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LR
10 RS3 Segmentectomy by 3D Navigation
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73
10. The lung is tailored along the interface of inating and
deating (Fig.10.17).
11. The completed segmentectomy (Fig.10.18).
The postoperative pathology of this patient was
microinvasive adenocarcinoma (MIA) with No. 12
lymph node negative.
10.3.3 Key Points oftheSurgical Procedure
(a) RV1 runs below B1 and drains into CV, rather than its
usual course running on the surface of the anterior hilum,
which makes RS3 segmentectomy simple and has less
chance to damage RV1.
(b) Dissecting the 12R lymph node after A2 and V2 are
divided facilitates exposure and division of B3. Dissect
B3 on the surface of CV.
10.4 Schematic Diagram oftheSurgical
Procedure
Schematic diagram of the surgical procedure for RS3 segmentectomy (Figs.10.19, 10.20, 10.21, 10.22, 10.23, 10.24,
10.25, 10.26, 10.27, 10.28, 10.29, and 10.30).
Fig. 10.17 Tailoring S3 along the interface
Fig. 10.19 Figure of descending dimension of RS3 segmentectomy
(The shadow is the range of excision: Red circles represent arteries;
Green circles represent bronchi)
RL UL
Fig. 10.18 Postoperative stumps of segmental surface after RS3
segmentectomy
Fig. 10.20 Panoramic gure of the RUL (Anterior view)
74
J. Liu and L. Yang
Fig. 10.21 Dissecting V3c
RML
RUL
RUL
RUL
Fig. 10.24 Dividing A3a+A3bi, A3bii
RULRLL
RML
Fig. 10.22 Dividing V3c
Fig. 10.23 Dissecting A3a+A3bi, A3bii
Fig. 10.25 Dissecting V3a
RUL
RUL
RML
Fig. 10.26 Dividing V3a
LR
10 RS3 Segmentectomy by 3D Navigation
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75
RML
Fig. 10.27 Dissecting B
RML
RUL
RL UL
RML
Fig. 10.30 The labeled gure of segmental stumps after RS3
3
segmentectomy
Suggested Reading
RUL
1. Gu Y, Duan R, Lv X, Song J. Airway Management of the Right
Anterior Segmentectomy through Uniportal video-assisted thoracoscopic surgery (VATS) after left pneumonectomy by an adapted
double-lumen endobronchial tube (DLT): a case report. BMC
Anesthesiol. 2019;19(1):82.
2. Stamenovic D, Messerschmidt A.Uniportal video-assisted thoraco-
scopic resection of anterior segment of the left upper lobe. Multimed
Man Cardiothorac Surg. 2018;2018 https://doi.org/10.1510/
mmcts.2018.002.
Fig. 10.28 Dividing B
3
Node
interface
Fig. 10.29 Locating the node and delineating the resected area
RS2b+RS3a Segmentectomy by 3D
Navigation
JixianLiu andYiwangYe
11.1 Summary ofMedical Records
A 35-year-old asymptomatic man was found to have a right
upper lobe (RUL) lung nodule that persisted despite antibiotic therapy. Chest CT (Figs.11.1, 11.2, and 11.3) showed an
8mm×9mm mixed ground glass opacity (mGGO) located
between RS
11.1.1 Indications andContraindications
2
and RS3.
11
(a) The lesion located deep in the RUL is less than 2cm in
diameter, with C/T (Consolidation/Tumor) ratio less
than 50%.
Fig. 11.1 Chest CT (Axial view) showing the nodule located between
RS2b and RS3a (Yellow circle: nodule and its 2cm margin)
Fig. 11.2 Chest CT (Coronal view) showing the nodule located
between the RS2b and RS3a (Yellow circle: nodule and its 2 cm
margin)
J. Liu (*) · Y. Ye
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_11
Fig. 11.3 Chest CT (Sagittal view) showing the nodule located
between RS2b and RS3a (Yellow circle: nodule and its 2cm margin)
77
78
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J. Liu and Y. Ye
(b) The nodule was found to persist on serial chest CT imag-
ing despite antibiotic therapy, raising the possibility of
early lung cancer.
(c) With the planning by 3D-CTDA reconstruction, the dis-
tance from the planned resection margin to the nodule
would be more than 2 cm after RS2b + RS3a
segmentectomy.
(d) The patient demonstrated good performance status,
without contraindications to operation.
11.2 Preoperative 3D-CTBA
Reconstruction
The projected resection sphere (including the nodule and a
2-cm margin) shows the margin located in RS2b + RS3a
(Fig.11.4), amenable to RS2b+RS3a segmentectomy.
11.2.1 Anatomical Features
The right upper bronchus (RUB) (Fig.11.5) is divided into
B1, B2 and B3 separately. B2 branches into B2a and B2b, B3
branches into B3a and B3b. The nodule is located between
B2b and B3a.
A1 and A3 are co-trunk separated from the upper trunk of
right superior pulmonary artery (RSPA), and A3a (Fig.11.6)
is located anteriorly and superiorly of B3a. A2 branches alone
from the interlobular artery and divides into A2a and A2b,
with A2b located below B2b.
The right superior pulmonary vein (RSPV) (Fig.11.7) is
divided into V1b, a central vein (V1a, V2a, V2b, and V2c), and
V3a (separated from the root of the RSPV). V2c, the intersegmental vein between S2b and S3a will be resected.
The operation needs to dissect V2c, A2b, B2b, B3a, and A3a
(Fig.11.8).
Fig. 11.4 Relationship between the nodule and 2cm margin and the
segmental interface of the RUL (Lateral view)
Fig. 11.5 Bronchial branches of the RUL (Lateral view)
Fig. 11.6 Relationship between arteries and bronchi of the RS2b+RS3a
(Lateral view)
11 R S2b+RS3a Segmentectomy by 3D Navigation
Fig. 11.7 Relationship between veins and bronchi of RS2b +RS3a
(Lateral view) CV: (Central Vein)
79
The fourth intercostal
space, right axillary
midline
The sixth intercostal
space, posterior
axillary line
Fig. 11.9 Incision layout
11.3.2 Surgical Procedures
Fig. 11.8 Relationship among arteries, veins, and bronchi of the
RS2b+RS3a (Lower lateral view)
11.3 Surgery Planning andProcedure
According to CT and preoperative 3D reconstruction,
RS2b+RS3a segmentectomy is undertaken, dissecting from
the junction of oblique ssure and horizontal ssure to the
cranial side.
11.3.1 Surgical Planning
A2b→B2b→V2c→B3a→A3a→RS2b+RS3a.
1. The patient undergoes double-lumen endotracheal intu-
bation and is positioned in the left lateral position. The
procedure requires two ports: The fourth intercostal in
the right axillary midline as the main operating port and
through thoracoscope; the sixth intercostal port in posterior axillary line for tractive instruments (Fig.11.9).
2. Probe to locate the nodule between RS2+RS3.
3. Retract the upper lung cranially and incise the pleura of
the interlobar ssure.
4. Expose the interlobar artery of right pulmonary artery,
dissecting A2 (Fig.11.10) distal to A2a and A2b, dissecting A2b (Fig.11.11), and dividing A2b.
5. Dissect B2 posterior to A2b and along the lateral edge of
the central vein. Dissect B2 distally until encountering
B2a and B2b (Fig.11.12), dividing B2b.
6. Lift the distal end of B2b, dissecting V2c (Fig. 11.13)
medial to the central vein, ligating and dividing V2c. A
12R lymph node is dissected for intraoperative frozen
pathology.
7. Dissect B3a ventrally at the level of the V2c stump
(Fig.11.14) and divide. According to 3D reconstruction,
the root of B3a is surrounded by several small branches
of A3a.
8. A3a is cranial, closely adjacent to B3a, and is mobilized
and divided (Fig.11.15).
9. Inate lung with 100% pure oxygen to an airway pres-
sure of 20–30mmHg in order to inate the parenchyma
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J. Liu and Y. Ye
Fig. 11.13 Dissecting V2c
Fig. 11.10 Dissecting A
Fig. 11.11 Dissecting A2b
2
Fig. 11.14 Dissecting B3a
Fig. 11.12 Dissecting B2b
of the upper lung. About 10min later, a clear interface
between ination and deation is seen, i.e., RS2b+RS3a
inating and Residual lungs deating (Fig.11.16).
10. The lung is tailored along the interface of ination and
deation (Fig.11.17).
Fig. 11.15 Dissecting A3a in front of B3a
11. Demonstrating the stumps of the adjacent segmental surface (Fig.11.18).
The postoperative pathology of this patient indicated
microinvasive adenocarcinoma (MIA) with a 12R lymph
node negative.
11 R S2b+RS3a Segmentectomy by 3D Navigation
Fig. 11.16 Showing the interface of ination and deation
81
11.3.3 Key Points oftheSurgical Procedure
(a) CV and V2c have thin walls with no vascular sheaths and
require an assistant to pull lung moderately around them
to form a micro-tension plane which will help to dissect
them.
(b) B3a and A3a are located on the deep surface of the inter-
lobar ssure, and the surface lung tissue needs to be dissected carefully to avoid bleeding which can inuence
view; B3a is surrounded by branches of A3a and needs to
be dissected carefully.
11.4 Schematic Diagram oftheSurgical
Procedure
Schematic diagram of the surgical procedure for RS2b+RS3a
segmentectomy (Figs. 11.19, 11.20, 11.21, 11.22, 11.23,
11.24, 11.25, 11.26, 11.27, 11.28, 11.29, 11.30, 11.31, and
11.32).
Fig. 11.17 Tailoring lung along the interface of inating and
deating
Fig. 11.18 Stumps of segmental surface after RS2b + RS3a
segmentectomy
Fig. 11.19 Figure of descending dimension of RS2b+RS3a segmen-
tectomy (The shadow is the range of excision: Red circles represent
arteries; Green circles represent bronchi)
82
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Middle lower
lobe bronchi
Interlobar
artery
Fig. 11.20 Panoramic gure of the RUL (Interlobular view)
J. Liu and Y. Ye
RUL
RML
Fig. 11.23 Dissecting B2b
RUL
Fig. 11.21 Dissecting A2b
Fig. 11.22 Dividing A2b
Fig. 11.24 Dividing B2b
Fig. 11.25 Dissecting V2c
11 R S2b+RS3a Segmentectomy by 3D Navigation
83
Fig. 11.26 Dividing V2c
Fig. 11.27 Dissecting B3a
Fig. 11.29 Dissecting A3a
Fig. 11.30 Dividing A3a
Fig. 11.28 Dividing B3a
Fig. 11.31 Locating the node and delineating the resected area
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