Management of the inter-segmental plane using the “Combined Dimensional Reduction Method” is safe and viable in uniport video-assisted thoracoscopic pulmonary segmentectomy

Abstract

Background: The management of the intersegmental plane (ISP) is challenging during uniport videoassisted thoracoscopic (VATS) pulmonary segmentectomy. Staplers and electrocautery have been used extensively in ISP management. However, both of them have their respective drawbacks. Currently, we have provided a revised technique termed as "Combined Dimensional Reduction Method" (CDR method), for managing the ISP with combined application of ultrasonic scalpel and staplers. The study aimed to review the outcomes of patients who underwent uniport VATS segmentectomy with or without the CDR method in our institute and assess the feasibility and safety of the CDR method.Methods: From March 2017 to February 2018, 220 patients who underwent uniport VATS segmentectomy were retrospectively reviewed. By using IQQA software, pulmonary structures were reconstructed as three-dimensional (3D) images, making the targeted structures could be identified preoperatively. For the management of the ISP, in the CDR group, we firstly used the ultrasonic scalpel to trim the 3D pulmonary structure along the intersegmental demarcation, making the remaining targeted parenchyma both sufficiently thin enough and located on a 2D plane; thus, enabling easy use of staplers in managing ISP. Whereas, in the non-CDR group, we only use the staplers to manage the ISPs. The clinical characteristics, complications, and postoperative pulmonary functions were compared between the two groups.Results: Propensity score analysis generated 2 well-matched pairs of 71 patients in CDR and non-CDR groups. There was no 30-day postoperative death or readmission in either group. The CDR group was significantly associated with the shorter operative time (178.3±35.8 vs. 209.2±28.7 min) (P=0.031) and postoperative stay (4.5±2.3 vs. 5.7±4.2 days) (P=0.041), compared to the non-CDR group. Moreover, no significant difference was observed in blood loss, a period of chest tube drainage, a period of ultrafine tube drainage, and postoperative pulmonary complications between the two groups. Moreover, the recovery rate of postoperative forced expiratory volume in 1 second (FEV1) or vital capacity (VC) at 1 and 3 months after segmentectomy was comparable between them. Conclusions:The CDR method could make segmentectomy easier and more accurate, and therefore has the potential to be a viable and effective technique for uniport VATS pulmonary segmentectomy.

A novel form of precise segmentectomy—Triumphal arch‐like anatomical segmentectomy

“…This technique is based on the combined dimensional reduction method. We finished nearly three‐fourths of the proximal parenchyma division with an ultrasonic scalpel to make the remaining peripheral parenchyma thin enough, and then tailored the remaining parenchyma using the stapler 3 . It decreases the risk of extension of the resection to the adjacent segment.…”

“…To a certain extent, the possibility of postoperative residual pulmonary torsion is reduced. Additionally, this technique has the advantages of being less costly 3,5 . Of course, the “tunnel‐line” dissection prolongs the operation time, and has higher requirements for the operator in terms of visual field exposure and tissue separation.…”

“…From the oblique fissure position, the targeted arteries A9 and targeted bronchi B9 were exposed and then divided by ligation or stapler (Figure 2a,b ). Then, we used a modified inflation‐deflation method 3 to create a demarcation line between the inflated targeted tissue and deflated adjacent tissue, showing preserved tissue straddling the target tissue, like an arch (Figure 2c,d ). Using the bronchial stump at the proximal end of the target tissue for traction, we used combined dimensional reduction (CDR) method 3 to perform the separation.…”

Electrocautery vs. Stapler in Comparing Safety for Segmentectomy of Lung Cancer: A Meta-Analysis

“…The most appropriate surgical instruments for segmentectomy in patients with lung cancer have been debated for a long time ( 20 , 21 ). It is generally believed that electrocautery is more applicable to primary tumor removal because its smaller and more flexible front end enables the precise outlining of the tumor boundaries and thus apparently reduces the removal of normal lung tissues and reserves more pulmonary functions for patients.…”

“…The outcomes showed a lower air leak time (1.7 vs. 4.5 days) and less cost (425 vs. 630.5 euros) in the electrocautery group accompanied by the usage of human fibrinogen and thrombin than stapler group for the completion of interlobar fissures during pulmonary lobectomy, which may indicate another proper range for the usage of electrocautery. Besides, the usage of other surgical techniques is also under controversy, such as the usage of three-dimensional reconstruction and Harmonic ultrasonic scalpel ( 21 ).…”