Thoracoscopic segmentectomy and lobectomy assisted by three-dimensional computed-tomography bronchography and angiography for the treatment of primary lung cancer

Abstract

BACKGROUND Anatomical segmentectomy has been proposed as a substitution for lobectomy for early-stage lung cancer. However, it requires technical meticulousness due to the complex anatomical variations of segmental vessels and bronchi. AIM To assess the safety and feasibility of three-dimensional computed-tomography bronchography and angiography (3D-CTBA) in performing video-assisted thoracoscopic surgery (VATS) for lung cancers. METHODS In this study, we enrolled 123 patients who consented to undergo thoracoscopic segmentectomy and lobectomy assisted by 3D-CTBA between May 2017 and June 2019. The image data of enhanced computed tomography (CT) scans was reconstructed three-dimensionally by the Mimics software. The results of preoperative 3D-CTBA, in combination with intraoperative navigation, guided the surgery. RESULTS A total of 59 women and 64 men were enrolled, of whom 57 (46.3%) underwent segmentectomy and 66 (53.7%) underwent lobectomy. The majority of tumor appearance on CT was part-solid ground-glass nodule (pGGN; 55.3%). The mean duration of chest tube placement was 3.5 ± 1.6 d, and the average length of postoperative hospital stay was 6.8 ± 1.8 d. Surgical complications included one case of pneumonia and four cases of prolonged air leak lasting > 5 d. Notably, there was no intraoperative massive hemorrhage, postoperative intensive-care unit stay, or 30-d mortality. Preoperative 3D-CTBA images can display clearly and vividly the targeted structure and the variations of vessels and bronchi. To reduce the risk of locoregional recurrence, the application of 3D-CTBA with a virtual 3D surgical margin help the VATS surgeon determine accurate distances and positional relations among the tumor, bronchial trees, and the intersegmental vessels. Three-dimensional navigation was performed to confirm the segmental structure, precisely cut off the targeted segment, and avoid intersegmental veins injury. CONCLUSION VATS and 3D-CTBA worked in harmony in our study. This combination also provided a new pattern of transition from lesion-directed location of tumors to computer-aided surgery for the management of early lung cancer.

Modified thoracoscopic wedge resection of limited peripheral lesions in S10 for children with congenital pulmonary airway malformation: Initial single-center experience

“…First, with the improvement in imaging technology and diagnostic level, the segmental vein can be clearly displayed. The operator can clarify the venous variation and its position relationship with the lesion through preoperative film reading, outline the boundary of the lesion through the segmental vein, and design the resection path of the internal edge of the lesion ( 16 , 17 ). Second, according to the traditional hilar approach, the vein is located in the deep surface of the artery and bronchus, which makes it difficult to expose it for dissection.…”

Lung segments from anatomy to surgery

“…Possible complications can also arise from variant anatomy: incorrect division of the intersegmental vein, or the accidental cutting of one of the veins supplying the bronchopulmonary segment, can cause postoperative hemoptysis [12,71,72]. Another example is confusion of the variant lingular segmental artery with an anterior segmental artery during a left upper or anterior segmentectomy [12].…”

“…In a segmentectomy to treat cancer, the surgical margins should be extending at least 2 cm outside the lesion or should be 2 cm greater than the tumor size [12,18,72]. For this to be possible, the size of the segment should be taken into account.…”

Harnessing 3D-CT Simulation and Planning for Enhanced Precision Surgery: A Review of Applications and Advancements in Lung Cancer Treatment

“…Iwano et al defined the virtual safety margin as a sphere extending 2 cm outside the tumor in preoperative 3D-CT simulation and reported that no positive surgical margin was achieved in all 17 primary lung cancers in 16 patients after segmentectomy [37]. Wu et al similarly reported 57 cases of VATS segmentectomy with preoperative 3D-CT simulation with a virtual 3D surgical margin defined as a sphere extending at least 2 cm outside the lesion or 2 cm greater than the tumor size and concluded that the combination of VATS and 3D-CT provided a transition from lesion-directed location of tumors to computeraided surgery for the management of early lung cancer [38]. Xu et al reported that 61 cases of u-VATS segmentectomy with intersegmental plane simulation by 3D reconstruction achieved a gross margin sufficiency of 100%, whereas 5 of 59 cases without intersegmental plane simulation did not achieve margin sufficiency [39].…”