Uniportal VATS approach to sub-lobar anatomic resections: literature review and personal experience

Segmentectomy versus lobectomy. Which factors are decisive for an optimal oncological outcome?

Low-dose computed tomography is being used for lung cancer screening in high-risk groups. Detecting lung cancer at an early stage improves the chance of optimal treatment and increases overall survival. This article compares segmentectomy vs. lobectomy as surgical options, in the case of stage I non-small cell lung carcinoma, ideally IA. To compare the 2 previously referred strategies, data were collected from articles (40 studies were reviewed), reviews, and systematic analyses in PubMed Central, as well as reviewing recent literature. Segmentectomy could be an equal alternative to lobectomy in early-stage NSCLC (tumour < 2 cm). It could be preferred for patients with a low cardiopulmonary reserve, who struggle to survive a lobectomy. As far as early-stage NSCLC is concerned, anatomic segmentectomy is an acceptable procedure in a selective group of patients. For better tumour and stage classification, a systematic lymph node dissection should be performed.

Comparison of three-dimensional and two-dimensional thoracoscopic segmentectomy in lung cancer

BACKGROUND

Thoracoscopic segmentectomy is considered to be a safe and effective procedure for early lung cancer. A three-dimensional (3D) thoracoscope can provide high resolution and accurate images. We compared the outcomes from using two-dimensional (2D) and 3D video systems in thoracoscopic segmentectomy for lung cancer.

METHODS

The data of consecutive patients diagnosed with lung cancer that underwent 2D or 3D thoracoscopic segmentectomy in Changhua Christian Hospital from January 2014 to December 2020 were retrospectively analyzed. Tumor characteristics and perioperative short-term outcomes (operative time, blood loss, incision numbers, length of stay and complication) were compared between 2D and 3D thoracoscopic segmentectomy.

RESULTS

Among the 192 patients, 68 patients underwent segmentectomy with a 2D thoracoscopic system and 124 patients had 3D thoracoscopic surgery. Patients undergoing 3D thoracoscopic segmentectomy had a shorter operative time (174.19 ± 64.63 min vs. 207.06 ± 72.99 min, p = 0.002), less blood loss (34.40 ± 43.58 ml vs. 50.81 ± 57.61 ml, p = 0.028), fewer incisions (1.50 ± 0.716 vs. 2.19 ± .058, p < 0.001) and a shorter length of stay (5.67 ± 3.44 days vs. 8.18 ± 11.862 days, p = 0.029). The postoperative complications were similar between the two groups. Surgical mortality was not found in any patient.

CONCLUSION

Our finding suggests that the incorporation of a 3D endoscopic system could facilitate thoracoscopic segmentectomy in lung cancer patients.

Artificial Intelligence-Based Hazard Detection in Robotic-Assisted Single-Incision Oncologic Surgery

THE PROBLEM

Single-incision surgery is a complex procedure in which any additional information automatically collected from the operating field can be of significance. While the use of robotic devices has greatly improved surgical outcomes, there are still many unresolved issues. One of the major surgical complications, with higher occurrence in cancer patients, is intraoperative hemorrhages, which if detected early, can be more efficiently controlled.

AIM

This paper proposes a hazard detection system which incorporates the advantages of both Artificial Intelligence (AI) and Augmented Reality (AR) agents, capable of identifying, in real-time, intraoperative bleedings, which are subsequently displayed on a Hololens 2 device.

METHODS

The authors explored the different techniques for real-time processing and determined, based on a critical analysis, that YOLOv5 is one of the most promising solutions. An innovative, real-time, bleeding detection system, developed using the YOLOv5 algorithm and the Hololens 2 device, was evaluated on different surgical procedures and tested in multiple configurations to obtain the optimal prediction time and accuracy.

RESULTS

The detection system was able to identify the bleeding occurrence in multiple surgical procedures with a high rate of accuracy. Once detected, the area of interest was marked with a bounding box and displayed on the Hololens 2 device. During the tests, the system was able to differentiate between bleeding occurrence and intraoperative irrigation; thus, reducing the risk of false-negative and false-positive results.

CONCLUSION

The current level of AI and AR technologies enables the development of real-time hazard detection systems as efficient assistance tools for surgeons, especially in high-risk interventions.

Uniportal video-assisted thoracic surgery basal segmentectomy: a single-center retrospective cohort study

BACKGROUND

Uniportal video-assisted thoracic surgery (VATS) basal segmentectomy is technically challenging and requires a deep understanding of the segmental anatomy of the lung. This report describes the uniportal VATS segmentectomy of basal segments using a single-direction approach.

METHODS

A total of 49 patients who underwent uniportal VATS basal segmentectomy between April 2019 and April 2021 were included in this retrospective study. All the surgeries were conducted using a single-direction approach. The resections of segments 7-8 were mainly performed using the interlobar fissure approach, while the resections of segments 9-10 were performed using the inferior pulmonary ligament approach.

RESULTS

A total of 33 patients underwent a single basal segmentectomy and 16 patients underwent combined basal segmentectomy/sub-segmentectomy. The median operative time was 120 min (range, 60-180 min), and the median blood loss was 20 mL (range, 10-100 mL). The median chest tube duration was 2 days (range, 1-5 days), and the median hospital stay after surgery was 4 days (range, 2-15 days). The morbidity rate after surgery was 6.1% (3/49). There were no perioperative deaths. The pathological examinations revealed 3 cases of adenocarcinoma in situ (AIS), 33 cases of minimally invasive adenocarcinoma, and 13 cases of lepidic-predominant invasive adenocarcinoma. No recrudescence or mortality was reported during the median follow-up time of 7 months (range, 2-25 months).

CONCLUSIONS

Uniportal VATS basal segmentectomy is a feasible and reliable technique based on our experience. This single-direction method allows the uniportal VATS basal segmentectomy to be performed in an easy manner with the targeted segmental bronchi and vessels exposed from superficial to deep in order of their appearance while avoiding the repeated turnover of the lung.

An aberrant medial basal segmental pulmonary artery (A7b) behind the superior segmental pulmonary vein (V6) in a patient undergoing right superior segment (S6) segmentectomy

Herein, we report the first case of a patient with lung cancer with an aberrant medial basal segmental pulmonary artery (A7b) behind the superior segmental pulmonary vein (V6) who underwent right superior segment (S6) segmentectomy via uniportal video-assisted thoracoscopic surgery (uVATS). A 56-year-old man with a right lower lobe pure ground-glass nodule (GGN), measuring 12 mm in diameter on computed tomography (CT) had an aberrant A7b branching from the basal pulmonary artery, which was located behind the V6 as detected on 3D CT. The right S6 segmentectomy, via uVATS, for the GGN was performed. The postoperative course was uneventful. The final pathological diagnosis was invasive adenocarcinoma (p-T1bN0M0, stage IA2) with no evidence of disease recurrence at 3-month follow-up. Thoracic surgeons should be aware of the possibility of damaging the A7b when dividing the V6 for S6 segmentectomy, especially during uVATS because of insufficient dorsal visibility.