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J. Liu and F. Long
13.1.1 Indications andContraindications
(a) The lesion located deep in the LLL is less than 2cm in
diameter, which C/T (Consolidation/Tumor) ratio of less
than 50%.
(b) The nodule had no change 2 months later after being
treated with antibiotics for 2 weeks, raising the possibility of early lung cancer.
(c) With the plan of the preoperative 3D-CTBA reconstruc-
tion, the distance of incisional margin to the nodule is
more than 2 cm after the procedure of LS6
segmentectomy.
(d) The patient was in good physical condition, with no con-
traindications to the surgery procedure.
13.2 Preoperative 3D-CTBA
Reconstruction
The marginal ball of this nodule (nodule and its 2cm margin) shows the margin is located in LS6 (Fig.13.4), and LS6
segmentectomy is required to satisfy the safe surgical
margin.
A6 (Fig.13.6) is divided from the interlobar artery that is
divided into A6a, A6b, and A6c.
The left inferior pulmonary vein (LIPV) (Fig. 13.7)
divides into V6 and V
7–10
. V6 divides into V6a, V6b, and V6c,
with V6a and V6b divided from a common trunk.
The operation needs to dissect A6, B6, and V6a (Figs.13.8
and 13.9).
13.2.1 Anatomical Features
The left lower bronchus (LLB) (Fig.13.5) divides into B6
7–10
and B
, with B6 dividing into B6a, B6b, and B6c.
Fig. 13.5 Bronchial branch of the LLL (Posterior view)
Fig. 13.4 Relationship between the safe margin of nodule and the seg-
mental interface of the LLL (Posterior view)
Fig. 13.6 Relationship between arteries and bronchi of LS6 (Posterior
view)
13 L S6 Segmentectomy by 3D Navigation
95
Fig. 13.9 Relationship among arteries, veins, and bronchi of the LS6
(Posterior view)
Fig. 13.7 Relationship between veins and bronchi of LS6 (Posterior
view)
Fig. 13.8 Relationship among arteries, veins, and bronchi of the LS6
(Posterior view)
13.3 Surgery Planning andProcedure
According to CT and preoperative 3D reconstruction, LS6
segmentectomy was performed. Dissect from the interlobar
ssure caudally.
13.3.1 Surgical Planning
A6→B6→V6a→LS6.
13.3.2 Surgical Procedures
1. The patient in right lateral position and double-lumen
tracheal intubation. The procedure is performed with a
single port: The fth intercostal space of left axillary
midine is main operating port through which thoracoscope and other instruments passed together.
2. Probe to locate the nodule within LS6.
3. Pull the LLL ventrally and incise the pleura behind the
hilum, 10L lymph node (Fig.13.10) is dissected for intraoperative frozen pathology.
4. Dissect the interlobar fissure and cut the poorly
formed part with the stapler (Fig.13.11), 12L lymph
node (Fig.13.12) is dissected for intraoperatively fro-
96
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Fig. 13.10 Dissecting No.10 lymph node
J. Liu and F. Long
zen pathology. Dividing A6 with the stapler
(Fig.13.13).
5. Dissect B6 from both the interlobar ssure and the posterior hilum (Fig.13.14), dividing it with the stapler above
V6.
6. Lift the B6 stump and dissect V6 behind it. Dissect V6 distal to V6a, and divide it. Take care to protect V6b and V6c
(Fig.13.15).
7. Inate lung with 100% pure oxygen having a pressure of
20–30mmHg to full ination of the LLL.About 10min
later, a clear interface of ination and deation is seen,
i.e., LS6 inating and Residual lungs deating
(Fig.13.16).
8. The lung is tailored along the interface of ination and
deation. Show the nodule located in the center of LS6
(Fig.13.17).
9. Show the stumps of segmental surface postoperatively
(Fig.13.18).
Fig. 13.11 Dividing the oblique ssure with the Stapler (LUL: left
upper lobe; LLL: left lower lobe)
Fig. 13.12 Dissecting 12L lymph node
Fig. 13.13 Dividing A
Fig. 13.14 Dissecting B
6
6
13 L S6 Segmentectomy by 3D Navigation
Fig. 13.15 Dissecting V6a
97
Fig. 13.18 Stumps of segmental surface after LS6 segmentectomy
The postoperative pathology of this patient was
microinvasive adenocarcinoma (MIA) with 10L, 12L
lymph nodes negative.
13.3.3 Key Points oftheSurgical Procedure
Fig. 13.16 Showing the interface of ination and deation
(a) Because the main operating area is in the posterior part
of the oblique ssure, the incision is selected in the fth
intercostal of the axillary midline, and the straight view
of the single port VATS (Video-Assisted Thoracoscopic
Surgery) is in the operative area.
(b) It is safer to expose V6 from the dorsal mediastinum rst
and then to dissect bluntly B6 from the front, which can
avoid to damage V6.
(c) V6b and V6c are intersegmental veins that need to be pre-
served. When dissecting V6a, care should be taken not to
damage them.
13.4 Schematic Diagram oftheSurgical
Procedure
Schematic diagram of the surgical procedure for LS6 segmentectomy (Figs.13.19, 13.20, 13.21, 13.22, 13.23, 13.24,
13.25, 13.26, and 13.27).
Fig. 13.17 Showing the nodule located within LS
6
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J. Liu and F. Long
Fig. 13.19 Figure of descending dimension of LS6 segmentectomy
(The shadow is the range of excision: Red circles represent arteries;
Green circles represent bronchi)
LLL
Fig. 13.21 Dissecting A
LUL
Fig. 13.22 Dividing A
LUL
6
LLL
6
LLL
LUL
Fig. 13.23 Dissecting B
Fig. 13.20 Panoramic gure of the LLL (Interlobar view)
6
13 L S6 Segmentectomy by 3D Navigation
LUL
LLL
LUL
Interlobar
artery
99
LLL
Fig. 13.24 Dividing B
LUL
6
Fig. 13.25 Dissecting V6a
LLL
LLL
Fig. 13.27 The labeled gure of segmental stumps after LS6
segmentectomy
Suggested Reading
1. Nakamura K, Okada M, Asamura H, etal. A phase III randomized
trial of lobectomy versus limited resection for small-sized peripheral non-small cell lung cancer (JCOG0802/WJOG4607L). Jpn J
Clin Oncol. 2010;40(3):271–4.
2. Okada M, Tsutani Y, Ikeda T, etal. Radical hybrid video-assisted
thoracic segmentectomy: long- term results of minimally invasive
anatomical sublobar resection for treating lung cancer. Interact
Cardiovasc Thorac Surg. 2012;14(1):5–11.
LUL
Fig. 13.26 Dividing V6a
RS8a Segmentectomy by 3D Navigation
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JixianLiu andXinyuLuan
14
14.1 Summary ofMedical Records
A 35-year-old female was found to have a nodule located in
the right lower lobe (RLL) on CT scan 4 months ago without
any physical sickness. The nodule was a little larger on reexamination CT 4 months later. Chest CT (Figs.14.1, 14.2,
and 14.3) showed a diameter of 18mm mixed ground glass
opacity (mGGO) located in the RS8a.
14.1.1 Indications andContraindications
(a) The lesion located deep in the RLL is less than 2cm in
diameter, which C/T (Consolidation/Tumor) ratio is less
than 50%.
(b) The nodule observed for 4 months became a little larger,
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 2 cm after the procedure of RS8a
segmentectomy.
(d) The patient was in good physical condition, with no con-
traindications to the surgery procedure.
Fig. 14.2 Chest CT (Coronal view) showing the nodule (Arrow)
located in the middle of RS8a. The yellow circle: identies a 2-cm
margin
Fig. 14.1 Chest CT (Axial view) showing the nodule (Arrow) located
in the middle of RS8a. The yellow circle: identies a 2-cm margin
J. Liu (*) · X. Luan
Department of Thoracic Surgery, Peking University Shenzhen
Hospital, Shenzhen, Guangdong, China
© 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_14
101
102
Fig. 14.3 Chest CT (Sagittal view) showing the nodule (Arrow)
located in the middle of RS8a. The yellow circle: identies a 2-cm
margin
J. Liu and X. Luan
Fig. 14.4 Relationship between the safe margin of nodule and the segmental interface of the RLL (Anterior view)
14.2 Preoperative 3D-CTBA
Reconstruction
The marginal ball of this nodule (nodule and its 2cm margin) shows the margin is located in RS8a (Fig.14.4), so RS8a
segmentectomy is required to satisfy the safe surgical
margin.
14.2.1 Anatomical Features
The right lower bronchus (RLB) (Fig.14.5) divides into B6
7–10
and B
artery.
, B8 divides into B8a and B8b.
A8a (Fig.14.6) emanates from A9, A8b from the interlobar
S8a segmentectomy does not need to dissect the vein.
The operation needs to dissect A8a and B8a (Fig.14.7).
Fig. 14.5 Bronchial branch of the RLL (Anterior view)
14 RS8a Segmentectomy by 3D Navigation
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Fig. 14.6 Relationship between arteries and bronchi of RLL (Anterior
view)
103
14.3.1 Surgical Planning
A8a→B8a→S8a.
14.3.2 Surgical Procedures
1. The patient is in left lateral position with double-lumen
tracheal intubation. The procedure is performed with a
single port: The fth intercostal of right axillary midline
is main operating port, through which the thoracoscope
and retractive instruments pass through.
2. Probe to locate the nodule within RS8a.
3. The poorly differentiated oblique ssure is dissected
(Fig.14.8); dissect A6 and A
is dissected for intraoperative frozen pathology.
9–10
. 12R lymph node (Fig.14.9)
Fig. 14.7 Relationship among arteries, veins, and bronchi of the RS8a
(Anterior view)
14.3 Surgery Planning andProcedure
According to CT and preoperative 3D reconstruction, RS8a
segmentectomy is performed. Dissect from interlobar ssure
caudally.
Fig. 14.8 Dissecting oblique ssure (RLL right lower lobe of lung,
RML right middle lobe)
Fig. 14.9 Dissecting 12R lymph node
104
4. Following the 3D navigation, A8a which is on the surface
of A9 is dissected and ligated with 3-0 silk thread and cut
off with an Ultrasonic knife (Fig.14.10).
5. Dissect B8a just behind A8a stump (Fig.14.11), and divide
it with a stapler.
6. Inate lung with 100% pure oxygen having a pressure of
20–30 mmHg to the full ination of the RLL. About
10min later, a clear interface of ination and deation is
seen, i.e., RS8a inating and residual lung deating
(Fig.14.12).
7. The lung is tailored along the interface of ination and
deation (Fig.14.13).
8. Show the stumps of segmental surface postoperatively
(Fig.14.14).
The postoperative pathology of this patient was
microinvasive adenocarcinoma (MIA) with 12R lymph
node negative.
J. Liu and X. Luan
Node
Fig. 14.12 Showing the interface of ination and deation
Node
Fig. 14.10 Dividing A8a
Fig. 14.11 Dissecting B
8
a bluntly
Fig. 14.13 Tailoring lung along the interface of ination and
deation
Fig. 14.14 Stumps of segmental surface after RS8a segmentectomy
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