Video-assisted thoracoscopic subsegmentectomy for small-sized pulmonary nodules

Abstract

Segmentectomy has been widely performed as one of the types of limited resections that are performed for the resection of small-sized lung nodules. Video-assisted thoracoscopic surgery has also been in demand as a minimally invasive surgery. Subsegmentectomy is a much more limited resection than segmentectomy, but the technique is complex because it requires keen anatomical identification of small pulmonary structures. Therefore, there has been little reported about subsegmentectomy in medical literature. The recent development of computed tomography is remarkable, and some reports describe three-dimensional computed tomography as providing useful information because it assists surgeons in the performance of thoracoscopic anatomical subsegmentectomy. The creation of an intersubsegmental line is a key process in subsegmentectomy, therefore, some methods have been reported. We have safely and accurately performed some video-assisted thoracoscopic subsegmentectomies for small-sized lung tumors, using the three-dimensional computed tomography simulation and creating the intersubsegmental line with the inflation-deflation technique. In this article, we describe the recent techniques and roles of video-assisted thoracoscopic subsegmentectomy, and offer prospects for this procedure with our clinical data. more anatomically detailed resection that can involve the dissection of hilar lymph nodes attached to the segment containing the tumor. Moreover, the oncological outcomes of segmentectomy in a propensity-matched study were comparable to those of lobectomy for patients with earlystage non-small cell lung cancer (6). Segmentectomy has thus become widely used worldwide (1). While wedge resection has been applied to smaller lung nodules located in peripheral parenchyma, segmentectomy has been applied to small-sized lung nodules that show not only GGOs, but also solid appearances located in deep parenchyma. Recent developed CT enabled the detection of small-sized pulmonary nodules containing GGO component. For such smaller pulmonary nodules, especially located in the deep parenchyma, subsegmentectomy may be an alternative procedure; this is because it is difficult to perform a wedge resection for hilum nodules located in the deep parenchyma and segmentectomy may be an excessive resection for appropriate surgical margins.The role of subsegmentectomy is therefore considered as an intermediate procedure between wedge resection and segmentectomy. Consequently, we have concluded that the best indications for subsegmentectomy are as follows: (I) lung tumors of indeterminate nature, but considered suspicious for malignancy; (II) planned resection of a cT1aN0M0 primary lung cancer tumor less than 2 cm in diameter, with a GGO ratio of greater than 80% by highresolution CT, in patients with good pulmonary function who are able to tolerate lobectomy ( Figure 1A,B,C); (III) compromised resection in patients who are considered to be poor candidates for lobectomy due to limited cardiopulmonary reserve or other organ failure; (...

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“…Various methods have been proposed to identify intersegmental planes during thoracoscopic pulmonary segmentectomy [10,13]. In the slip knot method, a specific ligation (slip knot) is applied to the target segment bronchus followed by bilateral ventilation, and then the knot is slipped to close the bronchus [14][15][16]. This method does not require a jet ventilator and anesthesiologist [17][18][19].…”

Effect of closed vacuum aspiration technique on lung collapse time in thoracoscopic anatomical segmentectomy

“…At present, the methods for determining the inter-segment boundary are inflation method, fluorescent staining method, and expansion collapse method. [14] The inflation method is related to the dispersion of the lung. If there is secretion in the airway, the inter-segment boundary is easily inaccurate, and the inflation gas is too large, causing some non-target segment tissue to inflate, resulting in miscut.…”

Current Minimally Invasive Surgical Approaches for Lung Cancer Treatment

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