Technical process and quality control of precise thoracoscopic lung segmentectomy_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

 CHEN Liang , WANG Jun , WU Weibing , ZHU Quan , WEN Wei , XU Jing , HE Zhicheng , XU Xinfeng , PAN Xianglong

Department of Thoracic Surgery, The First Affiliated Hospital of Nanjing Medical University, Jiangsu Province People’s Hospital, Nanjing, 210029, P.R.China;

Corresponding author：

CHEN Liang, Email: 2434794740@qq.com

Keywords：

Lung segmentectomy; three dimensional-computed tomography bronchography and angiography (3D-CTBA); intersegmental demarcation; quality control

DOI：

10.7507/1007-4848.201810065

Video：

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Thoracoscopic pulmonary segmentectomy is one of the important treatment methods for early lung cancer. Only the premise of surgical precision can make the radical resection of lesions and maximum reservation of healthy lung tissue be simultaneously guaranteed. As a representative of the precise lung operation, the " cone-shaped lung segmentectomy” focuses on the lesion, and combines the anatomical characteristic of the patient to design individualized operation scheme. The technological core consists of three parts, three dimensional-computed tomography bronchography and angiography (3D-CTBA) surgery path planning, accurate definition of intersegmental demarcation and anatomic dissection of intersegmental borders along the demarcation. This paper aims to explore the technical process and quality control of the key techniques of thoracoscopic precise segmentectomy, so as to standardize the segmentectomy procedure under the principle of radical and minimally invasive therapy.

Citation： CHEN Liang, WANG Jun, WU Weibing, ZHU Quan, WEN Wei, XU Jing, HE Zhicheng, XU Xinfeng, PAN Xianglong. Technical process and quality control of precise thoracoscopic lung segmentectomy. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2019, 26(1): 21-28. doi: 10.7507/1007-4848.201810065 Copy

1.	Churchill ED, Belsey R. Segmental pneumonectomy in bronchiectasis: the lingula segment of the left upper lobe. Ann Surg, 1939, 109(4): 481-499.
2.	Blades B. Conservation of lung tissue by partial lobectomy. Ann Surg, 1943, 118(3): 353-365.
3.	Overholt rh, Langer L. A new technique for pulmonary segmental resection; its application in the treatment of bronchiectasis. Surg Gynecol Obstet, 1947, 84(3): 257-268.
4.	Jensik RJ, Faber LP, Milloy FJ, et al. Segmental resection for lung cancer. A fifteen-year experience. J Thorac Cardiovasc Surg, 1973, 66(4): 563-572.
5.	Tsutani Y, Miyata Y, Nakayama H, et al. Oncologic outcomes of segmentectomy compared with lobectomy for clinical stage ⅠA lung adenocarcinoma: propensity score-matched analysis in a multicenter study. J Thorac Cardiovasc Surg, 2013, 146(2): 358-364.
6.	Landreneau RJ, Normolle DP, Christie NA, et al. Recurrence and survival outcomes after anatomic segmentectomy versus lobectomy for clinical stage Ⅰ non-small-cell lung cancer: a propensity-matched analysis. J Clin Oncol, 2014, 32(23): 2449-2455.
7.	Smith CB, Swanson SJ, Mhango G, et al. Survival after segmentectomy and wedge resection in stage Ⅰ non-small-cell lung cancer. J Thorac Oncol, 2013, 8(1): 73-78.
8.	Sienel W, Dango S, Kirschbaum A, et al. Sublobar resections in stage IA non-small cell lung cancer: segmentectomies result in significantly better cancer-related survival than wedge resections. Eur J Cardiothorac Surg, 2008, 33(4): 728-734.
9.	Hou B, Deng XF, Zhou D, et al. Segmentectomy versus wedge resection for the treatment of high-risk operable patients with stage I non-small cell lung cancer: a meta-analysis. Ther Adv Respir Dis, 2016, 10(5): 435-443.
10.	Bray F, Ferlay J, Soerjomataram I, et al. Global cancer statistics 2018: Globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin, 2018, 68(6): 394-424.
11.	Cheng X, Onaitis MW, D'amico TA, et al. Minimally invasive thoracic surgery 3.0: lessons learned from the history of lung cancer surgery. Ann Surg, 2018, 267(1): 37-38.
12.	Nakamura K, Saji H, Nakajima R, et al. A phase Ⅲ randomized trial of lobectomy versus limited resection for small-sized peripheral non-small cell lung cancer (JCOG0802/WJOG4607L). Jpn J Clin Oncol, 2010, 40(3): 271-274.
13.	Wu WB, Xu XF, Wen W, et al. Three-dimensional computed tomography bronchography and angiography in the preoperative evaluation of thoracoscopic segmentectomy and subsegmentectomy. J Thorac Dis, 2016, 8(Suppl 9): S710-S715.
14.	Boyden EA. Segmental Anatomy of The Lung. McGraw Hill, New York, 1954.
15.	Yamashita H. Roentgenologic Anatomy of the Lung, Igaku-shoin, Tokyo, Japan, 1978.
16.	Yao F, Wang J, Yao J, et al. Three-dimensional image reconstruction with free open-source OsiriX software in video-assisted thoracoscopic lobectomy and segmentectomy. Int J Surg, 2017, 39: 16-22.
17.	Li J, Nie L, Li Z, et al. Maximizing modern distribution of complex anatomical spatial information: 3D reconstruction and rapid prototype production of anatomical corrosion casts of human specimens. Anat Sci Educ, 2012, 5(6): 330-339.
18.	Wu WB, Xu XF, Wen W, et al. Thoracoscopic pulmonary sub-aubsegmentectomy based on three-dimensional images. Ann Thorac Surg, 2016, 102(5): e389-e391.
19.	El-Sherif A, Fernando HC, Santos R, et al. Margin and local recurrence after sublobar resection of non-small cell lung cancer. Ann Surg Oncol, 2007, 14(8): 2400-2405.
20.	Sienel W, Stremmel C, Kirschbaum A, et al. Frequency of local recurrence following segmentectomy of stage ⅠA non-small cell lung cancer is influenced by segment localisation and width of resection margins--implications for patient selection for segmentectomy. Eur J Cardiothorac Surg, 2007, 31(3): 522-527.
21.	Schuchert MJ, Pettiford BL, Keeley S, et al. Anatomic segmentectomy in the treatment of stage Ⅰ non-small cell lung cancer. Ann Thorac Surg, 2007, 84(3): 926-932.
22.	Frajhof L, Borges J, Hoffmann E, et al. Virtual reality, mixed reality and augmented reality in surgical planning for video or robotically assisted thoracoscopic anatomic resections for treatment of lung cancer. J Visualized Surg, 2018, 4: 143.
23.	Tan W, Ge W, Hang Y, et al. Computer assisted system for precise lung surgery based on medical image computing and mixed reality. Health Inf Sci Syst, 2018, 6(1): 10.
24.	Chicco P, Magnussen JS, Vu DH, et al. Determining the cross-sectional segmental anatomy of cadaveric human lungs. Clin Anat, 2001, 14(1): 10-14.
25.	Sekine Y, Ko E, Oishi H, et al. A simple and effective technique for identification of intersegmental planes by infrared thoracoscopy after transbronchial injection of indocyanine green. J Thorac Cardiovasc Surg, 2012, 143(6): 1330-1335.
26.	Zhang Z, Liao Y, Ai B, et al. Methylene blue staining: a new technique for identifying intersegmental planes in anatomic segmentectomy. Ann Thorac Surg, 2015, 99(1): 238-242.
27.	Tarumi S, Yokomise H. Video-assisted thoracoscopic segmentectomy using infrared thoracoscopy with indocyanine green. Kyobu Geka, 2016, 69(8): 671-675.
28.	Misaki N, Chang SS, Igai H, et al. New clinically applicable method for visualizing adjacent lung segments using an infrared thoracoscopy system. J Thorac Cardiovasc Surg, 2010, 140(4): 752-756.
29.	Sakamoto K, Kanzaki M, Mitsuboshi S, et al. A novel and simple method for identifying the lung intersegmental plane using thermography. Interact Cardiovasc Thorac Surg, 2016, 23(1): 171-173.
30.	Shields TW, Chief editor. General Thoracic Surgery, 2nd edn. Lea and Febiger, Philadelphia, 1983. 326-338.
31.	Wells FC, Milstein BB. Thoracic Surgical Techniques. Bailliere Tindall, London, 1990. 126-134.
32.	Van Allen CM, Lindskog GE, Richter HG. Collateral respiration. transfer of air collaterally between pulmonary lobules. J Clin Invest, 1931, 10(3): 559-590.
33.	Cordingley JL. Pores of Kohn. Thorax, 1972, 27(4): 433-441.
34.	Matsuoka H, Nishio W, Sakamoto T, et al. Selective segmental jet injection to distinguish the intersegmental plane using jet ventilation. Jpn J Thorac Cardiovasc Surg, 2003, 51(8): 400-401.
35.	Kamiyoshihara M, Kakegawa S, Morishita Y. Convenient and improved method to distinguish the intersegmental plane in pulmonary segmentectomy using a butterfly needle. Ann Thorac Surg, 2007, 83(5): 1913-1914.
36.	Otsuka T, Nakamura Y, Harada A, et al. Extremely rare but potential complication of diffuse brain edema due to air embolism during lung segmentectomy with selected segmental inflation technique by syringe needle during video-assisted thoracoscopic surgery. J Thorac Cardiovasc Surg, 2011, 142(5): e151-e152.
37.	Tsubota N. An improved method for distinguishing the intersegmental plane of the lung. Surg Today, 2000, 30(10): 963-964.
38.	Oizumi H, Kato H, Endoh M, et al. Slip knot bronchial ligation method for thoracoscopic lung segmentectomy. Ann Thorac Surg, 2014, 97(4): 1456-1458.
39.	Wang J, Xu X, Wen W, et al. Modified method for distinguishing the intersegmental border for lung segmentectomy. Thorac Cancer, 2018, 9(2): 330-333.
40.	翟荣, 徐心峰, 王俊, 等. 肺段切除术中改良膨胀萎陷法影响因素研究. 南京医科大学学报 (自然科学版), 2018, 8(8): 1136-1139.
41.	Overholt RH, Woods FM, Ramsay BH. Segmental pulmonary resection; details of technique and results. J Thorac Surg, 1950, 19(2): 207-225.
42.	Pearson GA, Cooper JD, Deslauriers J, et al. Chief editor. Pearson’s Thoracic &Amp; Esophageal Surgery, 3rd edn. Churchill Livingstone/Elsevier, Philadelphia, 2008. 887-893.
43.	Deng B, Cassivi SD, de Andrade M, et al. Clinical outcomes and changes in lung function after segmentectomy versus lobectomy for lung cancer cases. J Thorac Cardiovasc Surg, 2014, 148(4): 1186-1192.
44.	Asakura K, Izumi Y, Kohno M, et al. Effect of cutting technique at the intersegmental plane during segmentectomy on expansion of the preserved segment: comparison between staplers and scissors in ex vivo pig lung. Eur J Cardiothorac Surg, 2011, 40(1): e34-e38.
45.	Ohtsuka T, Goto T, Anraku M, et al. Dissection of lung parenchyma using electrocautery is a safe and acceptable method for anatomical sublobar resection. J Cardiothorac Surg, 2012, 7: 42.
46.	Miyasaka Y, Oh S, Takahashi N, et al. Postoperative complications and respiratory function following segmentectomy of the lung - comparison of the methods of making an inter-segmental plane. Interact Cardiovasc Thorac Surg, 2011, 12(3): 426-429.
47.	Tao H, Tanaka T, Hayashi T, et al. Influence of stapling the intersegmental planes on lung volume and function after segmentectomy. Interact Cardiovasc Thorac Surg, 2016, 23(4): 548-552.
48.	Saito H, Konno H, Atari M, et al. Management of intersegmental plane on pulmonary segmentectomy concerning postoperative complications. Ann Thorac Surg, 2017, 103(6): 1773-1780.
49.	Takagi K, Hata Y, Sasamoto S, et al. Late onset postoperative pulmonary fistula following a pulmonary segmentectomy using electrocautery or a harmonic scalpel. Ann Thorac Cardiovasc Surg, 2010, 16(1): 21-25.
50.	Ramsay BH. The anatomic guide to the intersegmental plane. Surgery, 1949, 25(4): 533-538.
51.	Wang J, Xu X, Wen W, et al. Technique for tailoring complex demarcation in lung segmentectomy. Thorac Cancer, 2018, 9(11): 1562-1564.

1. Churchill ED, Belsey R. Segmental pneumonectomy in bronchiectasis: the lingula segment of the left upper lobe. Ann Surg, 1939, 109(4): 481-499.
2. Blades B. Conservation of lung tissue by partial lobectomy. Ann Surg, 1943, 118(3): 353-365.
3. Overholt rh, Langer L. A new technique for pulmonary segmental resection; its application in the treatment of bronchiectasis. Surg Gynecol Obstet, 1947, 84(3): 257-268.
4. Jensik RJ, Faber LP, Milloy FJ, et al. Segmental resection for lung cancer. A fifteen-year experience. J Thorac Cardiovasc Surg, 1973, 66(4): 563-572.
5. Tsutani Y, Miyata Y, Nakayama H, et al. Oncologic outcomes of segmentectomy compared with lobectomy for clinical stage ⅠA lung adenocarcinoma: propensity score-matched analysis in a multicenter study. J Thorac Cardiovasc Surg, 2013, 146(2): 358-364.
6. Landreneau RJ, Normolle DP, Christie NA, et al. Recurrence and survival outcomes after anatomic segmentectomy versus lobectomy for clinical stage Ⅰ non-small-cell lung cancer: a propensity-matched analysis. J Clin Oncol, 2014, 32(23): 2449-2455.
7. Smith CB, Swanson SJ, Mhango G, et al. Survival after segmentectomy and wedge resection in stage Ⅰ non-small-cell lung cancer. J Thorac Oncol, 2013, 8(1): 73-78.
8. Sienel W, Dango S, Kirschbaum A, et al. Sublobar resections in stage IA non-small cell lung cancer: segmentectomies result in significantly better cancer-related survival than wedge resections. Eur J Cardiothorac Surg, 2008, 33(4): 728-734.
9. Hou B, Deng XF, Zhou D, et al. Segmentectomy versus wedge resection for the treatment of high-risk operable patients with stage I non-small cell lung cancer: a meta-analysis. Ther Adv Respir Dis, 2016, 10(5): 435-443.
10. Bray F, Ferlay J, Soerjomataram I, et al. Global cancer statistics 2018: Globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin, 2018, 68(6): 394-424.
11. Cheng X, Onaitis MW, D'amico TA, et al. Minimally invasive thoracic surgery 3.0: lessons learned from the history of lung cancer surgery. Ann Surg, 2018, 267(1): 37-38.
12. Nakamura K, Saji H, Nakajima R, et al. A phase Ⅲ randomized trial of lobectomy versus limited resection for small-sized peripheral non-small cell lung cancer (JCOG0802/WJOG4607L). Jpn J Clin Oncol, 2010, 40(3): 271-274.
13. Wu WB, Xu XF, Wen W, et al. Three-dimensional computed tomography bronchography and angiography in the preoperative evaluation of thoracoscopic segmentectomy and subsegmentectomy. J Thorac Dis, 2016, 8(Suppl 9): S710-S715.
14. Boyden EA. Segmental Anatomy of The Lung. McGraw Hill, New York, 1954.
15. Yamashita H. Roentgenologic Anatomy of the Lung, Igaku-shoin, Tokyo, Japan, 1978.
16. Yao F, Wang J, Yao J, et al. Three-dimensional image reconstruction with free open-source OsiriX software in video-assisted thoracoscopic lobectomy and segmentectomy. Int J Surg, 2017, 39: 16-22.
17. Li J, Nie L, Li Z, et al. Maximizing modern distribution of complex anatomical spatial information: 3D reconstruction and rapid prototype production of anatomical corrosion casts of human specimens. Anat Sci Educ, 2012, 5(6): 330-339.
18. Wu WB, Xu XF, Wen W, et al. Thoracoscopic pulmonary sub-aubsegmentectomy based on three-dimensional images. Ann Thorac Surg, 2016, 102(5): e389-e391.
19. El-Sherif A, Fernando HC, Santos R, et al. Margin and local recurrence after sublobar resection of non-small cell lung cancer. Ann Surg Oncol, 2007, 14(8): 2400-2405.
20. Sienel W, Stremmel C, Kirschbaum A, et al. Frequency of local recurrence following segmentectomy of stage ⅠA non-small cell lung cancer is influenced by segment localisation and width of resection margins--implications for patient selection for segmentectomy. Eur J Cardiothorac Surg, 2007, 31(3): 522-527.
21. Schuchert MJ, Pettiford BL, Keeley S, et al. Anatomic segmentectomy in the treatment of stage Ⅰ non-small cell lung cancer. Ann Thorac Surg, 2007, 84(3): 926-932.
22. Frajhof L, Borges J, Hoffmann E, et al. Virtual reality, mixed reality and augmented reality in surgical planning for video or robotically assisted thoracoscopic anatomic resections for treatment of lung cancer. J Visualized Surg, 2018, 4: 143.
23. Tan W, Ge W, Hang Y, et al. Computer assisted system for precise lung surgery based on medical image computing and mixed reality. Health Inf Sci Syst, 2018, 6(1): 10.
24. Chicco P, Magnussen JS, Vu DH, et al. Determining the cross-sectional segmental anatomy of cadaveric human lungs. Clin Anat, 2001, 14(1): 10-14.
25. Sekine Y, Ko E, Oishi H, et al. A simple and effective technique for identification of intersegmental planes by infrared thoracoscopy after transbronchial injection of indocyanine green. J Thorac Cardiovasc Surg, 2012, 143(6): 1330-1335.
26. Zhang Z, Liao Y, Ai B, et al. Methylene blue staining: a new technique for identifying intersegmental planes in anatomic segmentectomy. Ann Thorac Surg, 2015, 99(1): 238-242.
27. Tarumi S, Yokomise H. Video-assisted thoracoscopic segmentectomy using infrared thoracoscopy with indocyanine green. Kyobu Geka, 2016, 69(8): 671-675.
28. Misaki N, Chang SS, Igai H, et al. New clinically applicable method for visualizing adjacent lung segments using an infrared thoracoscopy system. J Thorac Cardiovasc Surg, 2010, 140(4): 752-756.
29. Sakamoto K, Kanzaki M, Mitsuboshi S, et al. A novel and simple method for identifying the lung intersegmental plane using thermography. Interact Cardiovasc Thorac Surg, 2016, 23(1): 171-173.
30. Shields TW, Chief editor. General Thoracic Surgery, 2nd edn. Lea and Febiger, Philadelphia, 1983. 326-338.
31. Wells FC, Milstein BB. Thoracic Surgical Techniques. Bailliere Tindall, London, 1990. 126-134.
32. Van Allen CM, Lindskog GE, Richter HG. Collateral respiration. transfer of air collaterally between pulmonary lobules. J Clin Invest, 1931, 10(3): 559-590.
33. Cordingley JL. Pores of Kohn. Thorax, 1972, 27(4): 433-441.
34. Matsuoka H, Nishio W, Sakamoto T, et al. Selective segmental jet injection to distinguish the intersegmental plane using jet ventilation. Jpn J Thorac Cardiovasc Surg, 2003, 51(8): 400-401.
35. Kamiyoshihara M, Kakegawa S, Morishita Y. Convenient and improved method to distinguish the intersegmental plane in pulmonary segmentectomy using a butterfly needle. Ann Thorac Surg, 2007, 83(5): 1913-1914.
36. Otsuka T, Nakamura Y, Harada A, et al. Extremely rare but potential complication of diffuse brain edema due to air embolism during lung segmentectomy with selected segmental inflation technique by syringe needle during video-assisted thoracoscopic surgery. J Thorac Cardiovasc Surg, 2011, 142(5): e151-e152.
37. Tsubota N. An improved method for distinguishing the intersegmental plane of the lung. Surg Today, 2000, 30(10): 963-964.
38. Oizumi H, Kato H, Endoh M, et al. Slip knot bronchial ligation method for thoracoscopic lung segmentectomy. Ann Thorac Surg, 2014, 97(4): 1456-1458.
39. Wang J, Xu X, Wen W, et al. Modified method for distinguishing the intersegmental border for lung segmentectomy. Thorac Cancer, 2018, 9(2): 330-333.
40. 翟荣, 徐心峰, 王俊, 等. 肺段切除术中改良膨胀萎陷法影响因素研究. 南京医科大学学报 (自然科学版), 2018, 8(8): 1136-1139.
41. Overholt RH, Woods FM, Ramsay BH. Segmental pulmonary resection; details of technique and results. J Thorac Surg, 1950, 19(2): 207-225.
42. Pearson GA, Cooper JD, Deslauriers J, et al. Chief editor. Pearson’s Thoracic &Amp; Esophageal Surgery, 3rd edn. Churchill Livingstone/Elsevier, Philadelphia, 2008. 887-893.
43. Deng B, Cassivi SD, de Andrade M, et al. Clinical outcomes and changes in lung function after segmentectomy versus lobectomy for lung cancer cases. J Thorac Cardiovasc Surg, 2014, 148(4): 1186-1192.
44. Asakura K, Izumi Y, Kohno M, et al. Effect of cutting technique at the intersegmental plane during segmentectomy on expansion of the preserved segment: comparison between staplers and scissors in ex vivo pig lung. Eur J Cardiothorac Surg, 2011, 40(1): e34-e38.
45. Ohtsuka T, Goto T, Anraku M, et al. Dissection of lung parenchyma using electrocautery is a safe and acceptable method for anatomical sublobar resection. J Cardiothorac Surg, 2012, 7: 42.
46. Miyasaka Y, Oh S, Takahashi N, et al. Postoperative complications and respiratory function following segmentectomy of the lung - comparison of the methods of making an inter-segmental plane. Interact Cardiovasc Thorac Surg, 2011, 12(3): 426-429.
47. Tao H, Tanaka T, Hayashi T, et al. Influence of stapling the intersegmental planes on lung volume and function after segmentectomy. Interact Cardiovasc Thorac Surg, 2016, 23(4): 548-552.
48. Saito H, Konno H, Atari M, et al. Management of intersegmental plane on pulmonary segmentectomy concerning postoperative complications. Ann Thorac Surg, 2017, 103(6): 1773-1780.
49. Takagi K, Hata Y, Sasamoto S, et al. Late onset postoperative pulmonary fistula following a pulmonary segmentectomy using electrocautery or a harmonic scalpel. Ann Thorac Cardiovasc Surg, 2010, 16(1): 21-25.
50. Ramsay BH. The anatomic guide to the intersegmental plane. Surgery, 1949, 25(4): 533-538.
51. Wang J, Xu X, Wen W, et al. Technique for tailoring complex demarcation in lung segmentectomy. Thorac Cancer, 2018, 9(11): 1562-1564.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Technical process and quality control of precise thoracoscopic lung segmentectomy

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