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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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6 LS
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4+5
Segmentectomy by 3D Navigation
39
Oblique Fissure
LUL
LLL
Fig. 6.8 Dissecting the oblique ssure
Fig. 6.7 Relationship among arteries, veins and bronchi of LS
(Anterior view)
4 + 5
6.3 Surgery Planning andProcedure
According to CT and preoperative 3D reconstruction, LS
segmentectomy is outlined. Dissection is completed from the
anterior hilum of LUL posteriorly and oblique ssure
cephalad.
4+5
6.3.1 Surgical Planning
4+5
V
→A5b→B
4+5
→Med.A4 & Med.A5a→LS
4+5
.
6.3.2 Surgical Procedures
1. The patient underwent double lumen endotracheal intu-
bation and was placed in the right lateral decubitus position. The procedure uses a dual-port approach, with the
left fourth intercostal space between the anterior and
mid-axillary lines as the main operating port and for the
thoracoscope, approximately 3 cm long, and the sixth
intercostal space in the left posterior axillary line for
assistant instruments.
2. Probe to locate the nodule within LS
3. The left upper lobe is drawn posteriorly and superiorly,
the pleura of oblique ssure and anterior hilar is opened
(Fig.6.8). An incomplete ssure is incised, a 11L lymph
node is dissected (Fig. 6.9) for intraoperative frozen
pathology.
4. The lowermost branch of the left superior pulmonary
vein is V
4+5
, dissected (Fig.6.10) and divided with the
Stapler.
4+5
.
Fig. 6.9 Dissecting 11L lymph node
Fig. 6.10 Dissecting V
4+5
5. A5b is the most anterior branch of the interlobar artery
trunk, dissected and divided with the endoGIA stapler
(Fig.6.11).
6. Along V
4 +5
and A5b upward, LB
4 +5
is dissected and
divided with the Stapler (Fig.6.12).
7. LB
4+5
is retracted upward to dissect Med.A4 & Med.A5a
along the inferior border of V
1+2+3
(Fig.6.13).
8. Inate the lung with 100% pure oxygen having a pressure of 20–30 mmHg to full ination. About 10 min
40
J. Liu and J. Wang
Fig. 6.11 Dividing A5b (LUB left upper bronchus)
Fig. 6.12 Dividing B
4+5
Fig. 6.14 The completed LS
4+5
segmentectomy
later, a clear interface of ination and deation is seen,
i.e., LS
4+5
inating and LS
1+2+3
deating.
9. The segmental plane is developed along the interface of
ination and deation and LS
4+5
is resected.
10. Show the stumps of segmental surface postoperative
(Fig.6.14).
The postoperative pathological diagnosis: Invasive
adenocarcinoma (pT1bN0M0) with the 11L lymph node
negative for carcinoma.
6.3.3 Key Operation Points
A4 and A5a are arteries of mediastinal type, which can only
be exposed after dividing B
4+5
.
6.4 Schematic Diagram oftheSurgical
Procedure
Schematic diagram of the surgical procedure for LS
mentectomy (Figs.6.15, 6.16, 6.17, 6.18, 6.19, 6.20, 6.21,
6.22, 6.23, 6.24, 6.25, 6.26, 6.27, and 6.28).
4+5
seg-
Fig. 6.13 Dissecting Med.A4 & Med.A5a
6 LS
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4+5
Segmentectomy by 3D Navigation
41
LUL
Interlobar Artery
Left Lower Bronchus
LLL
Fig. 6.18 Panoramic anatomy of LUL (Anterior view)
Fig. 6.15 Figure of descending dimension of LS
4+ 5
segmentectomy
(The shadow is the range of excision: Red circles represent arteries;
Green circles represent bronchi)
LUL LLL
Fig. 6.16 Panoramic anatomy of the interlobular left pulmonary artery
(Interlobular view)
Fig. 6.19 Dissecting V
4+5
Fig. 6.20 Dividing V
Fig. 6.17 Dissecting the 11L lymph node
4+5
42
J. Liu and J. Wang
Fig. 6.21 Dissecting A5b
Fig. 6.22 Dividing A5b
Fig. 6.24 Dividing B
4+5
Fig. 6.25 Dissecting Med.A4 & Med.A5a
Fig. 6.23 Dissecting B
Fig. 6.26 Dividing Med.A4 & Med.A5a
4+5
6 LS
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4+5
Segmentectomy by 3D Navigation
43
Margin
Nodules
Fig. 6.27 Locating the node and delineating the resected area
Suggested Reading
1. Dai C, Shen J, Ren Y, etal. Choice of surgical procedure for patients
with non-small-cell lung cancer ≤ 1cm or > 1 to 2cm among lobectomy, segmentectomy, and wedge resection: a population-based
study. J Clin Oncol. 2016;34(26):3175–82.
2. Khullar OV, Liu Y, Gillespie T, Higgins KA, etal. Survival after
sublobar resection versus lobectomy for clinical stage IA lung cancer: an analysis from the national cancer data base. J Thorac Oncol.
2015;10(11):1625–33.
Fig. 6.28 Segmental stumps after LS
4+5
.segmentectomy
Inerlobar Artery
Left Lower Bronchus
Extended LS3 Segmentectomy by 3D
Navigation
JixianLiu andWeiYue
7.1 Summary ofMedical Records
A 56-year-old asymptomatic woman was found to have a left
upper lobe (LUL) lung nodule on a CT scan that enlarged
during 4-month interval surveillance. Chest CT (Figs.7.1,
7.2, and 7.3) showed a mixed ground glass opacity (mGGO)
of about 22mm×16mm in size located in LS3.
7.1.1 Indications andContraindications
7
(a) The diameter of the nodule in the LUL is about 2 cm,
with C/T (Consolidation/Tumor) value of less than 50%.
(b) The nodule has been observed for 4 months. Results of
the review showed that the nodule enlarged, being considered the possibility of early lung cancer.
Fig. 7.1 Chest CT (Axial view) showing the nodule (arrow) located in
the LS3. The yellow circle: Identies a 2-cm margin
Fig. 7.2 Chest CT (Coronal view) showing the nodule (arrow) located
in the LS3. The yellow circle: Identies a 2-cm margin
J. Liu (*) · W. Yue
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_7
Fig. 7.3 Chest CT (Sagittal view) showing the nodule (arrow) located
in the LS3. The yellow circle: identies a 2-cm margin
45
46
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(c) With the planning of the preoperative 3D-CTBA recon-
struction, the incisional margin to the nodule is more
than 2 cm after the procedure of extended LS3
segmentectomy.
(d) The patient demonstrates excellent performance status
without contraindications to resection.
7.2 Preoperative 3D-CTBA
Reconstruction
The marginal ball of this pulmonary nodule (nodule and its
2cm margin) shows the margin is mainly located in LS3 and
partially extends into S
LS3 segmentectomy is required to achieve a satisfactory surgical margin.
1+2
(Fig.7.4), indicating that extended
J. Liu and W. Yue
7.2.1 Anatomical Features
The left upper lobe bronchus (Fig. 7.5) is divided into
1+2
B
+B3 and B
The left superior pulmonary arteries (LSPA) (Fig.7.6):
1 + 2
A
a + b and A
respectively; the two branches (A3b and A3a+c) of the A3
also branch off from the trunk of LSPA, respectively. A4b is
a mediastinal type artery emanating from the root of LSPA
alone, A4a and A5 are co-trunks emanating from the interlobular artery.
Fig. 7.4 Relationship between the safe margin of nodule and the segmental interface of the LUL (Lateral view)
4+5
1+2
, B
+B3 is divided into B
1 + 2
c emanate from the trunk of LSPA,
1+2
and B3.
Fig. 7.5 Bronchial branch of the LUL (Lateral view)
Fig. 7.6 Relationship between arteries and bronchi of the LUL
(Anterior view)
1+2 +3
V
and V
4+5
emanate from the left superior pulmo-
nary vein (LSPV) respectively (Figs.7.7 and 7.18), the trunk
1+2+3
of V
anterior hilum. V3c and V3a+ b emanate from the V
travels under B3 to the LSPV, not on the surface of
1+ 2+ 3
trunk, respectively; the intrasegmental vein of S3, V3c, will
be divided; V3b is the intersegmental vein between S3 and S4.
For this resection, V3a + b should be divided together to
ensure adequate margins.
7 Extended LS3 Segmentectomy by 3D Navigation
47
Fig. 7.7 Relationship among arteries, veins, and bronchi of the LUL
(Anterior view)
The operation will dissect V3c, A3b, A3a+c, V3a+b, and
B3 following the principle of proceeding “from the shallower
to the deeper.”
7.3 Surgery Planning andProcedure
According to CT and preoperative 3D reconstruction, the
extended LS3 segmentectomy is undertaken, dissecting from
the anterior hilum posteriorly.
7.3.1 Surgical Planning
V3c→A3b→A3a+c→V3a+b→B3→Extended LS3.
Fig. 7.8 Mark the nodule close to LS
Fig. 7.9 Dissecting 11L
1+2
with a suture
7.3.2 Surgical Procedures
1. The patient undergoes double-lumen endotracheal intu-
bation, positioned right lateral decubitus. The procedure
is completed with two ports: The fourth intercostal in
left axillary midline as main operating port and for the
video thoracoscope; the sixth intercostal port in posterior axillary line for retraction and assistance.
2. Probe to locate the nodule which is mainly located
within LS3, mark the nodule with a suture close to LS
(Fig.7.8) to facilitate identication of the 2-cm surgical
margin.
3. The LUL is retracted posteriorly and the pleura is incised
anterior to the hilum, with dissection of the 11L lymph
node (Fig. 7.9) to send for intraoperative frozen
pathology.
1+2
Fig. 7.10 Dissecting V3c
4. V3c is dissected (Fig.7.10) and divided.
5. Dissect A3b (Fig. 7.11) and A3a + c (Fig. 7.12) at the
superior border of V3c stumps, ligating and dividing
them individually.
6. Separate V3a + b along the surface of the V
1 + 2 + 3
(Fig.7.13), ligate and divide.
7. Dissect B3 between V
1+2
and A
1+2
a+b (Figs.7.14 and
7.27), and divide the segmental bronchus with a surgical
stapler.
48
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J. Liu and W. Yue
Fig. 7.11 Dissecting A3b
Fig. 7.12 Dissecting A3a+c
Fig. 7.14 Dissecting B
Fig. 7.15 Tailoring along the interface of inated LS3 and only par-
tially deated LS
3
1+2
8. Inate the lung with 100% pure oxygen to a peak inspiratory pressure of 20–30mmHg to the full ination of
the upper lung. About 10min later, a clear interface of
ination and deation is seen, i.e., LS3 inating and
residual lung deating.
9. The lung is tailored along the interface of the inated
LS3 and partially deated LS
nodule is very close to LS
1+2
(Fig.7.15) because the
1+2
, so LS3 and part of LS
1+2
are resected.
Fig. 7.13 Dissecting V3a+b
7 Extended LS3 Segmentectomy by 3D Navigation
Fig. 7.16 Segmental stumps after Extended LS3 segmentectomy
10. Show the stumps of the segmental surface postoperatively (Fig.7.16).
The postoperative pathology of this patient was microinvasive adenocarcinoma (MIA) with no involvement of
the 11L lymph node.
49
Fig. 7.17 Figure of descending dimension of LS3 segmentectomy
(The shadow is the range of excision: Red circles represent arteries;
Green circles represent bronchi)
7.3.3 Key Points oftheSurgical Procedure
1. The V
2. B3 which is surrounded by vessels can only be approached
1 +2 + 3
is an anatomical variant which converges
between S1 and S2 and drains into the left superior pulmonary vein from below B3 instead of the usual V
1+2
travel-
ing in front of the hilum.
when the arteries and the veins of S3 are dissected from
the anterior hilar. Dissection between V
1+2
and A
1+2
can
avoid inadvertent injury to the segmental airway and vessels of LS
1+2
.
7.4 Schematic Diagram oftheSurgical
Procedure
Schematic diagram of the surgical procedure for Extended
LS3 segmentectomy (Figs.7.17, 7.18, 7.19, 7.20, 7.21, 7.22,
7.23, 7.24, 7.25, 7.26, 7.27, 7.28, 7.29, and 7.30).
LUL
Fig. 7.18 Panoramic gure of the LUL (Anterior view)
Fig. 7.19 Dissecting V3c
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