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Fig. 11.32 The labeled gure of segmental stumps after RS2b+RS3a
segmentectomy
J. Liu and Y. Ye
Suggested Reading
1. Okada M, Mimura T, Ikegaki J, Katoh H, Itoh H, Tsubota N.A
novel video-assisted anatomic segmentectomy technique: selective
segmental ination via bronchoberoptic jet followed by cautery
cutting. J Thorac Cardiovasc Surg. 2007;133:753–8.
2. Kamiyoshihara M, Kakegawa S, Ibe T, Takeyoshi I. Buttery-
needle video-assisted thoracoscopic segmentectomy: a retrospective
review and technique in detail. Innovations. 2009;4:326–30.
RS1+RS2+RS3c Segmentectomy by 3D
Navigation
JixianLiu andZichunWei
12.1 Summary ofMedical Record
A 53-year-old female was found to have a nodule located in
the right upper lobe (RUL) on CT scan 3 months ago without
any physical sickness. She was treated with antibiotics for 2
weeks, with no signicant change of the nodule on reexamination CT 3 months later. Chest CT (Figs.12.1, 12.2,
and 12.3) showed a 12 mm × 9 mm mixed ground glass
opacity (mGGO) located in the middle of Right Upper Lobe
(RUL).
12
Fig. 12.1 Chest CT (Axial view) showing the nodule (Arrow) located
in the middle of RUL The yellow circle: identies a 2-cm margin
J. Liu (*) · Z. Wei
Department of Thoracic Surgery, Peking University Shenzhen
Hospital, Shenzhen, Guangdong, China
Fig. 12.2 Chest CT (Coronal view) showing the nodule (Arrow) located
in the middle of RUL The yellow circle: identies a 2-cm margin
Fig. 12.3 Chest CT (Sagittal view) showing the nodule (Arrow)
located in the middle of RUL The yellow circle: identies a 2-cm
margin
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
J. Liu, D. Wu (eds.), Segmentectomy for Early-Stage Lung Cancer, https://doi.org/10.1007/978-981-99-0143-2_12
85
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J. Liu and Z. Wei
12.1.1 Indications andContraindications
(a) The lesion located deep in the RUL is less than 2cm in
diameter, which C/T (Consolidation/Tumor) ratio is less
than 50%.
(b) The nodule had no change 3 months later after being
treated with antibiotics for 2 weeks, raising the possibility of early lung cancer.
(c) With the planning of the preoperative 3D-CTBA recon-
struction, the distance of incisional margin to the nodule
is more than 2cm after the procedure of RS1+RS2+RS3c
segmentectomy.
(d) The patient was in good physical condition, with no con-
traindications to the planned surgical procedure.
12.2 Preoperative 3D-CTBA
Reconstruction
The marginal ball of this nodule (nodule and its 2cm margin) shows the margin is located in RS1 + RS2 + RS3c
(Fig.12.4), so RS1+RS2+RS3c segmentectomy is required
to satisfy the safe surgical margin.
12.2.1 Anatomical Features
The right upper bronchus (RUB) (Fig.12.5) is divided into a
common trunk of B1+B2 and a dominant B3, with B3 divided
into B3a+B3b and B3c.
Notice: B3c is B2bi here, and because it is the dominant
segment, it is named B3c here.
A1 and A2 (Fig.12.6) is co-trunk artery emanating from
the upper trunk of the right superior pulmonary artery, with-
2 cm safe margin
Fig. 12.4 Relationship between the safe margin of nodule and the segmental interface of the RUL (Lateral view)
Fig. 12.5 Bronchial branch of the RUL (Anterior view)
Fig. 12.6 Relationship between arteries and bronchi of the RUL
(Posterior view)
12 R S1+RS2+RS3c Segmentectomy by 3D Navigation
87
out Asc.A2 emanating from the interlobar artery. A3 branches
into A3a, A3b, and A3c.
The right superior pulmonary Vein (RSPV) (Fig.12.7) is
divided into V1a+b that runs anteriorly to the hilar; central
venous (V2a+V2b+V2c+V3a) that converges among S1 and
S2, running below B3 to the RSPV.
The operation needs to dissect co-trunk of A1+A2, A3c,
V1a+b, V2a+b, and co-trunk of B1+B2, B3c (Fig.12.8).
Fig. 12.7 Relationship between veins and bronchi of the RUL (Lateral
posterior view)
12.3 Surgery Planning andProcedure
According to CT and preoperative 3D reconstruction,
RS1 + RS2 + RS3c segmentectomy is undergone. Dissect
from the anterior hilar dorsally.
12.3.1 Surgical Planning
V1a+b→A
+RS2+RS3c.
1+2
+A3c→B1+B2→V2a+b→B3c→RS1
12.3.2 Surgical Procedures
1. The patient in left lateral position and has double-lumen
tracheal intubation. The procedure undergone with single port: The fourth intercostal space at the right axillary
midline was a main operating port, through which the
thoracoscope and other instruments passed.
2. Probe to locate the nodule within RS1+RS2+RS3c.
3. Pull the upper lung dorsally and incise the pleura in front
of the hilum (Fig.12.9). 10R lymph node (Fig.12.10) is
dissected for intraoperative frozen pathology.
4. Dissect V1a+b (Fig.12.11), ligating and dividing it.
5. Dissect A1+A2+A3c together behind V1a+b stumps
(Fig.12.12), dividing them with the Stapler.
6. Pull the RUL ventrally and cephalad, after opening the
interlobular ssure, dissect bluntly B1+B2 (Fig.12.13).
Notice the distal branches of CV which is closely adjacent to the root of B1+B2, dividing it with the Stapler.
7. Dissect V2a+b behind the B1+B2 stumps (Fig.12.14),
paying attention to protect V2c which is in front of it.
Dividing V2a+b with the Stapler.
Fig. 12.8 Relationship among arteries, veins, and bronchi of the RUL
(Anterior view) Fig. 12.9 Dissecting the hilum
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J. Liu and Z. Wei
Fig. 12.10 Dissecting No.10 lymph node
Fig. 12.11 Dissecting V1a+b
Fig. 12.13 Dissecting B1+B
Fig. 12.14 Dissecting V2a+b (Interlobar view)
2
9. Inate lung with 100% pure oxygen having a pressure of
20–30 mmHg to fully inate the RUL. About 10min
later, a clear interface of ination and deation is seen,
i.e., RS1 + RS2 + RS3c inating and residual lungs
deating.
10. The lung is tailored along the interface of ination and
deation (Fig.12.16).
11. Show the stumps of the segmental surface postoperatively (Fig.12.17).
The postoperative pathology of this patient was
microinvasive adenocarcinoma (MIA) with 10R lymph
node negative.
Fig. 12.12 Dissecting A1+A2+A3c
8. The RUL is drawn dorsally, dissecting B3c (Fig. 12.15),
dividing it with the Stapler. Protect B3a and B3b below B3c.
12.3.3 Key Points oftheSurgical Procedure
(a) It is necessary to dissect B1+B2 bluntly because V2a+b
is very closely adjacent to it.
12 R S1+RS2+RS3c Segmentectomy by 3D Navigation
Fig. 12.15 Dissecting B3c (Anterior view)
89
(b) Care should be taken to protect V2c when dissecting
V2a + b, as V2c is an important anatomical marker of
surgical boundaries.
12.4 Schematic Diagram oftheSurgical
Procedure
Schematic diagram of the surgical procedure for
RS1+RS2+RS3c segmentectomy (Figs.12.18, 12.19, 12.20,
12.21, 12.22, 12.23, 12.24, 12.25, 12.26, 12.27, 12.28, 12.29,
12.30, 12.31, and 12.32).
Fig. 12.16 Tailoring lung along the interface of inating and
deating
Fig. 12.17 Stumps of segmental surface after RS1 + RS2 + RS3c
segmentectomy
Fig. 12.18 Figure of descending dimension of RS1+RS2+RS3c seg-
mentectomy (The shadow is the range of excision: Red circles represent
arteries; Green circles represent bronchi)
RUL
RML
Fig. 12.19 Panoramic gure of the RUL (Anterior view)
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Fig. 12.20 Dissecting V1a+b
J. Liu and Z. Wei
Fig. 12.23 Dividing A1+A2+A3c
RUL
Fig. 12.21 Dividing V1a+b
Fig. 12.22 Dissecting A1+A2+A3c
RML
RLL
Fig. 12.24 Panoramic gure of the RUL (Interlobar view)
RUL
Fig. 12.25 Dissecting B1+B2 from Interlobar ssure
12 R S1+RS2+RS3c Segmentectomy by 3D Navigation
91
RUL
Fig. 12.26 Dividing B1+B
2
Fig. 12.27 Dissecting V2a+b
Fig. 12.29 Dissecting B3c anteriorly
Fig. 12.30 Dividing B3c
Fig. 12.28 Dividing V2a+b
Fig. 12.31 Locating the nodes and delineating the resected area
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Fig. 12.32 The labeled gure of segmental stumps after
RS1+RS2+RS3c segmentectomy
J. Liu and Z. Wei
Suggested Reading
1. Saji H, Okada M, Tsuboi M, etal. Segmentectomy versus lobectomy
in small-sized peripheral non-small-cell lung cancer (JCOG0802/
WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial. Lancet. 2022;399:1607–17.
2. Dell’Amore A, Lomangino I, Cannone G, et al. Comparison of
operative and postoperative characteristics and outcomes between
thoracoscopic segmentectomy and lobectomy for non-small-cell
lung cancer: a propensity score matching study from the Italian
VATS Group Registry. Eur J Cardiothorac Surg. 2022;61:533–42.
LS6 Segmentectomy by 3D Navigation
JixianLiu andFeihuLong
13.1 Summary ofMedical Records
A 35-year-old female was found to have a nodule located in
the left lower lobe (LLL) on CT scan 2 months ago without
any physical sickness. She was treated with antibiotics for 2
weeks, with no signicant change of the nodule on reexamination CT 2 months later. Chest CT (Figs.13.1, 13.2,
and 13.3) showed a 10 mm × 9 mm mixed ground glass
opacity (mGGO) located in the middle of LS6.
13
Fig. 13.1 Chest CT (Axial view) showing the nodule (Arrow) located
in the middle of LS6. The yellow circle: identies a 2-cm margin
J. Liu (*) · F. Long
Department of Thoracic Surgery, Peking University Shenzhen
Hospital, Shenzhen, Guangdong, China
Fig. 13.2 Chest CT (Coronal view) showing the nodule (Arrow)
located in the middle of LS6. The yellow circle: identies a 2-cm
margin
Fig. 13.3 Chest CT (Sagittal view) showing the nodule (Arrow)
located in the middle of LS6. The yellow circle: identies a 2-cm
margin
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2023
J. Liu, D. Wu (eds.), Segmentectomy for Early-Stage Lung Cancer, https://doi.org/10.1007/978-981-99-0143-2_13
93
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