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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_839_Библиотеки_им_академика_М_И_Перельмана
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14 RS8a Segmentectomy by 3D Navigation
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
14.3.3 Key Points oftheSurgical Procedure
(a) The procedure proceeded mainly inside the oblique s-
sure. If the interlobar ssure is poor differentiated, it will
bring difculty to the surgical procedure, so more care
should be needed to dissect the ssure.
(b) A8a which emanates from A9 needs to be identied after
exposing A6 and A
9+10
.
14.4 Schematic Diagram oftheSurgical
Procedure
RLL
105
RUL
Interlobar artery
Schematic diagram of the surgical procedure for RS8a segmentectomy (Figs.14.15, 14.16, 14.17, 14.18, 14.19, 14.20,
14.21, and 14.22).
Fig. 14.16 Panoramic gure of the RLL (Interlobar view)
RULRLL
Interlobar artery
Fig. 14.17 Dissecting A8a
RLL
Fig. 14.18 Dividing A8a
Fig. 14.15 Figure of descending dimension of RS8a segmentectomy.
(The shadow is the range of excision: Red circles represent arteries;
Green circles represent bronchi)
Interlobar artery
106
J. Liu and X. Luan
RLL RUL
Fig. 14.19 Dissecting B8a
RLL
RLL
Interlobar artery
Fig. 14.22 The labeled gure of segmental stumps after RS8a
segmentectomy
RUL
Suggested Reading
1. Saji H, Okada M, Tsuboi M, etal. Segmentectomy versus lobectomy
in small-sized peripheral non-small-cell lung cancer (JCOG0802/
WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial. Lancet. 2022;399(10335):1607–17.
2. Suzuki K, Watanabe SI, Wakabayashi M, etal. A single-arm study of
sublobar resection for ground-glass opacity dominant peripheral lung
cancer. J Thorac Cardiovasc Surg. 2020;S0022–5223(20):33043–9.
3. Ito H, Suzuki K, Mizutani T, etal. Long-term survival outcome after
lobectomy in patients with clinical T1 N0 lung cancer. J Thorac
Cardiovasc Surg. 2020;S0022–5223(20):30054.
Fig. 14.20 Dividing B8a
RLL RUL
Fig. 14.21 Locating the node and delineating the resected area
LS9+LS10 Segmentectomy by 3D
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Navigation
JixianLiu andXinyuLuan
15
15.1 Summary ofMedical Records
A 42-year-old male was found to have a nodule located in the
left lower lobe (LLL) on CT scan 2 months ago without any
physical sickness. He was treated with antibiotics for 2
weeks, with no signicant change of the nodule on reexamination CT 2 months later. Chest CT (Figs.15.1, 15.2,
and 15.3) showed a 13 mm × 8 mm mixed ground glass
opacity (mGGO) located in the middle of LS9+LS10.
15.1.1 Indications andContraindications
(a) The lesion located deep in the LLL is less than 2cm in
diameter, and C/T (Consolidation/Tumor) ratio 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.
(c) With the planning of the preoperative 3D-CTBA recon-
struction, the distance of incisional margin to the nodule
Fig. 15.1 Chest CT (Axial view) showing the nodule (Arrow) located
in the middle of LS9 + LS10. The yellow circle: identies a 2-cm
margin
J. Liu (*) · X. Luan
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_15
Fig. 15.2 Chest CT (Coronal view) showing the nodule (Arrow)
located in the middle of LS9+LS10. The yellow circle: identies a 2-cm
margin
107
108
Fig. 15.3 Chest CT (Sagittal view) showing the nodule (Arrow)
located in the middle of LS9+LS10. The yellow circle: identies a 2-cm
margin
is more than 2 cm after the procedure of LS9 + LS10
segmentectomy.
(d) The patient was in good physical condition, with no con-
traindications to the surgery procedure.
J. Liu and X. Luan
Fig. 15.4 Relationship between the safe margin of nodule and the segmental interface of the LLL (Posterior view)
15.2 Preoperative 3D-CTBA
Reconstruction
The marginal ball of this nodule (nodule and its 2cm margin) shows the margin is located in the middle of LS9+LS10
(Figs.15.4), so LS9+LS10 segmentectomy is required to satisfy the safe surgical margin.
15.2.1 Anatomical Features
The left lower bronchus (LLB) (Fig.15.5) is divided into B6,
7+8
B
, B9, and B10 with B9 and B10 emanating from the com-
mon trunk.
A9 and A10 also emanate in the common trunk from inter-
lobar artery (Fig.15.6).
The left inferior pulmonary vein (LIPV) is observed from
the view of lower lobe ligament (Fig.15.7): V10b+c which
is the lowest branch of the LIPV is the intra-segmental vein
of S10; V10a which is located on the cranial side of V10b+c
and emanates from the surface of V8+V9 is also an intrasegmental vein of S10 that needs to be divided. V9 which is
the inter-segmental veins of S8 and S9 needs to be protected.
V9b which is the inter-segmental vein between S9b and S10b
needs to be divided. V9b can be exposed by pulling B9 stump
upward after dividing it.
The operation needs to dissect V10b+c, V10a, B9+B10,
A9+A10, and V9b.
Fig. 15.5 Bronchial branches of the LLL (Lateral view)
Fig. 15.6 Relationship between arteries and bronchi of LLL (Lateral
view)
A10
15 L S9+LS10 Segmentectomy by 3D Navigation
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V9
A9
B9
B10
V10a
109
Inferior pulmonary
ligament
V10b+
V8+9
V6
Fig. 15.7 Relationship among arteries, veins, and bronchi of the LLL
(Inferior view)
15.3 Surgery Planning andProcedure
According to CT and preoperative 3D reconstruction,
LS9+ LS10 segmentectomy is performed. Dissect from the
left inferior pulmonary vein cephalad.
15.3.1 Surgical Planning
V10b +c →V10a →B9+B10 →A9+A10 →V9b →LS9
+LS
10
15.3.2 Surgical Procedures
1. The patient is in the right lateral position and has double-
lumen tracheal intubation. The procedure is performed
with two ports: The fth intercostal of left axillary
midline as main operating port and insertion of the thoracoscope; the seventh intercostal port in posterior axillary line for retractive instruments.
2. Probe to locate the nodule within LS9+LS10.
3. Pull the left lower lobe cephalad and dissect the inferior
pulmonary ligament (Fig.15.8), the 9L lymph node is
dissected (Fig. 15.9) for intraoperative frozen
pathology.
4. Dissect the LIPV (Fig.15.10) to the distal side to nd
the lowest branch, that is V10b+c (Fig.15.11) which
can be divided by the stapler. Along V8+V9 to dissect
the rst branch that is V10a, ligating with 4-0 silk
thread (Fig.15.12) and dividing it with an ultrasound
knife.
5. Dissect bluntly co-trunk of B9+B10 (Fig.15.13) between
V8+V9 and V6, dividing them with the stapler.
Fig. 15.8 Dissecting inferior pulmonary ligament
Fig. 15.9 Dissecting 9L lymph node
Fig. 15.10 Dissecting LIPV
6. Lift the B9+B10 stumps and dissect co-trunk of A9+A10
bluntly (Fig.15.14) behind them, dividing them with the
stapler.
7. Lift the A9+A10 stump to dissect V9b (Fig.15.15) which
distributes between S9b and S10b, ligating it with silk
thread and dividing it.
8. Inate lung with 100% pure oxygen having a pressure of
20–30mmHg to the full ination of the LLL.About 10min
later, a clear interface of ination and deation is seen, i.e.,
LS9+LS10 inating and Residual lung deating (Fig.15.16).
110
J. Liu and X. Luan
Fig. 15.11 Dissecting V10b+c
Fig. 15.12 Ligating V10a with silk thread
Fig. 15.14 Dissecting co-trunk of A9+A10 Bluntly
Fig. 15.15 Dissecting V9b
Fig. 15.13 Dissecting co-trunk of B9+B10 Bluntly
9. The lung is tailored along the interface of ination and
deation (Figs.15.17 and 15.18).
10. Show the stumps of segmental surface postoperatively
(Fig.15.19).
Fig. 15.16 Showing the interface of inating and deating
The postoperative pathology was microinvasive adeno-
carcinoma (MIA) with 9L lymph node negative.
15.3.3 Key Points oftheSurgical Procedure
(a) When LS9+LS10 segmentectomy is performed, the pro-
cess from the lower pulmonary vein cephalad makes the
15 L S9+LS10 Segmentectomy by 3D Navigation
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Fig. 15.17 Tailoring lung along the interface of ination and deation
(From caudal to cephalad)
111
operation simple, but this process requires the operator
to adapt to the change of the surgical approach. First,
dissect the inferior pulmonary vein, then the inferior
lobar bronchus, and nally the inferior pulmonary artery.
(b) V9 is an important surgical margin, and operating
between V9 and V6 will not injure the structure of S8.
15.4 Schematic Diagram oftheSurgical
Procedure
Schematic diagram of the surgical procedure for LS9+LS10
segmentectomy (Figs. 15.20, 15.21, 15.22, 15.23, 15.24,
15.25, 15.26, 15.27, 15.28, 15.29, 15.30, 15.31, 15.32, and
15.33).
Fig. 15.18 Tailoring lung along the interface of ination and deation
(From ventral to dorsal)
Fig. 15.19 Stumps of segmental surface after LS9 + LS10
segmentectomy
Fig. 15.20 Figure of descending dimension of LS9+LS10 segmentec-
tomy (The shadow is the range of excision: Red circles represent arteries; Green circles represent bronchi)
112
J. Liu and X. Luan
LUL LLL
Fig. 15.21 Panoramic gure of the LLL (Inferior view)
LUL LLL
LUL LLL
Fig. 15.24 Dissecting V10a
LUL LLL
Fig. 15.22 Dissecting V10b+c
LUL LLL
Fig. 15.23 Dividing V10b+c
Fig. 15.25 Dividing V10a
LUL LLL
Fig. 15.26 Dissecting B9+B
10
15 L S9+LS10 Segmentectomy by 3D Navigation
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113
LUL LLL
Fig. 15.27 Dividing B9+B
10
LUL LLL
LUL LLL
Fig. 15.30 Dissecting V9b
LUL LLL
Fig. 15.28 Dissecting co-trunk of A9+A
10
LUL LLL
Fig. 15.29 Dividing A9+A
10
Fig. 15.31 Dividing V9b
LUL LLL
Fig. 15.32 Locating the node and delineating the resected area
114
LUL LLL
Fig. 15.33 The labeled gure of segmental stumps after LS9+ LS10
segmentectomy
J. Liu and X. Luan
Suggested Reading
1. Suzuki K, Watanabe SI, Wakabayashi M, etal. A single-arm study of
sublobar resection for ground-glass opacity dominant peripheral lung
cancer. J Thorac Cardiovasc Surg. 2020;S0022–5223(20):33043–9.
2. Ito H, Suzuki K, Mizutani T, etal. Long-term survival outcome after
lobectomy in patients with clinical T1 N0 lung cancer. J Thorac
Cardiovasc Surg. 2020;S0022–5223(20):30054.
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