If you don't remember your password, you can reset it by entering your email address and clicking the Reset Password button. You will then receive an email that contains a secure link for resetting your password
If the address matches a valid account an email will be sent to __email__ with instructions for resetting your password
Although the Lung Cancer Study Group published worse outcomes in patients with nonsmall cell lung cancer who underwent sublobar resection, these data are fairly old and not reflective of the current patient population or surgical techniques. With the change in lung cancer pathology over these past few decades, our increased understanding of lung cancer and the era of screening for lung cancer, video-assisted thorascopic segmentectomy will likely play a greater role in the management of our patients.
Minimally invasive techniques have proven to cause less pain, less blood loss, decreased chest tube duration, shorter lengths of stay, more rapid return to daily activities, less impaired pulmonary function, improvement in compliance with adjuvant chemotherapy, and equivalent oncologic results.
A number of studies have aimed to define the indications for nonanatomical (wedge) resections, anatomical (segmentectomy) resection, and lobectomy for nonsmall cell lung cancer (NSCLC). However, many studies are flawed making interpretation of the data challenging. Currently, there is an ongoing phase III randomized trial of lobectomy vs sublobar resection for peripheral NSCLC that will hopefully provide clarity. The improvement of high resolution computed tomographic (CT) imaging and reconstruction has increased the detection of early (<2 cm) stage lung cancer and therefore highlighted the role of VATS segmentectomy for the treatment of primary lung lesions and metastatic disease. The focus of this article will be on VATS segmentectomy, specifically superior and basilar resection, background, and indications followed by a detailed description of the operative technique.
Thoracoscopic segmentectomy (sublobar resection) is defined as the removal of a segment of the pulmonary lobe with individual vessel ligation without the need for thoracotomy or rib spreading.
Given vascular variation among patients, segmentectomy is considered technically more difficult than a lobectomy or wedge resection and should be done by experienced thoracic surgeons. Anatomically, Ewart
demonstrated that sublobar resection for tumors <3 cm in size resulted in increased locoregional recurrences compared to lobectomy. As a result of this, lobectomy has remained the standard treatment for patients with resectable NSCLC. Meanwhile, segmentectomy has been reserved for select patients with small (<2 cm) tumor size and compromised cardiopulmonary function that would otherwise be unable to tolerate a full lobar resection.
Lung cancer continues to be the leading cause of cancer-related deaths in developed countries.
reviewed 171 patients from 2004-2010, who underwent VATS lobectomy or segmentectomy for bronchiectasis with or without cavitary lung disease after adequate antimicrobial therapy. Technically, segmentectomy for infectious etiology poses a different set of challenges than for oncologic resection. Even if the patient has not had prior thoracic surgery, pleural adhesions are commonly encountered surrounding the affected lung segments. Also, in the setting of inflammation, the bronchial circulation will be hypertrophied making blunt dissection without cautery or clipping challenging. Lastly, inflammation of the lung parenchyma can make staple closure of the intersegmental lobe difficult (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8, Figure 9).
Defining the segmental anatomy can be a difficult task even for the experienced surgeon. CT angiography and 3-dimensional processing of CT images can be used preoperatively to define the course of the segmental vessels and therefore minimize error.
Segmentectomy of the lower lobe, including the superior segment and basilar segments, en bloc, is technically often the most straightforward segmentectomy to perform for the same reasons that lower lobectomies are often the most straight forward lobectomy to perform. This is because the anatomic separation of the structures to be divided is the most obvious, vascular injury is less likely and control of an injury is technically easier. Because the basilar segmental artery and bronchus are anterior, relative to the superior segmental artery and bronchus, a basilar segmentectomy is also typically more accessible with an anterior thorascopic approach.
The following illustrations and discussion will focus on highlighting the anatomic differences between the right and left sides as well as strategic maneuvers to facilitate the dissection when needed.
As retrospective and prospective studies continue to shed light on the role of segmentectomy in the treatment of malignant and benign lesions, thoracic surgeons have continued to improve on the surgical technique so it can be safely performed according to specific patient needs.
This detailed description of superior and basilar segmentectomy can serve as a tool for thoracic surgeons at all levels of training. Although previously sublobar resections were associated with increased risk of locoregional recurrence in comparison to lobectomy, there is growing evidence that recurrence and overall survival in the setting of early-stage NSCLC (stage 1 and II) is superior to nonanatomic (wedge) resections and equivalent to lobectomy in the appropriately selected patient.
In addition to the management of primary lung cancer, VATS segmentectomy is also an acceptable option for surgical resection of metastatic lesions, infection, carcinoid tumors, and benign nodules (eg, hamartomas). As the development of minimally invasive techniques continues to advance, teaching of complex procedures like superior and basilar segmentectomy to surgical trainees must also be reinforced.