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9.1.1 Indications andContraindications
(a) The nodule is an 11 mm × 15 mm mixed GGO
located in the center of RUL, difficult to obtain an
adequate surgical margin by non-anatomic wedge
resection.
(b) The nodule persisted despite antibiotic therapy, raising
the possibility of early lung cancer.
(c) Preoperative 3D-CTBA reconstruction demonstrates
that the planned surgical margin would be greater than
2cm for an extended RS2 segmentectomy.
(d) The patient demonstrates good physical condition, with
no contraindications to operation.
J. Liu and X. Li
9.2 Preoperative 3D-CTBA
Reconstruction
The estimated resection sphere (nodule and its 2cm margin)
shows the margin is located in RS2 very close to RS3
(Fig.9.4), leading to the decision to proceed with extended
RS2 segmentectomy.
9.2.1 Anatomical Features
The right upper lobe bronchus (Fig.9.5) is divided into B1,
B2, and B3 separately.
Fig. 9.5 Bronchial branches of the RUL (Posterior view)
Fig. 9.6 Relationship between arteries and bronchi of the RUL
(Posterior view)
The upper trunk of the right pulmonary artery (Fig.9.6)
includes A3, A1, and Rec A2, while the Asc A2 branches off
from the interlobar trunk of the right pulmonary artery distributing S2b and S2aii.
V1a, V2a, V2b, and V2c converge as the central vein (CV)
(Fig.9.7). V2b is an intrasegment vein of S2 that needs to be
divided. Since the planned surgical margin for this nodule is
close to S3, V2c needs to be divided.
The operation needs to dissect Rec A2, Asc A2, V2b, V2c,
and B2, protecting V2a.
Fig. 9.4 Relationship between the estimated surgical margin and the
RUL segmental interface (Anterior view)
9 Extended RS2 Segmentectomy by 3D Navigation
63
Fig. 9.7 Relationship among arteries, veins, and bronchi of the RS2
(Posterior view)
9.3 Surgery Planning andProcedure
According to CT and preoperative 3D reconstruction, the
extended RS2 segmentectomy is initiated, dissecting from
the interlobar ssure cephalad.
9.3.1 Surgical Planning
Asc.A2→B2→Rec.A2→V2c→V2b→RS
2
9.3.2 Surgical Procedures
1. The patient undergoes double-lumen tracheal intubation
and is placed in left lateral decubitus. The procedure is
completed with two ports: The fourth intercostal space
in right axillary midline serves as the main operating
port and for thoracoscope placement; the seventh intercostal space in the posterior axillary line is used for
placement of retraction.
2. Probe to locate the nodule within RS2 adjacent to RS3.
3. The posterior part of the oblique ssure is opened, submitting the 11R lymph node for intraoperative frozen
pathology (Fig. 9.8). Dissect and divide Asc.A2
(Fig.9.9).
4. The 12R lymph node between B2 and B3 is dissected
(Fig.9.10), with attention to preserving A3.
5. The central vein (CV) is located between B2 and B3, B2
is dissected and divided dorsal to the CV (Fig.9.11).
6. Retracting the upper lobe anteriorly and inferiorly, the
most dorsal branch of the upper trunk of the right pulmonary artery is Rec. A2 (Fig.9.12), and is divided.
Fig. 9.8 Dissecting the 11R lymph node and Asc.A2 (RUL right upper
lobe, RLL right lower lobe)
Fig. 9.9 Dividing Asc.A
2
7. Dissect and divide V2c from the interlobar ssure
(Fig.9.13) to expand the resected range.
8. Dissect along the CV distally to identify V2b (Fig.9.14),
dissect and divide it, taking care to preserve V2a.
9. Inate lung with 100% oxygen to peak airway pressure
of 20–30mmHg to inate the upper lung. About 10min
later, a clear interface of ination and deation is noted,
i.e., RS2+part of RS3 remains inated while the remaining parenchyma deates (Fig.9.15).
10. The segmentectomy is tailored along the interface of
aerated and deated lungs.
11. The divided stumps following segmentectomy (Fig.9.16).
The postoperative pathology indicated microinvasive
adenocarcinoma (MIA) with 11R and 12R lymph nodes
negative for malignancy.
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J. Liu and X. Li
Fig. 9.10 Dissecting 12R lymph node(s) (RUB right upper bronchus)
Fig. 9.11 Dissecting B
2
Fig. 9.13 Dissecting V2c
Fig. 9.14 Dissecting V2b
Fig. 9.15 Interface of ination and deation after the division of B
Fig. 9.12 Dissecting Rec.A2 (RUL right upper lobe)
2
9 Extended RS2 Segmentectomy by 3D Navigation
Fig. 9.16 Resection bed demonstrating divided stumps of segmental
structures after an extended RS2 segmentectomy
9.3.3 Key Points oftheSurgical Procedure
65
1. Rec.A2 and A1 are co-trunk, and care is taken to protect A1
when dissecting Rec.A2.
2. The dorsal side of the CV is B2, the ventral side is B3, and
the dissection of B2 behind the CV will not accidentally
injure B3.
9.4 Schematic Diagram oftheSurgical
Procedure
Schematic diagram of the surgical procedure for extended
RS2 segmentectomy (Figs.9.17, 9.18, 9.19, 9.20, 9.21, 9.22,
9.23, 9.24, 9.25, 9.26, 9.27, 9.28, and 9.29).
Fig. 9.17 Figure of descending dimension of extended RS2 segmen-
tectomy (The shadow is the range of excision: Red circles represent
arteries; Green circles represent bronchi)
RUL
RUL
RML
RLL
Fig. 9.18 Panoramic gure of the RUL (Interlobal view)
Fig. 9.19 Dissecting Asc.A
2
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J. Liu and X. Li
RUL
Fig. 9.20 Dividing Asc.A2; Dissecting B
Fig. 9.21 Dividing B
2
RUL
2
Fig. 9.23 Dissecting Rec.A
2
RUL
RLL
RML
Fig. 9.24 Dividing Rec.A
2
RUL
RLL
RML
Fig. 9.22 Relationship of arteries and veins of RUL (Anterior hilar
Fig. 9.25 Dissecting V2c
view)
9 Extended RS2 Segmentectomy by 3D Navigation
67
Fig. 9.26 Dividing V2c
RUL
RUL
RUL
RML
RLL
Fig. 9.29 The labeled gure of segmental stumps after extended RS2
segmentectomy
Suggested Reading
1. Cao C, D’Amico T, Demmy T, Dunning J, Gossot D, Hansen H,
etal. Less is more: a shift in the surgical approach to non-small-cell
lung cancer. Lancet Respir Med. 2016;4:e11–2.
2. Schuchert M, Pettiford B, Keeley S, D’Amato T, Kilic A, Close J,
etal. Anatomic segmentectomy in the treatment of stage I non-small
cell lung cancer. Ann Thorac Surg. 2007;84:926–33.
Fig. 9.27 Dissecting V2b
Fig. 9.28 Dividing V2b
RS3 Segmentectomy by 3D Navigation
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JixianLiu andLeiYang
10.1 Summary ofMedical Records
A 49-year-old asymptomatic woman was found to have a
right upper lobe (RUL) lung nodule that persisted despite
antibiotic therapy. Her chest CT (Figs.10.1, 10.2, and 10.3)
showed an 11 mm × 15 mm mixed ground glass opacity
(mGGO) located in the RS3.
10.1.1 Indications andContraindications
10
(a) The lesion, located deep in the RS3 is less than 2cm in
diameter, with C/T (Consolidation/Tumor) ratio less
than 25%.
Fig. 10.1 Chest CT (Axial view) showing the nodule located in the
RS3 (Yellow circle: nodule with 2cm margin)
Fig. 10.2 Chest CT (Coronal view) showing the nodule located in the
RS3 (Yellow circle: nodule with 2cm margin)
J. Liu (*) · L. Yang
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_10
Fig. 10.3 Chest CT (Sagittal view) showing the nodule located in the
RS3 (Yellow circle: nodule with 2cm margin)
69
70
J. Liu and L. Yang
(b) The nodule was unchanged in size despite antibiotic
therapy, raising the possibility of early lung cancer.
(c) With preoperative 3D-CTBA reconstruction, the surgi-
cal margin is estimated to be more than 2cm after RS3
segmentectomy.
(d) The patient was in good physical condition, no contrain-
dications to the surgery procedure.
10.2 Preoperative 3D-CTBA
Reconstruction
The estimated spherical 2cm margin of this nodule is contained within RS3 (Fig.10.4), indicating that RS3 segmentectomy would yield an adequate surgical margin.
10.2.1 Anatomical Features
The right upper bronchus (RUB) (Fig.10.5) is divided into a
common trunk of B1+B2 and a dominant B3, with B3 divided
into a common trunk of B3a+B3bi and B3bii.
The branch of the right superior pulmonary artery (RSPA)
(Fig.10.6): A1 branches separately from the upper trunk of
the RSPA; A2 branches separately from the interlobar artery;
A3 is divided into 2 branches, one of which is A3a+A3bi with
co-trunk out, another of which is A3bii separately.
Right superior pulmonary vein (RSPV) (Figs. 10.7 and
10.8): V3c that runs in front of the hilum is the intra-segment
vein of S3b. V3a is the intersegmental vein of S3a and S3b.
These two veins should be divided. V3b which runs below S3
and is the intersegmental vein between S3 and the right middle lobe needs to be retained. The central vein
Fig. 10.5 Bronchial branches of the RUL (Anterior view)
Fig. 10.4 Relationship between the resection margin and the segmen-
tal interface of the RUL (Lateral view)
Fig. 10.6 Relationship between arteries and bronchi of the RUL
(Anterior view)
10 RS3 Segmentectomy by 3D Navigation
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71
Fig. 10.9 Relationship among arteries, veins, and bronchi of the RS3
(Anterior view)
Fig. 10.7 Relationship between veins and bronchi of the RUL
(Anterior view)
Fig. 10.8 Relationship among arteries, veins, and bronchi of the RS3
(Anterior view)
(V1a + V1b + V2a – c + V3a) meets between B1 and B2,
courses below B3 to RSPV, and drains Venous blood of
S1+S2 and part of S3.
The operation needs to dissect V3c, co-trunk of A3a+ A3bi,
A3bii, V3a and B3 (Fig.10.9).
10.3 Surgery Planning andProcedure
According to CT and preoperative 3D reconstruction, RS3
segmentectomy is pursued. Dissect from the anterior hilum
dorsally.
10.3.1 Surgical Planning
V3c→A3a+A3bi&A3bii→V3a→B3→RS3.
10.3.2 Surgical Procedures
1. The patient has Left lateral position and double-lumen
tracheal intubation. The procedure is carried out with
two ports: The fourth intercostal space in right axillary
midline as main operating port and for thoracoscope
placement; the sixth intercostal port in posterior axillary
line for tractive instruments.
2. Probe to locate the nodule within RS3.
3. Pull the upper lung dorsally and incise the pleura in front
of the hilum.
4. V3c is dissected at the anterior hilum (Fig.10.10). Ligate
and divide V3c (Fig.10.11).
5. Dissect A3a + A3bi and A3bii below the V3c stumps
(Fig.10.12), dividing it to expose A1.
6. 12R lymph node (Fig.10.13) is dissected for intraoperative frozen pathology.
72
J. Liu and L. Yang
Fig. 10.10 Dissecting V3c
Fig. 10.11 Ligating and dividing V3c
Fig. 10.13 Dissecting a 12R lymph node
Fig. 10.14 Ligating V3a (CV: central vein)
Fig. 10.12 Dissecting A3a+A3bi and A3bii
7. Dissect V3a on the surface of the central vein (CV)
(Fig.10.14), ligate and divide.
8. Continue to dissect B3 along the CV surface (Fig.10.15)
and divide.
9. Inate lung with 100% pure oxygen to a peak pressure
of 20–30 mmHg to obtain full ination of the upper
lung. About 10min later, a clear interface of ination
and deation is seen, i.e., RS3 inated and residual lungs
deating (Fig.10.16).
Fig. 10.15 Dissecting B
Fig. 10.16 Showing the ination interface
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