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Address for reprints: Hiroyuki Oizumi, MD, PhD, Division of General Thoracic Surgery, Higashiyamato Hospital, 1-13-12 Nangai, Higashiyamato, Tokyo 207-0014, Japan.
Department of Surgery II, Faculty of Medicine, Yamagata University, Yamagata, JapanDepartment of General Thoracic Surgery, Higashiyamato Hospital, Tokyo, Japan
Department of Surgery II, Faculty of Medicine, Yamagata University, Yamagata, JapanDepartment of General Thoracic Surgery, Higashiyamato Hospital, Tokyo, Japan
We present a technique of lung segmentectomy, which divided four intersegmental planes preserving the interlobar fissure surface.
Cranial subsegment of the lateral basal segment (S9a) and some subsuperior segments (S∗) are bordered by 4 intersegmental planes. Often, this resection uses an incision of the intersegmental border between S6 and S8 at the interlobar fissure.
the chance for future operations for such patients should be considered. Thus, we are preserving the intersegmental plane between S6 and S8 and minimizing the exposure of the lung parenchymal raw surface to decrease future adhesions.
Case Report
A 73-year-old woman had received a right upper lobectomy for lung cancer 5 years previously. The left lower lobe nodular shadow gradually increased in size and density. The report was approved by the Ethics Committee of the Faculty of Medicine, Yamagata University (#2022-S-47, September 13, 2022), and informed written consent was obtained from the patient.
Surgical Plan
We used 3-dimensional computed tomography reconstruction to plan the resection area and assess the tumor's location and surgical margins.
The bronchus of the target segment branches from the common trunk of B9 and B10 (B9+10); therefore, the nomenclature of this segment is the subsuperior segment (S∗). Since the nodule was located on the periphery of S∗ and was close to S9a, we planned tumor removal by combined resection of these 2 areas (Figure 1). We planned to preserve the interlobar fissure surface to prevent future adhesion, as this patient had a risk of subsequent multiple metachronous lung cancer.
Figure 1Three-dimensional computed tomography indicates the nodule is located in S∗ and the S9a is close to it.
Two flexible 5-mm, one flexible 12-mm, and one 20-mm soft port were inserted, and a 30° 10-mm rigid scope was used. We identified the lower lobar segmental arterial branches in the interlobar fissure and ligated the artery of S∗ (A∗), then divided it. The neighboring bronchus B∗ was encircled and clipped, and the peripheral wall was incised. Insufflation of air into B∗ from outside of the bronchus with a nozzle inflated S∗ while the other segments collapsed. The peripheral bronchus was transected, and the stump was closed by clipping. The B9a bronchus was inaccessible, as the location was deep. Therefore, we decided to open the intersegmental plane between S∗ and the surrounding segments. The parenchymal incision of the S8, S10, and S6 border was made with electrocautery along the inflation–deflation line, and parenchymal tunneling was made bluntly between S∗ and S8 using a right-angle forceps. We grasped the peripheral B∗ stump and passed it peripherally through the tunnel. The retraction of B∗ from the peripheral side enabled the stapler insertion between the hilum and the incisions of the intersegmental plane. Then, we divided the intersegmental boundary of S∗ and S6 using staplers.
After this maneuver, the retraction of B∗ and S∗ parenchyma opened the intersegmental plane, thus enabling the isolation of B9a. We encircled the B9a, clipped, and transected it. We insufflated air into the B9a stump with a nozzle and ligated the distal stump. The A9a was clipped and dissected. Thin vascular branches into the target segment were divided, then the intersegmental plane between S9a and S9b was divided along the newly created inflation–deflation line. We sewed the cut surface with continuous sutures after the specimen retrieval (Video 1). The pathology of lobar lymph nodes showed no metastases. Operation time was 208 minutes, and total blood loss was 51 mL. The drain was removed on the first postoperative day. Histopathologic examination confirmed a papillary adenocarcinoma (pT1aN0M0-ⅠA1). The patient has been alive for 3 years postoperatively without recurrence.
Discussion
The number of cases of metachronous multiple lung cancers has been increasing, and sublobar resection is one of the treatments.
Segmentectomy may be an alternative if the location is deep or its localization is impossible. The more lung parenchymal raw surface, the more difficult subsequent surgeries become as the frequency and degree of adhesions increase.
Surgical planning using 3-dimensional computed tomography reconstruction with observation from various angles is key to performing precise anatomical sublobar resections.
The point of operation in this patient was to release the hilum precisely, to make incisions along the inflation–deflation line between the target segments, and then to use staplers at the middle lung area by retracting the bronchus through the bluntly created tunnel. Thus, the following manipulation of the peripheral branches and intersegmental plane divisions became easy. Also, the inflation–deflation method may have some merit over indocyanine green fluorescence when the intersegmental incision from the peripheral side is needed.
Conclusions
Interlobar fissure plane–preserving video-assisted thoracoscopic surgery segmentectomy or subsegmentectomy for which the segment has 4 intersegmental planes can be a feasible alternative technique.
Disclosures: The authors reported no conflicts of interest.
The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest.
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