Single-direction thoracoscopic basal segmentectomy

Abstract

Objective: Thoracoscopic anatomic single or combined basal segmentectomy is technically challenging because of the variation and deep location of vessels and bronchi in the parenchyma. This study aimed to describe thoracoscopic segmentectomy of basal segments using a single-direction method. Methods: This retrospective study included 137 patients who underwent single or combined thoracoscopic basal segmentectomy between April 2015 and August 2019. All procedures were performed via the preferred inferior pulmonary ligament approach or an interlobar fissure approach following a single-direction strategy. Results: Ninety patients underwent single basal segmentectomy, and 47 patients underwent combined basal segmentectomy. Median operative time was 125 minutes (range, 52-237 minutes), and median blood loss was 30 mL (range, 5-250 mL). Median chest tube duration was 2 days (range, 1-22 days), and median postoperative hospital stay was 4 days (range, 2-24 days). The postoperative morbidity rate was 5.1% (7/137). No perioperative deaths were identified. Pathological examination revealed 133 cases of lung cancer, 2 cases of metastasis, and 2 cases of benign tumors. No recurrence or mortality was observed during the median follow-up period of 15 months (range, 1-53 months). Conclusions: The single-direction method for thoracoscopic single or combined basal segmentectomy was feasible and safe in our experience. This method exposes the targeted vessels and bronchi from superficial to deep in order of their appearance and enables anatomic resection of a single segment or combined basal segments to be performed in a simple manner while avoiding dissection of a hypoplastic fissure or inessential splitting of the lung parenchyma.

Three-dimensional reconstruction facilitates thoracoscopic anatomical partial lobectomy by an inexperienced surgeon: a single-institution retrospective review

“…Thoracoscopic APL for basal segment or subsegment is technically challenging because of the variation and deep location of vessels and bronchi in the parenchyma (13). We have already described the detailed procedures of right S9+10 segmentectomy in previous reports (14).…”

Thoracoscopic subxiphoid right S9+10 segmentectomy: a case report

“…Anterior fissure dissection also gives an easier access to hilar and segmental LN dissection, a mandatory step in NSCLC indications. Furthermore, it facilitates for us the following Inferior pulmonary ligament approach, described by its defenders as a "stem branch technique" contributing to an easier reliable tracking of deeply located targeted segmental branches, successively, venous, bronchial, and then arterial one (7)(8)(9)(10). This unidirectional inferior approach avoids also unnecessary fissure dissection and airleaks that goes with it but is not totally satisfactory in an oncological perspective.…”

“…One is an "interlobar fissure-first" approach involving identification of lower lobe arterial branches before exposure of the hilum of basal segments by creating a posterior tunnel, allowing S 6 to be partially or totally separated from the basal segments through a posterior or a bidirectional approach (4)(5)(6). The other is a singledirectional "inferior pulmonary ligament" approach, tracking the target segmental branches, starting with venous distal confluence dissection, followed by bronchial elements before segmental arterial identification, described as the "stem-branch" technique, without the need for interlobar fissure dissection (7)(8)(9)(10).…”

Commentary: Basilar segmentectomy: A new weapon against cancer for the modern thoracic surgeon?

“…Identifying which patients truly benefit from basilar segmentectomy over lower lobectomy is a question not addressed by this study. Nonetheless, we believe this article by Liu and colleagues 6 provides novel information and describes a useful surgical technique that will become more relevant as we are increasingly called to address smaller and potentially less aggressive cancers. We acknowledge the authors for the excellent visual contents in the article, which are essential for the understanding of their technique.…”

“…The investigators' description of how to locate the relevant basilar segmental structures on computed tomography scan and during thoracoscopy is especially helpful. For the patients in this study, Liu and colleagues 6 generally started the dissection by retracting the lower lobe cranially and then dissecting the inferior pulmonary vein. In 75% of patients, this was possible, whereas they started the dissection in the fissure in the other 25% of patients.…”