Hybrid technique of virtual-assisted lung mapping and systemic indocyanine green injection for extended segmentectomy

Abstract

Background Various approaches have been used to assist and facilitate segmentectomy with favorable oncological outcomes. We describe a hybrid approach comprising virtual-assisted lung mapping (VAL-MAP), which is a preoperative bronchoscopic dye-marking technique, combined with systemic indocyanine green (ICG) injection. Clinical presentation An asymptomatic 64-year-old man was referred to our department because of a lung nodule detected during his annual medical checkup. The chest computed-tomography image revealed a 16-mm, partly solid, ground-glass nodule in the left segment 4. Because the nodule was hardly palpable and deeply located between the left upper division segment and the left lingular segment, we performed VAL-MAP to facilitate extended left lingulectomy. Five dye markings were undertaken preoperatively. Surgery to remove the nodule was then conducted via complete three-port video-assisted thoracic surgery. The VAL-MAP markings were easily identified intraoperatively and helped locate the nodule. The intersegmental plane was identified by the ICG injection. The resection line was determined based on the intersegmental plane identified by the ICG injection and the site of the nodule suggested by the VAL-MAP markings. Following the resection line, we thoracoscopically achieved extended lingulectomy with sufficient surgical margins. The patient was discharged with no complications. The pathological diagnosis was adenocarcinoma in situ. Conclusion The hybrid technique of VAL-MAP and systemic ICG injection can be useful for accomplishing successful extended segmentectomy.

How to identify the intersegmental plane?—a narrative review

“…They found that intravenous ICG method was totally concordant with the modified inflation-deflation method. Finally, the benefit of a hybrid technique of VAL-MAP and systemic injection was recently demonstrated for a nodule deeply located between the left upper division segment and the left lingular segment (34). Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.…”

Computed Tomography-Guided Localization and Extended Segmentectomy for Non-Small Cell Lung Cancer

“…However, another concern may be lung volume wasting. Extended segmentectomy is an alternative to increase safety margins during pulmonary nodule resection [ 11 ]. We defined extended segmentectomy as segmentectomy with a wedge resection of a neighbor segment ( Figure 2 ).…”

Commentary: We must constantly look at things in different ways

“…When nodules are found in peripheral segments or intersegmental planes, it is critical to carefully consider the tumor location and segmental region to provide radical surgical margins. 9 In conclusion, accurate knowledge of the nodule and intersegmental plane is required to perform a successfully complex segmentectomy. While VAL-MAP was initially designed to aid in tumor localization, the hybrid approach employing VAL-MAP and systemic indocyanine green injection showed efficacy in enabling segmentectomy.…”

“…When nodules are found in peripheral segments or intersegmental planes, it is critical to carefully consider the tumor location and segmental region to provide radical surgical margins. 9 …”

“…While VAL-MAP was initially designed to aid in tumor localization, the hybrid approach employing VAL-MAP and systemic indocyanine green injection showed efficacy in enabling segmentectomy. 9 As a result, the 2 techniques complement one another, locating the nodule and identifying the intersegmental plane, allowing us to perform segmentectomies, even with a minimally invasive approach. 4 “John Keating: Why do I stand up here?…”