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Techniques of Minimally Invasive Posterior Basal (S10) Segmentectomies of the Lower Lobes

  • Yasuhiro Tsutani
    Correspondence
    Address reprint requests to Yasuhiro Tsutani, MD, PhD or Morihito Okada, MD, PhD, Department of Surgical Oncology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 Japan.
    Affiliations
    Department of Surgical Oncology, Hiroshima University, Minami-ku, Hiroshima
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  • Morihito Okada
    Correspondence
    Address reprint requests to Yasuhiro Tsutani, MD, PhD or Morihito Okada, MD, PhD, Department of Surgical Oncology, Hiroshima University, 1-2-3 Kasumi, Minami-ku, Hiroshima, 734-8551 Japan.
    Affiliations
    Department of Surgical Oncology, Hiroshima University, Minami-ku, Hiroshima
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Open AccessPublished:January 31, 2022DOI:https://doi.org/10.1053/j.optechstcvs.2022.01.004
      Now, the standard treatment for clinical stage I non-small cell lung cancer (NSCLC) is lobectomy with systematic nodal dissection. Sublobar resections, such as segmentectomy and wedge resection are often performed in compromised patients with peripheral small-sized NSCLC who are unfit or at high risk for standard lobectomy or even in those with indolent NSCLC who are fit for lobectomy. Anatomical segmentectomy rather than non-anatomical wedge resection as sublobar resection is usually recommended. Segmentectomy could be subdivided according to the number and shape of intersegmental plane. Segmentectomy that creates one, linear intersegmental plane, with a relatively easier procedure, could be considered simple segmentectomy, that is, resection of the superior segmentectomy of the lower lobe, the upper division, or lingula segment of the left upper lobe. Segmentectomy that creates several, or intricate intersegmental planes, with more a complex procedure, could be considered complex segmentectomy, that is, one other than simple segmentectomy, such as non-superior segmentectomy of the basilar segment of the lower lobe. Because of procedural complexity and risk of increased complications and incurability, compared with simple segmentectomy, some general thoracic surgeons may have concerns to perform complex segmentectomies. In this article, we show the technique of posterior basal segmentectomies, which is one of the most challenging procedures in complex segmentectomy, through a hybrid video-assisted thoracic surgery approach.

      Keywords

      Central Message
      We present the technique of left posterior basal (S10) segmentectomy, which is one of the most challenging procedures in segmentectomy, through a hybrid video-assisted thoracic surgery approach.

      Introduction

      Although the standard treatment for resectable non–small cell lung cancer (NSCLC) is lobectomy with systematic nodal dissection based on the results of the randomized trial that compared lobectomy and sublobar resection conducted by the Lung Cancer Study Group,
      • Ginsberg RH
      • Rubinstein LV.
      Randomized trial of lobectomy versus limited resection for T1N0 non-small cell lung cancer. Lung cancer study group.
      sublobar resections are often performed in compromised operable patients who are at high risk for standard lobectomy. In the 2000s, several researchers found that segmentectomy for small-sized stage I lung cancers can yield outcomes equivalent to those of lobectomy even in patients who are fit for lobectomy.
      • Okada M
      • Koike T
      • Higashiyama M
      • et al.
      Radical sublobar resection for small-sized non-small cell lung cancer: A multicenter study.
      • Tsutani Y
      • Miyata Y
      • Nakayama H
      • et al.
      Oncologic outcomes of segmentectomy compared with lobectomy for clinical stage IA lung adenocarcinoma: Propensity score-matched analysis in a multicenter study.
      • Landreneau RJ
      • Normolle DP
      • Christie NA
      • et al.
      Recurrence and survival outcomes after anatomic segmentectomy versus lobectomy for clinical stage I non-small-cell lung cancer: A propensity-matched analysis.
      In addition, oncologic outcomes of segmentectomy were reported to be superior to those of wedge resection.
      • Koike T
      • Koike T
      • Yamato Y
      • et al.
      Prognostic predictors in non-small cell lung cancer patients undergoing intentional segmentectomy.
      ,
      • Tsutani Y
      • Handa Y
      • Shimada Y
      • et al.
      Comparison of cancer control between segmentectomy and wedge resection in patients with clinical stage IA non-small cell lung cancer.
      Therefore, segmentectomy has been becoming the optional treatment for NSCLC and has been chosen more frequently.
      Segmentectomy can be further categorized into simple or complex from the standpoint of technical aspect: resection of the right or left superior segment of the lower lobe (segment 6), the left upper-division, and the lingular segment is defined as simple, and complex segmentectomy is resection of segment other than that to be resected in the simple segmentectomy.
      • Suzuki K
      • Saji H
      • Aokage K
      • et al.
      Comparison of pulmonary segmentectomy and lobectomy: Safety results of a randomized trial.
      ,
      • Handa Y
      • Tsutani Y
      • Mimae T
      • et al.
      Surgical outcomes of complex versus simple segmentectomy for stage I non-small cell lung cancer.
      Moreover, complex segmentectomy is defined as resection of a segment that had more than 1 intersegmental plane. Two or more intersegmental planes make segmentectomy more technically difficult even for certified thoracic surgeons.
      In this article, we show the technique of left S10 segmentectomy, which is one of the most difficult procedures in complex segmentectomy of the basilar segment of the lower lobes, with hybrid video-assisted thoracic surgery approach (Figure 1, Figure 2, Figure 3, Figure 4, Figure 5, Figure 6, Figure 7, Figure 8).
      Figure 1
      Figure 1A HRCT and FDG-PET/CT scan of an 81-year-old female revealed a 1.5-cm solid nodule with maximum standardized uptake value of 1.7 located near the hilum of the left S10. The left S10 segmentectomy was proceeded, and the final pathological diagnosis was pT1b (1.5 cm) N0M0 acinar adenocarcinoma. A possible UIP pattern-finding was observed in the non-cancerous area. Pathological surgical margin was 1.5 cm.
      HRCT = high-resolution computed tomography; FDG-PET/CT = [18F]-fluoro-2-deoxyglucose-positron emission tomography/computed tomography; UIP = usual interstitial pneumonia.
      Figure 2
      Figure 2Port placement for the hybrid VATS approach. The operator stands on the dorsal side of the patient. A camera port (10 mm) is placed in the ninth intercostal space over the midaxillary line, and an access thoracotomy (40-50 mm) is made in the sixth intercostal space over the auscultatory triangle. The access thoracotomy is opened with a wound retractor without rib spreading. The skin incision can be extended if the operator has difficulty in performing the procedure. Dissection of the intersegmental plane and hilum is performed by using mainly direct visualization through the access thoracotomy, by using an upside-down grip with 30-cm-long scissors. Most of the procedures are performed with instruments not specialized for endoscopic surgery. A camera port is also used for the introduction of the stapler for pulmonary vessel and bronchi dissection. VATS = video-assisted thoracic surgery.
      Figure 3
      Figure 3The inferior pulmonary ligament is divided to expose the inferior pulmonary vein. The inferior pulmonary vein is exposed for S10-segmentectomy. Cutting the inferior pulmonary ligament exposes the root of V6 and common basal pulmonary vein. V6b + c is exposed peripherally to serve as a landmark for later cutting between S6 and S10.
      Figure 4
      Figure 4The pulmonary artery is identified at the interlobar fissure, and periarterial dissection is carried out distally to expose the superior segmental branch (A6) and common basal branch (A8, A9, and A10) to the lower lobe and the lingular branch to the upper lobe. Each branch is exposed and A10 is taped, and interlobar, lobar, and segmental lymph nodes (#11, 12, and 13) are removed for intraoperative pathologic analysis. When lymph node metastases are present, the surgical procedure must be converted to a lobectomy. At the proximal site around the hilum, the lung parenchyma, along with A10, is divided by electrocautery from the proximal to the distal site to separate the targeted S10 from the preserved S6 and S8 + 9. After cutting A10 with stapler, B10 can be seen behind it.
      Figure 5
      Figure 5The lung parenchyma, along with V6b and V6c, is divided by stapler to separate the diseased S10 from the preserved S6. This work makes the hilum of S10 to be exposed well.
      Figure 6
      Figure 6After B8, B9, and B10 are isolated, B10 is cut with stapler.
      Figure 7
      Figure 7V10 is isolated and cut with stapler. After lifting the distal B10 stump, V9b, which is between S9 and S10, is isolated. Then, intersegmental line between S9 and S10 is divided along with V9b with stapler.
      Figure 8
      Figure 8After dissecting hilar and subcarinal lymph nodes, left S10 segmentectomy is completed. S6 and S8+9 were completely separated. The raw surface of the remaining intersegmental plane after cutting by electrocautery or stapler is sealed with polyglycolic acid felt and fibrin glue to prevent air leakage. In this case, staples were used for dividing the intersegmental plane because this patient had interstitial pneumonia on preoperative HRCT. HRCT = high-resolution computed tomography.

      Comment

      We perform segmentectomy for patients with cT1N0 NSCLC of 2 cm or less, or indolent tumor such as ground-glass opacity-dominant lung adenocarcinoma of 2-3 cm even in patients who are fit for lobectomy. When lymph node metastases are evident by frozen section analysis or the resection margin is insufficient, the surgical procedure must be converted to a lobectomy in patients who are fit for lobectomy.
      Between 2007 and 2017, we performed 117 complex segmentectomies for clinical stage IA (≤3 cm) NSCLC. Compared with 92 simple segmentectomies during the same period, median operative time was significantly longer for the complex (180 minutes) Vs the simple (143.5 minutes) segmentectomy groups (P < 0.0001); however, estimated blood loss was not significantly different (median 50 mL Vs 40 mL, respectively, P = 0.43).
      • Handa Y
      • Tsutani Y
      • Mimae T
      • et al.
      Surgical outcomes of complex versus simple segmentectomy for stage I non-small cell lung cancer.
      Median surgical margins were similar (16 mm Vs 17.5 mm, respectively, P = 0.21).
      • Handa Y
      • Tsutani Y
      • Mimae T
      • et al.
      Surgical outcomes of complex versus simple segmentectomy for stage I non-small cell lung cancer.
      No significant difference was found in any postoperative analysis, including overall complications (24.8% Vs 22.8%, P = 0.87), major complications (6.0% Vs 9.8%, P = 0.43), or prolonged air leakage (11.9% Vs 10.9%, P = 0.83) between the complex and simple segmentectomy groups, respectively.
      • Handa Y
      • Tsutani Y
      • Mimae T
      • et al.
      Surgical outcomes of complex versus simple segmentectomy for stage I non-small cell lung cancer.
      When comparing the surgical results between complex segmentectomy (n = 99) and location adjusted lobectomy (n = 94) in patients with clinical stage IA NSCLC (≤2 cm), no significant differences were detected in 30-day mortality (0% Vs 0%), overall complications (26.3% Vs 21.3%) and prolonged air leakage (11.1% Vs 9.6%) rates between the 2 groups, respectively.
      • Handa Y
      • Tsutani Y
      • Mimae T
      • et al.
      Complex segmentectomy in the treatment of stage IA non-small-cell lung cancer.
      Comparable results were obtained for 5-year overall (93.5% Vs 96.4%, respectively; P = 0.21) or recurrence-free (92.3% Vs 88.5%, respectively; P = 0.82) survivals after complex segmentectomy or lobectomy.
      • Handa Y
      • Tsutani Y
      • Mimae T
      • et al.
      Complex segmentectomy in the treatment of stage IA non-small-cell lung cancer.
      Our experience suggests that complex segmentectomy is an acceptable option to treat a patient with early NSCLC with comparable short- and long-term outcomes after simple segmentectomy or lobectomy.
      Posterior basal segmentectomy is one of the most difficult procedures in complex segmentectomy because S10 does not face interlobar fissure and A10 + B10 are not always easy to be identified. To expose the hilum of S10 (A10, B10, and V10) well, we prefer to divide S10 from S6 first (Fig. 5). To divide the intersegmental plane, we usually identify the intersegmental plane with jet ventilation and cut the intersegmental parenchyma using cautery.
      • Okada M
      • Tsutani Y
      • Ikeda T
      • et al.
      Radical hybrid video-assisted thoracic segmentectomy: Long-term results of minimally invasive anatomical sublobar resection for treating lung cancer.
      At the proximal portion around the hilum, the intersegmental plane is approached along the intersegmental vein, and the plane is divided along the inflation-deflation line at the peripheral site using electrocautery. However, for emphysematous lung or interstitial lung disease, the jet ventilation method can be omitted because inflation-deflation line sometimes would be unclear, and staplers can be used to divide the intersegmental plane to prevent the postoperative alveolar fistula in such lung conditions. In addition, surgical margin (more than 2 cm or tumor size) must be taken priority over dividing the accurate intersegmental plane to avoid the local recurrence. In the present case, we intentionally did not use the jet ventilation method and used staplers to divide the intersegmental planes at the preserved segmental side to take the sufficient surgical margin because the patient had interstitial pneumonia and the tumor was impalpable during the operation.

      Appendix. Supplementary materials

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      Linked Article

      • Commentary: Approaches for Thoracoscopic Lateral and Posterior Basal Segmentectomy
        Operative Techniques in Thoracic and Cardiovascular SurgeryVol. 27Issue 3
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          Video-assisted thoracoscopic surgery (VATS) for a lateral (S9) and posterior (S10) basal segmentectomy is recognized as the most challenging in segmentectomy with the exception of some combined sub-segmentectomies. This technical article from Tsutani and Okada demonstrated a strong maneuverable procedure for a S10 segmentectomy through a well-designed single dorsal incision, which is quite different from the most common ventral incision.1
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