Objective To assess the safety and clinical outcomes of segmentectomy in one- or two-staged video-assisted thoracoscopic surgery (VATS) for bilateral lung cancer. MethodsWe retrospectively enrolled 100 patients who underwent VATS segmentectomy for bilateral lung cancer at the Department of Thoracic Surgery of Peking Union Medical College Hospital from December 2013 to May 2022. We divided the patients into two groups: a one-stage group (52 patients), including 17 males and 35 females with a mean age of 55.17±11.09 years, and a two-stage group (48 patients), including 16 males and 32 females with a mean age of 59.88±11.48 years. We analyzed multiple intraoperative variables and postoperative outcomes. Results All 100 patients successfully completed bilateral VATS, and at least unilateral lung received anatomical segmentectomy. Patients in the one-stage group were younger (P=0.040), had lower rate of comorbidities (P=0.030), were less likely to have a family history of lung cancer (P=0.018), and had a shorter interval between diagnosis and surgery (P=0.000) compared with patients in the two-stage group. Wedge resection on the opposite side was more common in the one-stage group (P=0.000), while lobectomy was more common in the two-stage group. The time to emerge from anesthesia in the one-stage group was longer than that in the first and second operations of the two-stage group (P=0.000, P=0.002). Duration of surgery and anesthesia were similar between two groups (P>0.05). Total number of lymph node stations for sampling and dissection (P=0.041) and lymph nodes involved (P=0.026) were less in the one-stage group. Intraoperative airway management was similar between two groups (P>0.05). The one-stage group was associated with lower activities of daily living (ADL) scores. Conclusion Segmentectomy is safe in one- or two-staged VATS for bilateral lung cancer, including contralateral sublobectomy and lobectomy. Duration of surgery and perioperative complications are similar between two groups, but the one-stage group is associated with lower ADL scores. On the basis of comprehensive consideration in psychological factors, physical conditions and personal wishes of patients, one-staged sequential bilateral VATS can be the first choice.
ObjectiveTo analyze the application effects of artificial intelligence (AI) software and Mimics software in preoperative three-dimensional (3D) reconstruction for thoracoscopic anatomical pulmonary segmentectomy. MethodsA retrospective analysis was conducted on patients who underwent thoracoscopic pulmonary segmentectomy at the Second People's Hospital of Huai'an from October 2019 to March 2024. Patients who underwent AI 3D reconstruction were included in the AI group, those who underwent Mimics 3D reconstruction were included in the Mimics group, and those who did not undergo 3D reconstruction were included in the control group. Perioperative related indicators of each group were compared. ResultsA total of 168 patients were included, including 73 males and 95 females, aged 25-81 (61.61±10.55) years. There were 79 patients in the AI group, 53 patients in the Mimics group, and 36 patients in the control group. There were no statistical differences in gender, age, smoking history, nodule size, number of lymph node dissection groups, postoperative pathological results, or postoperative complications among the three groups (P>0.05). There were statistical differences in operation time (P<0.001), extubation time (P<0.001), drainage volume (P<0.001), bleeding volume (P<0.001), and postoperative hospital stay (P=0.001) among the three groups. There were no statistical differences in operation time, extubation time, bleeding volume, or postoperative hospital stay between the AI group and the Mimics group (P>0.05). There was no statistical difference in drainage volume between the AI group and the control group (P=0.494), while there were statistical differences in operation time, drainage tube retention time, bleeding volume, and postoperative hospital stay (P<0.05). ConclusionFor patients requiring thoracoscopic anatomical pulmonary segmentectomy, preoperative 3D reconstruction and preoperative planning based on 3D images can shorten the operation time, postoperative extubation time and hospital stay, and reduce intraoperative bleeding and postoperative drainage volume compared with reading CT images only. The use of AI software for 3D reconstruction is not inferior to Mimics manual 3D reconstruction in terms of surgical guidance and postoperative recovery, which can reduce the workload of clinicians and is worth promoting.
Objective To verify the feasibility and accuracy of the "lung surface intersegmental constant proportion landmarks", developed by our center, in identifying intersegmental planes during pulmonary segmentectomy. MethodsWe prospectively enrolled the patients who planned to receive thoracoscopic segmentectomy in West China Hospital of Sichuan University and The Third People's Hospital of Chengdu from September 2021 to October 2021. We took a relatively objective and feasible method, intravenous injection of indocyanine green, in identifying intersegmental planes as standard control. We intraoperatively judged the consistency between "lung surface intersegmental constant proportion landmarks" and intravenous injection of indocyanine green in identifying intersegmental planes. We discerned main landmarks of intersegmental plane by the constant proportion segment module, which was built based on the "lung surface intersegmental constant proportion landmarks", as well as distinguished the planes with discrepant fluorescence by peripheral intravenous indocyanine green injection. When the distance between the landmarks determined by the "ung surface intersegmental constant proportion landmarks" and the segmental boundaries displayed by indocyanine green fluorescence staining was ≤1 cm, the landmarks were judged to be consistent with the planes with discrepant fluorescence. As long as one of the landmarks was judged to be consistent, the method was considered to be feasible and accurate. Results A total of 21 patients who underwent thoracoscopic segmentectomy were enrolled, with 5 male and 16 female patients. The median age was 55 years, ranging from 34 to 76 years. A total of 11 patients received left-side surgery, while 10 patients received right-side surgery. In the operations of 21 pulmonary segmentectomies, at least one intersegmental landmark determined by the "lung surface intersegmental constant proportion landmarks" was consistent with the intersegmental plane determined by indocyanine green fluorescence staining in each patient. ConclusionThe intersegmental landmarks determined by the "lung surface intersegmental constant proportion landmarks" are consistent with that determined by indocyanine green fluorescence staining. The method of "lung surface intersegmental constant proportion landmarks" is feasible and accurate in identifying intersegmental planes during pulmonary segmentectomy.
ObjectiveTo explore the feasibility and clinical value of free-of-puncture positioning in three-dimension-guided anatomical segmentectomy for ground-glass nodule (GGN) compared with percutaneous positioning.MethodsClinical data of 268 enrolled patients undergoing anatomical pulmonary segmentectomy from October 2018 to June 2019 were retrospectively collected, including 75 males and 193 females with an average age of 56.55±12.10 years. The patients were divided into two groups, including a percutaneous positioning group (n=89) and a free-of-puncture positioning group (n=179). Perioperative data of the two groups were compared.ResultsThe average CT scan times of the percutaneous positioning group was 3.01±0.98 times, and the numerical rating scale (NRS) score of puncture pain was 3.98±1.61 points. Pulmonary compression pneumothorax (≥30%) occurred in 7 (7.87%) patients and intercostal vascular hemorrhage occurred in 8 (8.99%) patients after puncture. Lung nodules were successfully found and removed in both groups. There was no statistically significant difference between the two groups in the location of nodules (P=0.466), operation time (151.83±39.23 min vs. 154.35±33.19 min, P=0.585), margin width (2.07±0.35 cm vs. 1.98±0.28 cm, P=0.750), or the number of excised subsegments (2.83±1.13 vs. 2.73±1.16, P=0.530).ConclusionAnatomical segmentectomy with three-dimensional navigation avoids the adverse consequences of puncture, which has the same clinical efficacy and meets the requirements of oncology compared with percutaneous positioning. The free-of-puncture positioning method can be used for GGN located in the central region of pulmonary segment/subsegment or adjacent to intersegment veins instead of percutaneous positioning.
Recently, anatomical segmentectomy emerges as a hot spot in clinical research for surgical treatment of early-stage lung cancer. The techniques of segmentectomy are more elaborate and complicated than lobectomy, because of the considerable anatomic variations of segment blood vessels and bronchus. In a long term, video-assisted thoracic surgery is the mainly minimally invasive approach. As a new approach of minimally invasive surgery, da Vinci robot system possesses three-dimensional and high definition view, better dexterity mechanical wrist and tremor filtering system, which are the main advantages over video-assisted thoracic surgery. All the superiorities of robot system provide good supports for performing segmentectomy. Robot-assisted segmentectomy has been carried out in many medical centers in China and abroad until now. However, most surgery cases often lack adequate controls on quality.
Thoracoscopic pulmonary segmentectomy is one of the important treatment methods for early lung cancer. Only the premise of surgical precision can make the radical resection of lesions and maximum reservation of healthy lung tissue be simultaneously guaranteed. As a representative of the precise lung operation, the " cone-shaped lung segmentectomy” focuses on the lesion, and combines the anatomical characteristic of the patient to design individualized operation scheme. The technological core consists of three parts, three dimensional-computed tomography bronchography and angiography (3D-CTBA) surgery path planning, accurate definition of intersegmental demarcation and anatomic dissection of intersegmental borders along the demarcation. This paper aims to explore the technical process and quality control of the key techniques of thoracoscopic precise segmentectomy, so as to standardize the segmentectomy procedure under the principle of radical and minimally invasive therapy.
ObjectiveTo compare the clinical application of empirical thoracoscopic segmentectomy and precise segmentectomy planned by artificial intelligence software, and to provide some reference for clinical segmentectomy. MethodsA retrospective analysis was performed on the patients who underwent thoracoscopic segmentectomy in our department from 2019 to 2022. The patients receiving empirical thoracoscopic segmentectomy from January 2019 to September 2021 were selected as a group A, and the patients receiving precise segmentectomy from October 2021 to December 2022 were selected as a group B. The number of preoperative Hookwire positioning needle, proportion of patients meeting oncology criteria, surgical time, intraoperative blood loss, postoperative chest drainage time, postoperative hospital stay, and number of patients converted to thoracotomy between the two groups were compared. Results A total of 322 patients were collected. There were 158 patients in the group A, including 56 males and 102 females with a mean age of 56.86±8.82 years, and 164 patients in the group B, including 55 males and 109 females with a mean age of 56.69±9.05 years. All patients successfully underwent thoracoscopic segmentectomy, and patients whose resection margin did not meet the oncology criteria were further treated with extended resection or even lobectomy. There was no perioperative death. The number of positioning needles used for segmentectomy in the group A was more than that in the group B [47 (29.7%) vs. 9 (5.5%), P<0.001]. There was no statistical difference in the number of positioning needles used for wedge resection between the two groups during the same period (P=0.572). In the group A, the nodule could not be found in the resection target segment in 3 patients, and the resection margin was insufficient in 10 patients. While in the group B, the nodule could not be found in 1 patient, and the resection margin was insufficient in 3 patients. There was a statistical difference between the two groups [13 (8.2%) vs. 4 (2.4%), P=0.020]. There was no statistical difference between the two groups in terms of surgical time, intraoperative blood loss, duration of postoperative thoracic drainage, postoperative hospital stay, or conversion to open chest surgery (P＞0.05). Conclusion Preoperative surgical planning performed with the help of artificial intelligence software can effectively guide the completion of thoracoscopic anatomical segmentectomy. It can effectively ensure the resection margin of pulmonary nodules meeting the oncological requirements and significantly reduce the number of positioning needles of pulmonary nodules.
Objective To evaluate the security and clinical value of the combination of three-dimensional computed tomography-bronchography and angiography (3D-CTBA) and indocyanine green (ICG) staining in video-assisted thoracic surgery (VATS) segmentectomy. Methods The clinical data of 125 patients who received VATS segmentectomy from January 2020 to January 2021 in our hospital were retrospectively analyzed. There were 40 (32.0%) males and 85 (68.0%) females with an average age of 54.8±11.1 years. Results The procedure was almost identical to the preoperative simulation. All intersegment planes were displayed successfully by ICG reverse staining method. There was no allergic patient. A total of 130 pathological specimens were obtained from the 125 patients. The mean operation time was 126.8±41.9 min, the time of first appearance of fluorescence was 22.7±4.9 s, the mean mark time was 65.6±20.3 s, the median blood loss was 20.0 (10.0-400.0) mL, the postoperative hospital stay was 5.6 (4.0-28.0) d, and the postoperative retention of chest tube time was 3.2 (2.0-25.0) d. Pathological results showed that microinvasive adenocarcinoma was the most common type (38.5%, 50/130), followed by invasive adenocarcinoma (36.9%, 48/130); there were 3 metastatic tumors (3/130, 2.3%).Conclusion The combination of 3D-CTBA and ICG reverse staining is proved to be a safe, necessary and feasible method. It solves the difficult work encountered in the procedure of segmentectomy, and it is worth popularizing and applying in clinic.
ObjectiveTo share the clinical experience of thoracoscopic unidirectional posterolateral basal segmentectomy via inferior pulmonary ligament.MethodsAll the patients were in the healthy lateral position, with endoscopy holes in the 8th intercostal space of the middle axillary line and 2-3 cm operation holes in the 5th intercostal space of the front axillary line. Anatomical segmentectomy of the posterolateral basal vein, bronchus and artery was performed through the inferior pulmonary ligament upward in turn. The clinical data of this group were analyzed retrospectively.ResultsFrom December 2015 to October 2018, 32 patients underwent thoracoscopic unidirectional posterolateral basal segmentectomy, including 8 males and 24 females, aged 13-71 (52.6±13.7) years. All patients successfully completed the operation, including 9 patients of left lower pulmonary posterolateral basal segmentectomy, 23 patients of right lower pulmonary posterolateral basal segmentectomy. The operation time was 80-295 (133.4 ±40.5) minutes, intraoperative bleeding volume was 20-300 (52.6±33.8) mL, drainage time was 2-14 (4.2±2.3) days, hospitalization time was 4-15 (6.9 ±2.4) days. No death occurred during hospitalization. Postoperative complications included atelectasis in 1 patient and persistent pulmonary leakage over 3 days (4 or 6 days respectively) in 2 patients , chylothorax in 1 patient. All of them recovered smoothly after non-operative treatments. Postoperative pathology showed that 29 patients of primary adenocarcinoma or atypical adenomatoid hyperplasia, including 5 patients of adenocarcinoma in situ, 9 patients of micro-invasive adenocarcinoma, 12 patients of invasive adenocarcinoma, 3 patients of atypical adenomatoid hyperplasia. One patient was of intestinal metastatic adenocarcinoma, 1 patient of inflammatory lesion and 1 patient of bronchiectasis. 3-21(9.6±4.6) lymph nodes were resected in the patients with primary pulmonary malignant tumors. And no metastasis was found.ConclusionThe operation of thoracoscopic unidirectional posterolateral basal segmentectomy via inferior pulmonary ligament is easy. There is no need to open intersegmental tissue. It can protect lung tissue better. The operative method is worthy of clinical promotion.
Objective To share the clinical experience of video-assisted thoracoscopic surgery (VATS) anatomic basal segmentectomy by single-direction method. Methods The clinical data of 352 patients who underwent VATS anatomic basal segmentectomy in West China Hospital between April 2015 and April 2021 were retrospectively reviewed, including 96 males and 256 females with a median age of 50 (range, 26-81) years. All basal segmentectomies were performed under thoracoscopy, through the interlobar fissure or inferior pulmonary ligament approach, and following the strategy of single-direction and the method of "stem-branch". ResultsAll patients underwent basal segmentectomy successfully (49 patients of uniportal procedure, 3 patients of biportal procedure and 300 patients of triportal procedure) without addition of incisions or conversion to thoracotomy and lobectomy. The median operation time was 118 (range, 45-340) min, median intraoperative blood loss was 20 (range, 5-500) mL, median drainage time was 2 (range, 1-22) d and median postoperative hospital stay was 4 (range, 2-24) d. The postoperative complications included pneumonia in 6 patients, prolonged drainage (air leakage duration＞5 d or drainage duration＞7 d) in 18 patients, cerebral infarction in 1 patient and other complications in 2 patients. All patients were treated well and discharged without main complaints. No perioperative death happened. ConclusionVATS anatomic basal segmentectomy is feasible and safe. It can be performed in a simple manner following the strategy of single-direction.