The arterial-ligation-alone method for identifying the intersegmental plane during thoracoscopic anatomic segmentectomy

Abstract

Background: Currently, methods for identifying the intersegmental plane during anatomical segmentectomy can be classified into 2 categories: the bronchial method and the vascular method. One of the vascular methods, the arterial-ligation-alone method, has not yet been validated or objectively evaluated in a large case series. We thus aimed to confirm that the arterial-ligation-alone method could effectively and accurately identify the intersegmental plane. Methods: We retrospectively reviewed the records of 104 patients who were scheduled for thoracoscopic anatomic segmentectomy. Preoperative three-dimensional (3D) reconstruction was performed on all the affected lungs to distinguish the targeted segmental arteries, veins and bronchi. The procedure was as follows: first, based on the 3D reconstruction of the lung, the targeted segmental arteries were distinguished and ligated. Second, bilateral pulmonary ventilation was performed with pure oxygen. When the affected lung had completely inflated, contralateral pulmonary ventilation was performed. After waiting for some time, the first intersegmental plane could be obtained, and the time was recorded as T1, with an electric coagulation hook being used for marking. Thirdly, when the targeted segmental veins and bronchi had been ligated, the second intersegmental plane could be obtained by the inflation-deflation method as before, with the waiting time being recorded as T2. The differences between the 2 intersegmental planes were evaluated by 2 experienced chief thoracic surgeons.Result: In a total of 99 (95.2%) patients, the intersegmental planes were successfully and accurately identified by the arterial-ligation-alone method. Ultimately, 85 (81.7%) patients underwent thoracoscopic anatomic segmentectomy. The results for evaluating the differences between the 2 planes were as follows:completely consistent (94 cases, 94.9%), basically consistent (5 cases, 5.1%), and discrepant (0 cases, 0%).The mean T1 was 13.6±2.7 minutes (range, 8-25 minutes), and the mean T2 was 13.0±2.6 minutes (range, 8-23 minutes), with P=0.100 (95% CI). For 99 patients, the mean nodule size was 1.1±0.34 cm. In the 85 patients who underwent segmentectomy, the mean margin width was 2.84±0.51 cm, the mean operative duration was 165.6±18.3 minutes, the mean operative hemorrhage was 52.1±20.2 mL, and the mean duration of chest tube drainage was 3.9±1.3 days. Postoperative complications related to operative procedures occurred in 2 cases. Conclusions: The arterial-ligation-only method can effectively, accurately and inexpensively identify the intersegmental plane, and is especially suitable for the patients whose veins or bronchi are difficult to anatomize. Whether the target bronchus is ligated has no effect on the intersegmental plane.

Surgeon Knowledge of the Pulmonary Arterial System and Surgical Plan Confidence Is Improved by Interactive Virtual 3D-CT Models of Lung Cancer Patient Anatomies

“…A statistically significant (p < 0.05) improvement in surgeon opinion on ease and confidence in planning was observed, with a median difference of 2 when the CT Likert scale score was subtracted from the 3D-CT Likert scale score. and statistical priors can complement existing approaches to fissure identification such as bronchial ligation (17), arterial ligation (18), and indocyanine green (ICG) (19). In future work, we plan to add this additional information to the virtual 3D models.…”

“…Various computational techniques exist on how to estimate the inter-segmental fissure when it cannot be directly observed in the CT scan ( 13 , 16 ). Virtual 3D models with segmental surfaces derived from medical scans and statistical priors can complement existing approaches to fissure identification such as bronchial ligation ( 17 ), arterial ligation ( 18 ), and indocyanine green (ICG) ( 19 ). In future work, we plan to add this additional information to the virtual 3D models.…”

Demarcation of arteriopulmonary segments: a novel and effective method for the identification of pulmonary segments

“…30,31 The automatic approach has only achieved an overall detection sensitivity of 77% compared with the manual approach and is not satisfactory in the clinical setting. 12 In addition, Fu et al 32 reported that the intersegmental planes are inaccurate when using this method because of the presence of pores of Kohn, canals of Lambert, and direct airway anastomosis. Although Fu et al 32 confirmed that arterial ligation alone allowed for identification of the intersegmental planes in 99 (95.2%) patients during thoracoscopic anatomical segmentectomy, they could not accurately identify the intersegmental plane and the spatial location of the mass in a pulmonary segment before the surgical operation to shorten the surgical time.…”

“…12 In addition, Fu et al 32 reported that the intersegmental planes are inaccurate when using this method because of the presence of pores of Kohn, canals of Lambert, and direct airway anastomosis. Although Fu et al 32 confirmed that arterial ligation alone allowed for identification of the intersegmental planes in 99 (95.2%) patients during thoracoscopic anatomical segmentectomy, they could not accurately identify the intersegmental plane and the spatial location of the mass in a pulmonary segment before the surgical operation to shorten the surgical time. Therefore, we have herein proposed a novel and effective way to segment the lung into arteriopulmonary segments.…”

“… 12 In addition, Fu et al. 32 reported that the intersegmental planes are inaccurate when using this method because of the presence of pores of Kohn, canals of Lambert, and direct airway anastomosis. Although Fu et al.…”