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LS10b+c Segmentectomy by 3D
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Navigation
JixianLiu andDanMa
16
16.1 Summary ofMedical Records
A 60-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.16.1, 16.2,
and 16.3) showed a 12.6mm×9.6mm mixed ground glass
opacity (mGGO) located in the middle of LS10b+c.
16.1.1 Indications andContraindications
(a) The lesion located deep in the LLL is less than 2cm in
diameter, with C/T (Consolidation/Tumor) ratio less
than 50%.
(b) The nodule had no change 2 months 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 2 cm after the procedure of LS10b + c
segmentectomy.
Fig. 16.1 Chest CT (Axial view) showing the nodule (Arrow) located
in the middle of LS10b+c. The yellow circle: identies a 2-cm margin
J. Liu (*)
Department of Thoracic Surgery, Peking University Shenzhen
Hospital, Shenzhen, Guangdong, China
D. Ma
Johnson & Johnson Medical Shanghai Ltd., Shanghai, 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_16
Fig. 16.2 Chest CT (Coronal view) showing the nodule (Arrow)
located in the middle of LS10b+c. The yellow circle: identies a 2-cm
margin
115
116
Fig. 16.3 Chest CT (Sagittal view) showing the nodule (Arrow)
located in the middle of LS10b+c. The yellow circle: identies a 2-cm
margin
(d) The patient was in good physical condition, with no con-
traindications to the surgery procedure.
J. Liu and D. Ma
LS10
b+c
Fig. 16.4 Relationship between the safe margin of nodule and the segmental interface of the LLL (Lateral view)
16.2 Preoperative 3D-CTBA
Reconstruction
The marginal ball of this nodule (nodule and its 2cm margin) is completely located in the LS10b + c (Fig. 16.4), so
LS10b+c segmentectomy is required to satisfy the safe surgical margin.
16.2.1 Anatomical Features
Left lower lobar bronchus (Fig.16.5) divides into B6, B
B9 and B10, with B10 dividing into proximal B10a and distal
B10b+c.
Left inferior pulmonary artery: A6 is the uppermost branch
of the interlobar artery; A
7+8
is the most anterior branch of
7+8
,
Fig. 16.5 Bronchial branch of the LLL (Posterior view)
117
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Fig. 16.8 Relationship among arteries, veins, and bronchi of the LLL
(Inferior view)
Fig. 16.6 Relationship between arteries and bronchi of LLL (Lateral
view)
Fig. 16.7 Relationship between veins and bronchi of LLL (Inferior
view)
the interlobar artery. A9+A10b (Fig.16.6) is divided in the
common trunk from the interlobar artery and A10a and A10c
divided in the common trunk from the interlobar artery.
From the view of inferior pulmonary ligament cephalad,
left inferior pulmonary vein (LIPV) (Fig. 16.7) is divided
7+8
into V
, V9+V10a in co-trunk, V10b+c, and V6.
The operation needs to dissect V10b + c, B10b + c, and
A10b+c (Fig.16.8).
16.3 Surgery Planning andProcedure
According to CT and preoperative 3D reconstruction,
LS10b + c segmentectomy is performed. Dissect from left
inferior pulmonary vein cephalad.
16.3.1 Surgical Planning
V10b+c→B10b+c→A10b+c→LS10b+c.
16.3.2 Surgical Procedures
1. The patient is in the right lateral position and has doublelumen tracheal intubation. The procedure is performed
with two ports: The fth intercostal space of left axillary
midline as main operating port and where the thoracoscope enters, and the seventh intercostal port in posterior
axillary line for retractive instruments.
2. Probe to locate the nodule within LS10b+c.
3. Pull the left lower lobe cephalad and dissect the inferior
pulmonary ligament (Fig.16.9), the 9L lymph node is dissected (Fig.16.10) for the intraoperative frozen pathology.
4. Dissect the LIPV (Fig.16.11) to the distal side to nd the
lowest branch V10b+c. On its surface, there are usually several small branches, ligating and dividing them (Fig.16.12).
5. Dissect V10b + c (Fig. 16.13), identify V9 which is in
front of it and V10a which is above it. Dividing V10b+c
with the stapler.
118
J. Liu and D. Ma
Left inferior
pulmonary vein
Fig. 16.9 Dissecting inferior pulmonary ligament
Fig. 16.10 Dissecting station 9L lymph node
Fig. 16.12 Dividing small branches on V10b+c
Fig. 16.13 Dissecting V10b+c
Left inferior
pulmonary vein
Fig. 16.11 Dissecting the left inferior pulmonary vein
6. Dissect B10b+c (Fig.16.14) beside the V10a and divide
it with the stapler.
7. Draw the B10b + c cephalad to show A10b and A10c
(Fig. 16.15) which is located beside the V10a, cutting
them off together with the stapler (Fig.16.16).
8. Inate lung with 100% pure oxygen having a pressure of
20–30 mmHg to the full ination of the LLL. About
10min later, a clear interface of ination and deation is
seen, i.e., LS10b+c inating and Residual lungs deating.
Fig. 16.14 Dissecting B10b+c bluntly
9. The lung is tailored along the interface of inating and
deating (Fig.16.17).
10. Show the stumps of segmental surface postoperatively
(Fig.16.18).
The postoperative pathology of this patient was
microinvasive adenocarcinoma (MIA) with 9L lymph
node negative.
16 LS10b+c Segmentectomy by 3D Navigation
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Fig. 16.15 Dissecting A10b+c
Fig. 16.16 Dividing A10b+c with the stapler
119
Fig. 16.18 Stumps of segmental surface after LS10b + c
segmentectomy
16.3.3 Key Points oftheSurgical Procedure
(a) There are many small branches on the inferior surface of
LIPV which should be carefully dissected to avoid
bleeding.
(b) LS10b + c segmentectomy is a combined sub-
segmentectomy that is relatively simple to proceed from
the inferior pulmonary ligament cephalad. From the 3D
reconstruction image, the key point of the operation is
the full dissection of the basal segment vein of LIPV to
the distal to expose V10a. V10a is an important boundary
marker between LS10a and LS10b+c and dissecting vessels below V10a can avoid damaging the vessels of other
segments.
Fig. 16.17 Tailoring lung along the interface of inating and
deating
16.4 Schematic Diagram oftheSurgical
Procedure
Schematic diagram of the surgical procedure for LS10b+c
segmentectomy (Figs. 16.19, 16.20, 16.21, 16.22, 16.23,
16.24, 16.25, 16.26, 16.27, 16.28, 16.29, and 16.30).
120
Small branches
Fig. 16.19 Figure of
descending dimension of
LS10b+c segmentectomy
(The shadow is the range of
excision: Red circles
represent arteries; Green
circles represent bronchi)
J. Liu and D. Ma
Fig. 16.20 Panoramic gure of the LLL (Inferior view)
LLL
Small
branches
Fig. 16.21 Dissecting V10b+c small branches
16 LS10b+c Segmentectomy by 3D Navigation
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 16.22 Dividing V10b+c small branches
Small
branches
121
Fig. 16.25 Dissecting B10b+c
Fig. 16.23 Dissecting V10b+c
Fig. 16.24 Dividing V10b+c
Fig. 16.26 Dividing B10b+c
Fig. 16.27 Dissecting A10b+c
122
Fig. 16.28 Dividing A10b+c
J. Liu and D. Ma
Fig. 16.30 The labeled gure of segmental stumps after LS10b + c
segmentectomy
Suggested Reading
1. Winckelmans T, Decaluwé H, De Leyn P, Van Raemdonck
D.Segmentectomy or lobectomy for early-stage non-small-cell lung
cancer: a systematic review and meta-analysis. Eur J Cardiothorac
Surg. 2020;57(6):1051–60.
2. Chen L, Fang W. [A review on comparison of lobectomy and seg-
mentectomy in the treatment of early stage non-small cell lung cancer]. Zhongguo Fei Ai Za Zhi. 2019;22(8):526–31.
Fig. 16.29 Locating the node and delineating the resected area
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