P < .001), but the difference between the lobectomy and Seg ≥2S was not significant (P = .21). The forced expiratory volume in 1 second of the preserved target lobe was significantly lower in the Seg ≥2S group than in the Seg <2S group (P < .001). The number of resected SSs was 6 to 12 in lobectomy, 4 to 7 in Seg ≥2S, and 1 to 4 in Seg <2S. Although the %PPF after segmentectomy of less than 5 SSs (Seg <5SS) was significantly higher than that after lobectomy (P < .001), the %PPF after segmentectomy of 5 or more SSs (Seg ≥5SS) was not significantly different from that after lobectomy (P = .68).

CONCLUSIONS

Both the Seg ≥2S and Seg ≥5SS groups did not differ from lobectomy in %PPF because of the low function of preserved target lobe.

Robotic Approach to Combined Anatomic Pulmonary Subsegmentectomy: Technical Aspects and Early Results

BACKGROUND

Minimally invasive techniques are increasingly being used in pulmonary segmentectomy and combined subsegmentectomy. However, there are no reports as yet on robotic combined anatomic subsegmentectomy (CAS). In this report, we describe related clinical data and operative techniques and present our early results.

METHODS

Clinical data of patients undergoing robotic CAS were retrospectively reviewed. A combined subsegmentectomy was defined as the resection of 2 or more subsegments that involved 2 or more adjacent segments. The study enrolled patients who underwent completely portal robotic CAS.

RESULTS

Between May 2015 and January 2018, a single surgeon performed completely portal robotic CAS for 16 patients. In the CAS-treated patients, 75% of the lesions were located in the right upper lobe, and none required conversion to thoracotomy. Median operative time was 175 minutes (range, 75 to 294 minutes), and mean postoperative hospital stay was 4 days (range, 2 to 11 days). Although 1 patient experienced a prolonged air leak, the other 15 recovered uneventfully. Within a median follow-up period of 15 months, there were no deaths or tumor recurrences.

CONCLUSIONS

Completely portal robotic CAS is a safe and effective procedure in a select subset of patients, proving quite suitable for smaller (<2 cm) multisegment lung cancers, particularly lesions of the right upper lobe. A robotics approach facilitates complex and challenging CAS, the disadvantage being lengthy operative times during early acquisition of skills.

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.

Thoracoscopic Pulmonary Sub-Subsegmentectomy Based on Three-Dimensional Images

Thoracoscopic anatomic pulmonary segmentectomy and subsegmentectomy have become sophisticated surgical solutions for complex pulmonary diseases. The rapid development of three-dimensional computed tomographic angiography (3DCTA) has made it possible to provide more refined individualized anatomic details and has consequently enabled subsubsegmentectomy (SSS). In this study, we report two successful thoracoscopic anatomic SSSs of the left S¹⁺²aii and S³aii under the guidance of 3DCTA reconstructed images. To the best of our knowledge, these are the first two cases of SSSs ever detailed reported. The nomenclature of subsubsegments is adopted according to the Japanese Committee on the Nomenclature for Bronchial Branching.

Complete video-assisted thoracoscopic multi-subsegmentectomy based on patients' specific virtual 3-D pulmonary models

INTRODUCTION

Video-assisted thoracoscopic surgery is widely used for resecting early-stage non-small cell lung cancer. Segmentectomy and subsegmentectomy require a thorough knowledge of the 3-D bronchovascular anatomy of the lung. Previously, our department reported using a 3-D pulmonary model of a patient for thoracoscopic surgical treatment of non-small cell lung cancer. This study investigates multi-segmentectomy for patients with non-small cell lung cancer.

METHODS

Between July 2001 and January 2012, 943 patients underwent surgical resection of primary lung cancer. Of these, 11 patients had video-assisted thoracoscopic multi-subsegmentectomy. For preoperative simulation, virtual 3-D pulmonary models have been constructed since July 2001.

RESULTS

The mean age of patients was 69.2 ± 11.6 years (range, 43.0-86.0 years). Histological diagnoses included adenocarcinoma in eight patients, squamous cell carcinoma in two, and large cell carcinoma (neuroendocrine tumor) in one. Tumor size was ≤ 10 mm in one patient, 11-15 mm in four, 16-20 mm in four, and 21-25 mm in two. One patient was treated without lymphadenectomy, nine patients underwent additional hilar lymphadenectomy, and one patient underwent additional hilar and mediastinal lymphadenectomy. No patients were converted to thoracotomy. All patients had a macroscopically negative surgical margin. The pathological stage of patients was IA in nine patients, IB in one, and IIA in one. No pulmonary vessel injuries were found. Three patients had a prolonged lung air leak (> 6 days).

CONCLUSION

Using a reconstructed 3-D pulmonary model, this study demonstrates that video-assisted thoracoscopic multiple subsegmentectomy is feasible with adequate margins in selected patients.

Port-access thoracoscopic anatomical lung subsegmentectomy

OBJECTIVES

The diagnosis of small lung nodules has increased in recent years; limited resection and minimally invasive surgery are highly desirable in patients with these lesions. While wedge resection may be curative for small lung nodules, the technique is sometimes difficult to perform when the tumour nodule is near the pulmonary hilum. In such situations, either anatomical segmentectomy or subsegmentectomy can obtain an adequate surgical margin; port-access thoracoscopic surgery is the preferred type of minimally invasive surgery. Three-dimensional (3D) computed tomography (CT) simulations are reportedly useful in planning and performing thoracoscopic surgery. We use 3D CT simulation to aid thoracoscopic segmentectomy for small lung nodules and subsegmentectomy for even smaller nodules and conduct here a retrospective evaluation of the clinical results of subsegmentectomy. We present our technique for 3D CT simulation-assisted port-access thoracoscopic subsegmentectomy in the superior segment of the left lower lobe.

METHODS

Between July 2008 and June 2012, 15 patients underwent port-access thoracoscopic subsegmentectomy. We evaluated the pathological diagnoses, the tumour sizes, the indications, the operative times and the volumes of blood loss.

RESULTS

Seven patients were diagnosed with lung cancer (LC) and eight had metastatic lung tumours (MLT). The median tumour size was 12 mm. The indication for using this surgical technique was to secure surgical margins in 13 patients (LC, 6; MLT, 7) and because of poor surgical risk in two patients (LC, 1; MLT, 1). The mean surgical time was 166 min and the median blood loss was 19 ml. There were no recurrences.

CONCLUSIONS

Port-access thoracoscopic lung subsegmentectomy using 3D CT simulation can be safely performed and is able to secure adequate surgical margins.

Changes in cerebral oxygenation in patients with pulmonary dysfunction after lung resection

Lung resection would be associated with lower jugular bulb oxygen saturation (SjvO₂) values in patients with moderate to severe pulmonary dysfunction. We aimed to study the effects of lung resections on the postoperative changes in SjvO₂, incidence of SjvO₂ < 50%, pulmonary functions, cerebral blood flow equivalent (CBFE), and arterial to jugular difference in oxygen content (AjvDO₂) in the patients with pulmonary dysfunction. Fifty-three patients scheduled for lung resection were allocated on the basis of forced vital capacity (FVC %) and forced expiratory volume in 1 second (FEV(1)%) into the following: good FVC and FEV₁ (n = 14), mild (n = 14), moderate (n = 13), and severe (n = 12) pulmonary dysfunction groups. After lung resections, patients with pulmonary dysfunctions had significantly lower SjvO₂, CBFE, FEV₁, and FVC (P < .001), higher AjvDO₂ (P < .001), and frequent episodes with SjvO₂ < 50% (P < .03). Perioperative changes in FEV₁ had a significant negative correlation with SjvO₂ desaturation (P < .002). Patients with pulmonary dysfunction showed significant SjvO₂ < 50% after lung resection, which is correlated to the perioperative changes in FEV₁.

Dissection of lung parenchyma using electrocautery is a safe and acceptable method for anatomical sublobar resection

BACKGROUND

Anatomic sublobar resection is being assessed as a substitute to lobectomy for primary lung cancers. However, persistent air leak after anatomic sublobar resection is prevalent and increasing surgical morbidity and costs. The use of electrocautery is being popularized recently in anatomic sublobar resection. We have retrospectively evaluated the safety and efficacy of intersegmental plane dissection using electrocautery.

METHODS

Between April 2009 to September 2010, 47 patients were treated with segmentectomy for clinical T1N0M0 non-small cell lung cancers. The intersegmental plane was dissected using electrocautery alone or in combination with staplers. We evaluated the methods of dividing intersegmental plane (electrocautery alone or combination with electrocautery and staplers), intraoperative blood loss, duration of chest tube placement, duration of surgery, preoperative FEV1.0%, incidence of prolonged air leak, length of postoperative hospital stay, postoperative pulmonary function at 6 months after surgery and the cost for sealing intersegmental plane.

RESULTS

Among the 47 patients, 22 patients underwent intersegmental plane dissection with electrocautery alone and 25 patients did in combination with electrocautery and staplers. The mean number of stapler cartridges used was only 1.3 in electrocautery and staplers group. Mean age, gender, number of patients whose FEV1% < 70% were similar between two groups. There was no statistical difference between electrocautery alone and combination with electrocautery and staplers group in duration of surgery (282 vs. 290 minutes), intraoperative blood loss (203 vs.151 ml), duration of chest tube placement (3.2 vs. 3.1 days), postoperative hospital stay (11.0 vs.10.0 days), postoperative loss of FEV1.0 (13 vs.8 %), loss of FVC (11 vs. 6 %) or incidence of minor postoperative complications [9 % (2/22) vs. 16 % (4/25), p = 0.30)]. However, incidence of prolonged air leak was higher in electrocautery alone group than in combination with electrocautery and staplers group [14 % (3/22) vs. 4 % (1/25), p = 0.025)]. The cost of materials for sealing air leaks amounted to €964 per patient in the electrocautery alone group and €1594 per patient in combination with electrocautery and staplers group.

CONCLUSIONS

The number of patients with prolonged air leak was higher in the electrocautery alone group. The use of staplers in addition to electrocautery may lead to reduced prolonged air leak. However, the use of electrocautery for intersegmental plane dissection appeared to be safe with acceptable postoperative complications and effective in reducing costs.

Combined subsegmentectomy for S(2)(b) (horizontal subsegment of the posterior segment) and S(3)(a) (lateral subsegment of the anterior segment) in the right upper pulmonary lobe

A technique for combined resection of S(2)(b) (horizontal subsegment of the posterior segment) and S(3)(a) (lateral subsegment of the anterior segment) of the right upper lobe of the lung is presented. Although both the S(2)(b) and S(3)(a) should be resected from the interlobar fissure, an approach for the artery and bronchus of S(3)(a) (A(3)(a) and B(3)(a), respectively) is easier from the ventral side of the hilum rather than from the interlobar fissure, because B(3) runs in back of V(2) at the interlobar fissure. To resolve this contradiction, we devised a procedure as follows: (1) A(2)(b) and B(2)(b) are cut at the interlobar fissure; (2) A(3)(a) and B(3)(a) are cut from the ventral side of hilum; (3) the peripheral stumps of A(3)(a) and B(3)(a) are transferred to the interlobar fissure; and (4) subsegments of S(3)(a) and S(2)(b) are resected with the peripheral stumps of A(2)(b), B(2)(b), A(3)(a), and B(3)(a) from the side of the interlobar fissure. We believe this procedure makes the combined resection of S(2)(b) and S(3)(a) easy.