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1+2
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LS
+LS3 Segmentectomy by 3D
Navigation
JixianLiu, HeWang, and XuxingPeng
5
5.1 Summary ofMedical Records
A female, 57 years old, with irritating dry cough for more
than 2 months, underwent a CT chest examination (Figs.5.1,
5.2, and 5.3) and found a mixed ground glass nodule (mGGN)
with a diameter of about 25mm×13mm in the S
the left upper lobe (LUL). It was treated with antibiotic, with
no signicant change on re-examination CT 2 months later.
1+2
+S3 of
5.1.1 Indications andContraindications
(a) The size of the nodule of the Left Upper lobe (LUL) is
less than 3cm in diameter, which C/T (Consolidation/
Tumor) value is 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.
Fig. 5.1 Chest CT (Horizontal view) showing the nodule (Arrow)
located between LS
margin
J. Liu (*) · H. Wang · X. Peng
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_5
1+ 2
and LS3. The yellow circle: identies a 2-cm
Fig. 5.2 Chest CT (Coronal view) showing the nodule (Arrow) located
between LS
1+2
and LS3. The yellow circle: identies a 2-cm margin
29
30
J. Liu et al.
Fig. 5.3 Chest CT (Sagittal view) showing the nodule (Arrow) located
between LS
1+2
and LS3. The yellow circle: identies a 2-cm margin
(c) With the planning of the preoperative 3D-CTBA
reconstruction, the distance of incision margin to the
nodule is greater than 2 cm after LS
1 + 2
+ LS3
segmentectomy.
(d) The patient was in good physical condition, no contrain-
dications to the surgery procedure.
5.2 Preoperative 3D-CTBA
Reconstruction
The safety margin of this pulmonary nodule (bounded by
2cm around the nodule) shows the margin is located within
1+2
S
+S3 of the LUL (Fig.5.4), so the LS
1+2
+LS3 segmen-
tectomy is required to satisfy the safe surgical margins.
5.2.1 Anatomical Features
The left upper lobe bronchus (Fig. 5.5) is divided into
1+ 2
B
+B3 and B
1+2
B
and B3.
The LUL arteries (Figs.5.6 and 5.7): The two branches
1+2
(A
a+b and A
monary trunk with common trunk; A3 emanate alone from
the root of the left pulmonary artery trunk; the A
two parts; one is mediastinal type, with A4b and A5 branching
off from the root of the pulmonary artery, directing between
the superior pulmonary vein and upper lobe bronchus toward
the lingual segment, the another is A4a branching off from
the interlobular artery.
4+ 5
, where the B
1+2
ci) of the A
1+ 2
+B3 are divided into
1+2
branch off from the pul-
4+5
includes
Fig. 5.4 Relationship between the safe margin of nodule and the lung
segment interface of the LUL (Anterior view)
Fig. 5.5 Bronchial branch of LUL (Anterior view)
Note: The ne artery A
1+2
cii branching to S
1+2
cii found
intraoperatively was not reconstructed preoperatively.
The LUL vein (Fig.5.8) branches into the V
4+5
V
, with V
B3 and B
1+2
1+2
traveling below B3 and branching between
.
1 + 2 + 3
and
The operation can be undergone from interlobar ssure
cephalad, needing to dissect A
1 + 2
V
+V3a + V3c, and B
1 +2
1 + 2
1 +2
cii, A
a + b + ci, A3,
+B3, preserving V3b
(Intersegmental vein between S3 and S4).
5 LS
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1+2
+LS3 Segmentectomy by 3D Navigation
31
5.3 Surgery Planning andProcedure
5.3.1 Surgical Planning
Fig. 5.6 Relationship between arteries and bronchi of LUL (Anterior
view)
A
1+ 2
B
1+2
cii→A
1+ 2
a+ b+ci →A3→V
+B3→LS
1+2
+LS3.
1+ 2
+V3a+ V3c→
5.3.2 Surgical Procedure
1. Probe to locate the nodule, located between LS
2. The upper lung is drawn cephalad, the pleura of oblique
ssure is opened. Then the poorly differentiated ssure is
incised, the L11 lymph node is removed (Fig.5.9) and
sent for pathology; the A
1+2
cii are dissected, ligated, and
divided (Figs.5.10 and 5.11).
3. Pull the upper lung tissue ventrally to reveal the pulmonary trunk, dissect A
1+2
a+b+ci (Fig.5.12), and divide
it with Stapler (Fig.5.13).
4. Continue cephalad to dissect A3 (Fig.5.14) and divide it
with the stapler (Fig.5.15).
5. The upper lung is retracted dorsally to reveal the left
superior pulmonary vein, and V
1+ 2
+V3a+ V3c is dis-
sected above V3b (Fig.5.16) and divide with a stapler.
6. Dissect B
1+2
+B3 (Figs.5.17 and 5.18) and divide them
with a stapler.
1+2
+LS3.
Fig. 5.7 Relationship between arteries and bronchi of LUL (Posterior
view)
Fig. 5.9 Opening the oblique ssure and dissecting of the 11L lymph
node (LUL left upper lobe, LLL left lower lobe)
Fig. 5.8 Relationship among arteries, veins, and bronchi of LUL
(Anterior view)
Fig. 5.10 Dissecting A
1+2
cii
32
J. Liu et al.
Fig. 5.11 Ligating and dividing A
Fig. 5.12 Dissecting A
1+2
a+b+ci
1+2
cii (PA Pulmonary Artery)
Fig. 5.15 Dividing A3 with the stapler
Fig. 5.16 Dissecting V
1+2
+V3a+V3c from the anterior of the hilum
Fig. 5.13 Dividing A
1+2
a+b+ci with the stapler
Fig. 5.14 Pulling the left upper lung ventrally and dissecting A
Fig. 5.17 Dissecting B
1+2
ting V
+V3a+V3c
1+2
+B3 from the anterior of the hilar after cut-
7. Inate the lung with pure oxygen having a pressure of
20–30 mmHg to full ination. About 10min later, a clear
interface of ination and deation is seen, i.e., LS
inated and LS
4+5
deated.
1+ 2
+LS3
8. The lung is divided along the interface of ination and
deation and LS
1 +2
+ LS3 is resected (Figs. 5.19 and
5.20).
The nal pathological diagnosis was adenocarcinoma
(pT1cN0M0).
3
5 LS
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1+2
+LS3 Segmentectomy by 3D Navigation
33
1+2
1+2
+B3 from interlobular ssure and dividing
+LS3
Fig. 5.18 Dissecting B
it with the stapler
Fig. 5.20 The labeled gure
of segmental stump of
postoperative LS
segmentectomy
Fig. 5.19 Tailoring the lung along the interface of inating and
deating
5.3.3 Key Points oftheSurgical Procedure
clips after ligation, and the distal end was divided with
an ultrasonic knife.
1+2
(a) A
cii in the patient is a very small branch emanating
from the interlobar artery, which was too thin to be
reconstructed from 3D-CTDA.It needed careful dissection to prevent damage. It was reinforced with titanium
(b) The artery of the lingula segment is mediastinal type and
travels between the upper pulmonary vein and the left
upper bronchus; the operator needs to notice it when
1+2
V
+V3a+V3c is dissected.
34
5.4 Schematic Diagram oftheSurgical
Procedure
J. Liu et al.
LLL
Schematic diagram of the surgical procedure for LS
1+2
+LS3
segmentectomy (Figs. 5.21, 5.22, 5.23, 5.24, 5.25, 5.26,
5.27, 5.28, 5.29, 5.30, 5.31, 5.32, 5.33, and 5.34).
Fig. 5.21 Figure of descending dimension of LS
tomy (The shadow is the range of excision: Red circles represent arteries, Green circles represent bronchi)
1+2
+LS3 segmentec-
LUL
Fig. 5.23 Dissecting A
LUL
1+2
cii
LLL
LLL
LUL
Fig. 5.22 Figure of panoramic anatomy of LUL (From interlobular
view)
Fig. 5.24 Dividing A
LUL
Fig. 5.25 Dissecting A
1+2
1+2
cii
LLL
a+b+ci
5 LS
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1+2
+LS3 Segmentectomy by 3D Navigation
35
LUL
Fig. 5.26 Dividing A
1+2
a+b+ci
LLL
LLL
LUL
Fig. 5.29 Panoramic Anatomy of LUL (anterior view)
LUL LLL
LLL
LUL
Fig. 5.27 Dissecting A
LUL
Fig. 5.28 Dividing A
3
LLL
Fig. 5.30 Dissecting V
LUL
Fig. 5.31 Dividing V
3
1+2
+V3a+V3c
1+2
+V3a+V3c
36
J. Liu et al.
LLL
LUL
Fig. 5.32 Dissecting B
LUL
Fig. 5.33 Dividing B
1+2
+B3 from interlobular ssure
1+2
3
+B
Fig. 5.34 The labeled gure of segmental stumps
Suggested Reading
1. Subramanian M, McMurry T, Meyers BF, etal. Long- term results
for clinical stage IA lung cancer- comparing lobectomy and sublobar resection. Ann Thorac Surg. 2018;106:375–81.
2. Cao J, Yuan P, Wang Y, etal. Survival rates after lobectomy, segmentectomy, and wedge resection for non-small cell lung cancer. Ann
Thorac Surg. 2018;105:1483–91.
4+5
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
LS
Segmentectomy by 3D Navigation
JixianLiu andJunbinWang
6.1 Summary ofMedical Records
A lung nodule was discovered on chest CT in a 54-year-old
man. Following a short course of antibiotics, no signicant
change in the nodule was noted on re-examination CT 6
months later. The CT scan (Figs.6.1, 6.2, and 6.3) showed a
1.8cm×1.6cm mGGO in LS
4+5
.
6.1.1 Indications andContraindications
6
(a) The size of the nodule of the left upper lobe (LUL) is
less than 2 cm in diameter, with C/T (Consolidation/
Tumor) value of less than 50%.
Fig. 6.1 Chest CT (Axial view) showing the left upper lobe lung nodule (arrow) located within LS
margin
4+5
. The yellow circle: identies a 2-cm
Fig. 6.2 Chest CT (Coronal view) showing the nodule (arrow) located
within LS
4+5
. The yellow circle: identies a 2-cm margin
J. Liu (*) · J. Wang
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_6
Fig. 6.3 Chest CT (Sagittal view) showing the nodule (arrow) located
within LS
4+5
. The yellow circle: identies a 2-cm margin
37
38
(b) The nodule demonstrated no resolution after being
treated with antibiotics for 2 weeks, raising the possibility of early lung cancer.
(c) With preoperative 3D-CTBA reconstruction, the esti-
mated surgical margin will be over 2cm with LS
4 +5
segmentectomy.
(d) The patient demonstrated good physical condition, with-
out contraindications to operation.
6.2 Preoperative 3D-CTBA
Reconstruction
The estimated 2cm margin of this nodule (Fig.6.4) indicates
4+5
that LS
segmentectomy is required.
6.2.1 Anatomical Features
J. Liu and J. Wang
Fig. 6.5 Bronchial branches of the left upper lobe (Anterior view)
The LUL bronchus (Fig.6.5) is divided into B
4+5
and B
is divided into three branches: namely B4, B5a, and
1+2+ 3
and B
4+5
B5b.
4+5
A
(Fig.6.6) has three branches: A4 and A5a which ema-
nate from the root of the left superior pulmonary artery
Fig. 6.4 Relationship between the 2-cm margin and the segmental
interface of the LUL (Anterior view)
Fig. 6.6 Relationship between arteries and bronchi of LS
view)
4+5
(Lateral
together are mediastinal type arteries (Med.A4 & Med.A5a),
while A5b emanates from the interlobar artery and accompanies the corresponding bronchus.
4+ 5
V
(Fig.6.7) emanates from the lowermost branch of
the left superior pulmonary vein.
Dissection of V
4+5
, A5b, B
4+5
, and Med.A4 & Med.A5a is
required for segmentectomy.
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