How to demarcate intersegmental plane with resected-segments inflation method using the slip knot technique in thoracoscopic anatomic segmentectomy

Abstract

Intersegmental demarcation line on the surface of the visceral pleura could not be found at thoracoscopic findings. The resected segments inflation (RSI) method has been reported as a useful technique for visualizing the intersegmental demarcation line during segmentectomy. Thoracoscopic anatomic segmentectomy is performed as follows: firstly, the pulmonary vein and artery of the segment planned for resection are dissected from the hilum in order to isolate the segmental bronchus located behind the pulmonary artery. Secondly, a monofilament non-absorbable suture is passed through the segmental bronchus, and a slip-knot is made outside the thorax. Thirdly, bilateral lung ventilation with pure oxygen is conducted. When the affected segment has inflated sufficiently, the slip knot suture is pulled and the segmental bronchus is ligated and collapse of the lung is made on reserved segments. Fourthly, as inflation of the affected segment and collapse of the reserved segments could be found, resection of intersegmental plane could be easily performed with the inflation-deflation line and the intersegmental pulmonary vein. If resected segmental bronchus could be identified, thoracoscopic segmentectomy with the slip-knot technique would be applicable. This slip-knot procedure is economical and is not need special instrument. RSI methodAir is sent to the objective segmental bronchus located at the center of the basic pulmonary structure. The affected segment is inflated and reserved segments are collapsed and an intersegmental plane could be identified. If this is visualized well, resection of intersegmental plane could be easily performed with the inflation-deflation line and the intersegmental pulmonary vein. The lung parenchyma that is undergoing dissection of the intersegmental plane shows changes of the color by containing the air, which serves as a landmark during dissection. This method is advantageous in that inflated segments enable identify the surgical margin from the tumor to the intersegmental plane in an air-filled condition (6).Several methods for sending air to the resected segments have been reported. They include the jet ventilation method (7,8), and the butterfly needle method (9,10). The butterfly needle method involves the risk of an air embolism due to possible entry of air into the vein neighboring the bronchus (11,12). In this paper, we demonstrated that a new slip knot technique to make intersegmental demarcation line during segentectomy. Slip knot techniqueWe have been using the RSI method to identify the intersegmental plane. In the past, bronchoscopy was used to send air to the objective bronchus. However, this technique is skillful and the inflated segments become an obstacle to perform a thoracoscopic procedure in narrow intrathoracic space. To resolve the problems, we developed the slip knot technique, and use this technique to perform thoracoscopic anatomic segmentectomy.The modified Roeder knot is a method of ligation that is employed for the slip knot technique (13). A 3-0 or 4...

Recent fluorescence-based optical imaging for video-assisted thoracoscopic surgery segmentectomy

“…Above all, the accurate intraoperative identification of the target intersegmental plane is essential to the procedure, especially with regard to video-assisted thoracoscopic surgery (VATS) segmentectomy. Several intraoperative methods for identifying the intersegmental plane have been reported (9)(10)(11)(12).…”

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“…However, serious risks have been reported concerning this air insufflating method (17). To address these issues, we developed the slip-knot method and have used it to successfully perform thoracoscopically anatomical segmentectomy (18,19). The aim of this study was to describe a series of portaccess thoracoscopic anatomical segmentectomies using the slip-knot method and to determine the feasibility of this method by assessing surgical and clinical results of 221 resections.…”

“…The slip-knot was made outside of the thorax and advanced by pulling the opposite side of the thread ( Figure 1A). Bilateral ventilation was started with 100% oxygen ( Figure 1B) (19). After lung expansion the suture was pulled, which ligated the bronchus and blocked the outflow of air from the affected segment.…”

Novel techniques for video-assisted thoracoscopic surgery segmentectomy

“…Okada et al reported the use of selective segmental inflation via jet ventilation (25). Endoh et al reported the use of a slip knot to close the selective segmental bronchi (26). After inflating the whole lung, they closed the targeted segmental bronchi using a slip knot.…”