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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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Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 7.20 Dividing V3c
J. Liu and W. Yue
Fig. 7.23 Dissecting A3a+c
Fig. 7.21 Dissecting A3b
Fig. 7.22 Dividing A3b
Fig. 7.24 Dividing A3a+c
Fig. 7.25 Dissecting V3a+b
7 Extended LS3 Segmentectomy by 3D Navigation
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Fig. 7.26 Dividing V3a+b
Fig. 7.27 Dissecting B
3
Fig. 7.29 Locating the node and delineating the resected area
Fig. 7.30 The labeled gure of segmental stumps after Extended LS3
segmentectomy
Suggested Reading
1. Cao J, Yuan P, Wang Y, etal. Survival rates after lobectomy, segmentectomy, and wedge resection for non-small cell lung cancer. Ann
Thorac Surg. 2018;105:1483–91.
2. Subramanian M, McMurry T, Meyers BF, etal. Long- term results
for clinical stage IA lung cancer- comparing lobectomy and sublobar resection. Ann Thorac Surg. 2018;106:375–81.
Fig. 7.28 Dividing B
3
RS1 Segmentectomy by 3D Navigation
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
JixianLiu andXiaoqiangLi
8.1 Summary ofMedical Records
A 43-year-old asymptomatic woman was found to have a
right upper lobe (RUL) lung nodule on a CT scan. She was
treated with antibiotics for 2 weeks, with no signicant
change of the nodule on re-examination. Her chest CT
(Figs.8.1, 8.2, and 8.3) showed an 8-mm pure ground glass
opacity (pGGO) located in the RS1.
8
Fig. 8.1 Chest CT (axial view) showing the nodule located in the RS1
(Yellow circle: nodule and its 2cm margin)
Fig. 8.2 Chest CT (coronal view) showing the nodule located in the
RS1 (Yellow circle: nodule and its 2cm margin)
Fig. 8.3 Chest CT (sagittal view) showing the nodule located in the
RS1 (Yellow circle: nodule and its 2cm margin)
J. Liu (*) · X. Li
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_8
53
54
Fig. 8.4 Relationship between the safe margin of nodule and the RUL
segmental interfaces (Anterior view)
8.1.1 Indications andContraindications
J. Liu and X. Li
(a) This 8mm pure GGO located in the center of RS1 would
not be amenable to non-anatomic wedge resection with
adequate surgical margin.
(b) Despite a short course of antibiotic therapy, persistence
of the nodule is suspicious for early lung cancer.
(c) With the use of preoperative 3D-CTBA reconstruction,
the prospective incisional margin is more than 2cm after
RS1 segmentectomy (Fig.8.4).
(d) The patient has good performance status, without con-
traindications to operation.
8.2 Preoperative 3D-CTBA
Reconstruction
The marginal ball of this nodule (nodule and its 2cm margin) shows the margin is completely located in RS1 (Fig.8.4),
so the RS1 segmentectomy is required to satisfy the safe surgical margin.
8.2.1 Anatomical Features
The right upper lobe bronchus (Fig.8.5) is divided into B1,
B2, and B3, B1 and B2 emanating from the common trunk.
The RA1 (Fig.8.6) divides into A1b which emanates separately from the upper trunk of the right superior pulmonary
artery and A1a emanating from the upper trunk in form of
co-trunk with Rec A2.
Fig. 8.5 Segmental bronchi of the RUL (Lateral view)
Fig. 8.6 Relationship between segmental arteries and bronchi of the
RUL (Lateral view)
V1a, an intrasegmental vein (Fig. 8.7), will be divided.
V1b which is the intersegmental vein of S1 and S3 will be
preserved. V2a, which travels between B1 and B3 to right
superior pulmonary vein (RSPV) above which is the boundary of RS1 (Fig.8.8).
The operation needs to dissect V1a, A1b, A1a, and B1.
8 RS1 Segmentectomy by 3D Navigation
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 8.7 Relationship between segmental veins and bronchi of the
RUL (Lateral view)
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8.3.2 Surgical Procedures
1. The patient undergoes double-lumen endotracheal
intubation and is placed in the left lateral decubitus
position. Two ports are placed: The third intercostal in
right axillary midline as main operating port and for
thoracoscope placement; the port in the fth intercostal space in the posterior axillary line for retraction
(Fig.8.9).
2. Probe to locate the nodule within RS1.
3. Retract the upper lung posteriorly and incise the anterior
hilar pleura to expose V1a, A1b, and A1a + Rec. A2
(Fig. 8.10) and dissect the station 12R lymph node for
intraoperative frozen pathological examination
(Fig.8.11).
4. Following the 3D navigation, dissect the V1a, supercial
intrasegmental vein (Fig. 8.12), ligating and dividing
between 4 and 0 silk ties (Fig.8.13).
Fig. 8.8 Relationship among segmental arteries, veins, and bronchi of
the RS1 (Lateral view)
8.3 Surgery Planning andProcedure
Main operating port
Assistant port
Fig. 8.9 Layout of incision
According to CT and preoperative 3D reconstruction, RS1
segmentectomy is undertaken, dissecting from superior
hilum posteriorly.
8.3.1 Surgical Planning
V1a→A1b→A1a→RB1→RS
1
Fig. 8.10 Demonstration of V1a, A1b and A1a+Rec.A
2
56
Fig. 8.11 Dissecting the station 12R lymph node
J. Liu and X. Li
Fig. 8.14 Dissecting A1b
Fig. 8.12 Dissecting V1a
Fig. 8.13 Ligating V1a with 4-0 silk thread
5. At the upper edge of V1a, dissect A1b separately (Fig.8.14)
and A1a from co-trunk of A1a+Rec.A2 (Fig.8.15), taking
care to protect Rec.A2. Ligate and divide these,
respectively.
Fig. 8.15 Dissecting A1a and ligating it with a 4-0 silk thread
Fig. 8.16 Demonstrating B
1
6. Dissect B1 ventral to the Rec.A2 and above the V2a
(Fig.8.16) and divide using the stapler (Fig.8.17).
7. Inate lung with 100% pure oxygen to peak airway pressure of 20–30mmHg to insufate the upper lobe. About
10min later, a clear interface of ination and deation is
seen, i.e., RS1 inating and the remaining parenchyma
deating (Fig.8.18).
8 RS1 Segmentectomy by 3D Navigation
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57
Fig. 8.17 Dividing B
Fig. 8.18 Showing the interface of inating and deating
1
8. The membrane-like structure between the inating RS1
and the deating RS2 + RS3 is opened by means of
“Inward Opening” fashion (Fig.8.19).
9. The lung is tailored along the interface of inating and
deating (Fig.8.20).
The postoperative pathology of this patient was
microinvasive adenocarcinoma (MIA) with the station
12R lymph node negative for malignancy.
Fig. 8.19 Opening the interface between S1 and S2, S
Fig. 8.20 Postoperative stumps of segmental surface after RS1
segmentectomy
3
8.3.3 Key Points oftheSurgical Procedure
1. V2a which travels between B1 and B3 to the right superior
pulmonary vein, instead of the usual route below B3
toward the central vein. V2a is exposed for a long route in
the operative area and needs careful protection.
2. A1a and Rec.A2 originate from the common trunk, and
more attention should be taken to protect Rec.A2 when
dissecting A1a. B1 traverses ventrally close to Rec.A2.
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8.4 Schematic Diagram oftheSurgical
Procedure
Schematic diagram of the surgical procedure for RS1 segmentectomy (Figs.8.21, 8.22, 8.23, 8.24, 8.25, 8.26, 8.27,
8.28, 8.29, 8.30, and 8.31).
J. Liu and X. Li
Fig. 8.24 Dividing V1a
RUL
Fig. 8.21 Figure of descending dimension of RS1 segmentectomy
(The shadow is the range of excision: Red circles represent arteries;
Green circles represent bronchi)
RUL
RML
Fig. 8.22 RUL anterior hilum (Anterior view)
Fig. 8.25 Dissecting A1b
RUL
Fig. 8.26 Dividing A1b, dissecting A1a
Fig. 8.23 Dissecting V1a
Fig. 8.27 Dividing A1a
8 RS1 Segmentectomy by 3D Navigation
Данная книга находится в списке для перевода на русский язык сайта https://meduniver.com/
Fig. 8.28 Dissecting B
1
59
RUL
Fig. 8.31 The labeled gure of segmental stumps after RS1
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. Wang J, Xu XF, Wen W, Wu WB, Zhu Q, Chen L.Modied method
for distinguishing the intersegmental border for lung segmentectomy. Thorac Cancer. 2018;9:330–3.
Fig. 8.29 Dividing B
1
Fig. 8.30 Locating the nodule and delineating the resection planes
Extended RS2 Segmentectomy by 3D
Navigation
JixianLiu andXiaoqiangLi
9.1 Summary ofMedical Records
A 65-year-old asymptomatic woman was found to have
a right upper lobe (RUL) lung nodule that persisted
despite empiric antibiotic therapy. Her chest CT
(Figs. 9.1, 9.2, and 9.3) showed an 11 mm × 15 mm
mixed ground glass opacity (mGGO) located in the RS2
adjacent to RS3.
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Fig. 9.1 Chest CT (Axial view) showing the nodule located in the RS2
adjacent to RS3 (Yellow circle: nodule and 2cm margin)
J. Liu (*) · X. Li
Department of Thoracic Surgery, Peking University Shenzhen
Hospital, Shenzhen, Guangdong, China
Fig. 9.2 Chest CT (Coronal view) showing the nodule located in the
RS2 adjacent to RS3 (Yellow circle: nodule and its 2cm margin)
Fig. 9.3 Chest CT (Sagittal view) showing the nodule located in the
RS2 adjacent to RS3 (Yellow circle: nodule and its 2cm margin)
© 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_9
61
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