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Fig. 7.20 Dividing V3c

J. Liu and W. Yue

Fig. 7.23 Dissecting A3a+c

Fig. 7.21 Dissecting A3b

Fig. 7.22 Dividing A3b

Fig. 7.24 Dividing A3a+c

Fig. 7.25 Dissecting V3a+b

7 Extended LS3 Segmentectomy by 3D Navigation

Fig. 7.26 Dividing V3a+b

Fig. 7.27 Dissecting B

Fig. 7.29 Locating the node and delineating the resected area

Fig. 7.30 The labeled gure of segmental stumps after Extended LS3

segmentectomy

Suggested Reading

1. Cao J, Yuan P, Wang Y, etal. Survival rates after lobectomy, segmentectomy, and wedge resection for non-small cell lung cancer. Ann Thorac Surg. 2018;105:1483–91.

2. Subramanian M, McMurry T, Meyers BF, etal. Long- term results for clinical stage IA lung cancer- comparing lobectomy and sublobar resection. Ann Thorac Surg. 2018;106:375–81.

Fig. 7.28 Dividing B

RS1 Segmentectomy by 3D Navigation

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JixianLiu andXiaoqiangLi

8.1 Summary ofMedical Records

A 43-year-old asymptomatic woman was found to have a right upper lobe (RUL) lung nodule on a CT scan. She was treated with antibiotics for 2 weeks, with no signicant change of the nodule on re-examination. Her chest CT (Figs.8.1, 8.2, and 8.3) showed an 8-mm pure ground glass opacity (pGGO) located in the RS1.

Fig. 8.1 Chest CT (axial view) showing the nodule located in the RS1

(Yellow circle: nodule and its 2cm margin)

Fig. 8.2 Chest CT (coronal view) showing the nodule located in the RS1 (Yellow circle: nodule and its 2cm margin)

Fig. 8.3 Chest CT (sagittal view) showing the nodule located in the RS1 (Yellow circle: nodule and its 2cm margin)

J. Liu (*) · X. Li Department of Thoracic Surgery, Peking University Shenzhen Hospital, Shenzhen, Guangdong, China

Fig. 8.4 Relationship between the safe margin of nodule and the RUL segmental interfaces (Anterior view)

8.1.1 Indications andContraindications

J. Liu and X. Li

(a) This 8mm pure GGO located in the center of RS1 would

not be amenable to non-anatomic wedge resection with adequate surgical margin.

(b) Despite a short course of antibiotic therapy, persistence

of the nodule is suspicious for early lung cancer.

the prospective incisional margin is more than 2cm after RS1 segmentectomy (Fig.8.4).

(d) The patient has good performance status, without con-

traindications to operation.

8.2 Preoperative 3D-CTBA Reconstruction

The marginal ball of this nodule (nodule and its 2cm margin) shows the margin is completely located in RS1 (Fig.8.4), so the RS1 segmentectomy is required to satisfy the safe surgical margin.

8.2.1 Anatomical Features

The right upper lobe bronchus (Fig.8.5) is divided into B1, B2, and B3, B1 and B2 emanating from the common trunk.

The RA1 (Fig.8.6) divides into A1b which emanates separately from the upper trunk of the right superior pulmonary artery and A1a emanating from the upper trunk in form of co-trunk with Rec A2.

Fig. 8.5 Segmental bronchi of the RUL (Lateral view)

Fig. 8.6 Relationship between segmental arteries and bronchi of the

RUL (Lateral view)

V1a, an intrasegmental vein (Fig. 8.7), will be divided. V1b which is the intersegmental vein of S1 and S3 will be preserved. V2a, which travels between B1 and B3 to right superior pulmonary vein (RSPV) above which is the boundary of RS1 (Fig.8.8).

The operation needs to dissect V1a, A1b, A1a, and B1.

8 RS1 Segmentectomy by 3D Navigation

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Fig. 8.7 Relationship between segmental veins and bronchi of the RUL (Lateral view)

8.3.2 Surgical Procedures

1. The patient undergoes double-lumen endotracheal

intubation and is placed in the left lateral decubitus position. Two ports are placed: The third intercostal in right axillary midline as main operating port and for thoracoscope placement; the port in the fth intercostal space in the posterior axillary line for retraction (Fig.8.9).

2. Probe to locate the nodule within RS1.

3. Retract the upper lung posteriorly and incise the anterior

hilar pleura to expose V1a, A1b, and A1a + Rec. A2 (Fig. 8.10) and dissect the station 12R lymph node for intraoperative frozen pathological examination (Fig.8.11).

4. Following the 3D navigation, dissect the V1a, supercial

intrasegmental vein (Fig. 8.12), ligating and dividing between 4 and 0 silk ties (Fig.8.13).

Fig. 8.8 Relationship among segmental arteries, veins, and bronchi of the RS1 (Lateral view)

8.3 Surgery Planning andProcedure

Main operating port

Assistant port

Fig. 8.9 Layout of incision

According to CT and preoperative 3D reconstruction, RS1 segmentectomy is undertaken, dissecting from superior hilum posteriorly.

8.3.1 Surgical Planning

V1a→A1b→A1a→RB1→RS

Fig. 8.10 Demonstration of V1a, A1b and A1a+Rec.A

Fig. 8.11 Dissecting the station 12R lymph node

J. Liu and X. Li

Fig. 8.14 Dissecting A1b

Fig. 8.12 Dissecting V1a

Fig. 8.13 Ligating V1a with 4-0 silk thread

5. At the upper edge of V1a, dissect A1b separately (Fig.8.14) and A1a from co-trunk of A1a+Rec.A2 (Fig.8.15), taking care to protect Rec.A2. Ligate and divide these, respectively.

Fig. 8.15 Dissecting A1a and ligating it with a 4-0 silk thread

Fig. 8.16 Demonstrating B

6. Dissect B1 ventral to the Rec.A2 and above the V2a (Fig.8.16) and divide using the stapler (Fig.8.17).

7. Inate lung with 100% pure oxygen to peak airway pressure of 20–30mmHg to insufate the upper lobe. About 10min later, a clear interface of ination and deation is seen, i.e., RS1 inating and the remaining parenchyma deating (Fig.8.18).

8 RS1 Segmentectomy by 3D Navigation

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Fig. 8.17 Dividing B

Fig. 8.18 Showing the interface of inating and deating

8. The membrane-like structure between the inating RS1 and the deating RS2 + RS3 is opened by means of “Inward Opening” fashion (Fig.8.19).

9. The lung is tailored along the interface of inating and deating (Fig.8.20).

The postoperative pathology of this patient was microinvasive adenocarcinoma (MIA) with the station 12R lymph node negative for malignancy.

Fig. 8.19 Opening the interface between S1 and S2, S

Fig. 8.20 Postoperative stumps of segmental surface after RS1

segmentectomy

8.3.3 Key Points oftheSurgical Procedure

1. V2a which travels between B1 and B3 to the right superior pulmonary vein, instead of the usual route below B3 toward the central vein. V2a is exposed for a long route in the operative area and needs careful protection.

2. A1a and Rec.A2 originate from the common trunk, and more attention should be taken to protect Rec.A2 when dissecting A1a. B1 traverses ventrally close to Rec.A2.

8.4 Schematic Diagram oftheSurgical Procedure

Schematic diagram of the surgical procedure for RS1 segmentectomy (Figs.8.21, 8.22, 8.23, 8.24, 8.25, 8.26, 8.27,

8.28, 8.29, 8.30, and 8.31).

J. Liu and X. Li

Fig. 8.24 Dividing V1a

RUL

Fig. 8.21 Figure of descending dimension of RS1 segmentectomy (The shadow is the range of excision: Red circles represent arteries; Green circles represent bronchi)

RUL

RML

Fig. 8.22 RUL anterior hilum (Anterior view)

Fig. 8.25 Dissecting A1b

RUL

Fig. 8.26 Dividing A1b, dissecting A1a

Fig. 8.23 Dissecting V1a

Fig. 8.27 Dividing A1a

8 RS1 Segmentectomy by 3D Navigation

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Fig. 8.28 Dissecting B

RUL

Fig. 8.31 The labeled gure of segmental stumps after RS1 segmentectomy