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3 3D Reconstruction ofLung by MIMICS

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Fig. 3.9 Modify the angiogenesis

Fig. 3.10 Reconstruction of the distal trachea

Fig. 3.11 Tracheal centerline extraction

S. Liu

3 3D Reconstruction ofLung by MIMICS

Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/

Fig. 3.12 Bilateral lung contours and generation of lobar ssures

Fig. 3.13 Segmented lung lobes

Fig. 3.14 Segmentation of lung segments

S. Liu

Fig. 3.15 Completed lung reconstruction

Suggested Reading

1. Ginsberg RG, Rubinstein LV.Randomized trial of lobectomy versus limited resection for T1N0 non-small cell lung cancer. Lung cancer study group. Ann Thorac Surg. 1995;60:615–22.

2. Cao C, D’Amico T, Demmy T, Dunning J, Gossot D, Hansen H, etal. Less is more: a shift in the surgical approach to non-small-cell lung cancer. Lancet Respir Med. 2016;4:e11–2.

3. Schuchert M, Pettiford B, Keeley S, D’Amato T, Kilic A, Close J, etal. Anatomic segmentectomy in the treatment of stage I non-small cell lung cancer. Ann Thorac Surg. 2007;84:926–33.

Indications andTechnical Details

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ofSegmentectomy forLung Cancer

JixianLiu andGuangxianMao

4.1 Indications ofSegmentectomy forLung Cancer

In 1995, Lobectomy had been established as the standard method by the Lung Cancer Study Group (LCSG) in the treatment of early-stage lung cancer by showing that lobectomy provides a signicant survival advantage over sublobar resection. Sublobar resection had been considered a compromise option for patients who could not tolerate lobectomy (e.g., comorbidities of high-risk, advanced age, and low cardiopulmonary function). However, the study (a) included subjects whose tumors measured over 2cm in diameter, or who had received non-anatomic wedge resections; (b) did not identify signicantly different overall survival; and (c) lacked complete pulmonary function testing data.

In recent years, as low-dose CT lung cancer screening has become more prevalent, an increasing number of patients have been diagnosed with small pulmonary nodules or with predominantly ground glass opacities (GGOs). Notably, the histology of GGOs is usually adenocarcinoma in situ (AIS) or microinvasive adenocarcinoma (MIA). The results of many retrospective studies also suggest that thoracoscopic sublobar resection has comparable local recurrence and long-term survival rates to lobectomy in the treatment of subsolid pulmonary nodules. The choice of surgical approach for small nodules, especially small ground glass nodules, has been a controversial topic in the general thoracic surgery community.

The current surgical indications recommended for intentional segmentectomy for lung cancer by National Comprehensive Cancer Network (NCCN) guidelines are

peripheral nodules ≤2cm in diameter for which at least one of the following criteria are met: (1) the histological type is AIS; (2) the pulmonary nodule has more than 50% GGO component by CT; and (3) The tumor doubling time has more than 400 days by CT follow-up.

Supported by published reports of the Japan Clinical Oncology Group clinical trials, notably JCOG0802, JCOG0804, and JCOG1211 (Fig. 4.1), sublobar resection can be a good choice for early lung cancer. In the JCOG1211 study, segmentectomy was found to be a suitable choice for early cancer when the diameter of the lung nodule is less than 3 cm and the consolidation/tumor ratio (C/T ratio) is less than 0.5, if adequate margins are secured. The JCOG0802 study demonstrated that for peripheral non-small cell lung cancer with nodules ≤2cm in diameter and C/T ratio ≥0.5, segmentectomy was no worse than lobectomy in terms of 5-year overall survival, and lung function was better preserved than lobectomy.

In our clinical practice, we have found that in patients with completely solid nodules with a diameter of less than 1 cm diagnosed as NSCLC (non-small cell lung cancer), intrapulmonary metastases, pleural spread, and N2 lymph node metastases are still identied. Our indications for intentional segmentectomy for NSCLC are as follows:

(i) Nodule is located in the middle one-third part of lung. (ii) The diameter of nodule is less than 3cm. (iii) The C/T ratio was 0.5 or less. (iv) The intraoperative frozen pathology of parenchymal

lymph nodes (N1) sampled in the corresponding surgical area is negative.

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

Tumor size

C/T ratio

Fig. 4.1 Recommended surgical approach determined by tumor size and consolidation/tumor ratio, as summarized by the Japan Clinical Oncology Group (Courtesy of GCOG)

4.2 Technical Key Point ofSegmentectomy with3D Navigation

0 cm

2.0 cm

3.0 cm

JCOG0804

PII Wide

wedge

resection

PII Segmentectomy

0.25 0.5

JCOG1211

J. Liu and G. Mao

1.0

JCOG0802

PIII Lobectomy vs

Segmentectomy

Standard procedure

Lobectomy

4.2.1 Choice ofIncision

The location and number of incisions are selected according to the planned anatomic resection. Due to the adjustable angle of the thoracoscope, the bending properties of the surgical instruments, and ability to adjust the angle of the stapler, most procedures can be performed through a single port by experienced surgeons. In our single port approach, operative visualization (thoracoscope) A, placement of the assistant’s retraction instruments (oval forceps) B, and the primary operating instruments (curved suction and electrocautery hook or Ultrasonic knife) C, are all accessed through a single port (Fig.4.2).

Upper lobe segmentectomies are performed through a single port in the fourth intercostal space of the mid-axillary line. Middle and lower lobe segmentectomies are performed through the fth intercostal space between the mid-axillary and posterior axillary lines. The upper apical segmentectomies can be performed through the third intercostal port in the mid-axillary line, which provides a better inline vision.

When the operating angle is not good, a “modied single operating port” approach is pursued, in which another port (Fig.4.3) can be added for the procedure which is mainly for retraction and the access of the stapler, with the endoscope still entering through the main operating port. The method not only adapts to the operating habits of most surgeons, it also reduces the difculty of procedure. When the basal segmentectomy (S9 and S10) of both lower lungs are resected, a conventional three-port procedure is recommended, allowing for different operating angles.

Fig. 4.2 Incision layout

Fig. 4.3 Modied single operating port

4 Indications andTechnical Details ofSegmentectomy forLung Cancer

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Fig. 4.5 Wang’s technique

Fig. 4.4 Special instruments for segmentectomy. (a) Curved suction

tube; (b) Double joint separation forceps (head bent 15°); (c) Double joint separation forceps (head bent 90°); (d) Double joint tissue forceps

4.2.3.2 “Wang’s Technique”

The “Wang’s technique” (Fig.4.5) is a practical and instructable maneuver proposed by Dr. Jun Wang, using the hook electrocautery (typically right hand) and curved suction (typically left hand), allowing sharp and blunt dissection simul-

4.2.2 Selection ofSurgical Instruments

taneously while aspirating shed blood from the operative eld. The operating space is the shape of a thin cylinder,

Segmentectomy may be more meticulous than lobectomy,

which is suitable for the procedure of segmentectomy. and special instruments for segmentectomy are often chosen (Fig.4.4) with ner graspers or multiple angles to facilitate dissection around distal vasculature or segmental airways.

4.2.3.3 Dissection ofSegmental Vessels andBronchus

1. Dissection of arteries: The targeted lobar artery and its

segmental branches are dissected rst and then compared

4.2.3 Operational Skills

with the 3D reconstruction diagram. The targeted segmental arteries should be dissected distally while the

4.2.3.1 “From theShallower totheDeeper” toDissect theTargeted Segmental Structures

Three-dimensional (3D) reconstruction provides an understanding of the adjacent relationships between vessels and bronchus within the targeted segment before operation, helping determine the surgical approaches and dissecting sequence. Segmentectomy by 3D navigation can be undertaken according to the principle of “From the shallower to the deeper,” that is, after the supercial structures have been dissected, the deeper structures then become supercial.

For most upper lobe segmentectomy, the approach can be taken from the membrane-like structure of the anterior hilum moving posteriorly. For RS2b + RS3a segmentectomy, the approach can be chosen from the interlobular ssure cranially. For S6 segmentectomy, the approach can be performed from interlobular ssure caudally. For lower lobe S9 or S10, the approach can be chosen from the inferior pulmonary ligament moving cephalad. All these approaches follow “from the shallower to the deeper.”

untargeted segmental arteries should be visualized but not fully dissected to avoid damage when mobilizing the targeted segmental structures from the retained segmental hilar structures. The segmental artery has a vascular sheath on its surface, which should be opened and dissected distally along its longitudinal axis. The direction of the arterial branches and their proximity to the surrounding veins and bronchi can be conrmed according to 3D reconstruction to prevent inadvertent injury. Small arteries can be ligated with 4-0 silk sutures (Fig. 4.6); larger arteries can be divided using an articulating surgical stapler.

2. Dissection to veins: Ligation is more suitable for control of vein branches that have thinner walls, since division with even narrow tissue depth staple cartridges may result in ongoing bleeding. The intrasegmental veins are dissected in the same way as the segmental arteries; intersegmental veins are important markers of the resected extent of lung segment and need to be adequately dissected. The intrasegmental vein collects many small

Fig. 4.6 Ligating the small artery with silk thread

J. Liu and G. Mao

Fig. 4.8 Dissecting bronchus with ne forceps

Small vein

Fig. 4.7 Dissecting ne venous branches with an ultrasonic scalpel

branches along its course, which are more likely to cause vascular damage and bleeding when dissected with hook electrocautery. Dissecting veins with an ultrasonic scalpel is safe (Fig.4.7).

3. Dissection to Bronchus: Segmental bronchus surrounded by intrasegmental or intersegmental vessels can be dissected using blunt-tipped forceps, especially 15° forceps, in close proximity to the targeted bronchus (Fig.4.8) to avoid vessels injury. Segmental or subsegmental bronchi are sometimes sufciently thin that these can be divided and sealed with a narrow thickness (white) stapler cartridge (Fig.4.9).

4.2.3.4 Vessel-Dissected Ination-Deation

Method

At present, the boundary of the lung segment is mainly determined by ination-deation method, in which the lung is inated with 100% pure oxygen after dividing the blood vessels and bronchi of the targeted segment, so the targeted lung

Fig. 4.9 Dividing and closing the bronchus with the surgical stapler

segment is inated, and the remaining lung is deated about 10min later to determine the intersegmental interface. This method has two problems: rst, prolonged waiting time, worse in patients with emphysema; second, the pressure usually requires 25–30 cm H2O to allow the oxygen to pass through Koch’s orice to expand the targeted segment that has no bronchus. Sometimes such pressure may lead to lung injury. We have attempted the “Vessel-dissected ination and deation method” based on the principle that oxygen in the deating lung is mainly carried out by blood, not bronchus.

The segmental interface of inating and deating after only dividing the vessels of the targeted segment is consistent with the interface obtained by dividing the segmental vessels and bronchus (Figs. 4.10 and 4.11). The pressure which expands targeted segments completely is usually below 20cm H2O.During the waiting time taken to visualize this interface, dissection of the targeted bronchus can reduce the operating time.

4 Indications andTechnical Details ofSegmentectomy forLung Cancer

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Fig. 4.10 The intersegmental plane is dened by dividing only the targeted artery

Fig. 4.12 Relationship between the safe margin of nodule and the segmental interface of the RUL (Lateral view)

Fig. 4.11 The intersegmental plane dened after dividing both the segmental artery and segmental bronchus

4.2.3.5 Denition ofTargeted Segments or Subsegments

The extent of the operation is delimited according to the estimated sphere representing a safe surgical margin of 2cm as determined by the preoperative 3D-CTBA reconstruction (Fig.4.12). Operation between intersegmental veins will not cause accidental injury to the structures of the untargeted segments (Figs.4.13 and 4.14).

4.2.3.6 Segmental Gate Dissection

When the interface of ination-deation is clear, the intersegmental planes can be dissected with hook electrocautery in the cut mode to dene the interface. The intersegmental

Fig. 4.13 When the RS1 segmentectomy is undergone, V1b and V2a which are intersegmental veins need to be preserved

Fig. 4.14 When the RS1 segmentectomy is undertaken, V1b and V2a which are intersegmental veins should be preserved

Fig. 4.15 Wave opening to LS

plane is not at but resembles the wave of the sea, so the operative approach is also named as “Wave Opening” (Fig.4.15). That means the interface without intersegmental veins is rst opened to form a deep “wave” and then a shallow “wave” including tubular structures is dissected later. In this way, the dissected interface is clear and usually leakage free. After the targeted hilar structure is fully dissected, “Dimensional reduction tailoring” can be undertaken to make the intersegmental plane unfold after operation.

After dividing the targeted segmental vessels and bronchi, the segmental hilum can be dissected in an “Inward Opening” fashion, i.e., by dissecting the severed bronchus as far as possible to be away from the preserved structure. The thin anvil of the stapler is inserted into the intersegmental space gently and red to reduce the intersegmental air leak. However, care should be taken to position the cartridge anvil between the intersegmental plane in situ and then bring the lung tissue into the suture jaws with oval forceps to avoid bleeding.