Identification of the intersegmental plane during thoracoscopic segmentectomy: state of the art

During thoracoscopic segmentectomy, where direct palpation of the tumour is not always possible, achieving adequate margins from the cancer is of crucial importance. It is thus mandatory to accurately identify the intersegmental plane (ISP). Indeed, inadequate determination and division of the ISP can lead to unsatisfactory oncological results. Our systematic review focused on the effectiveness of the different techniques for identifying the ISP, highlighting the fact that a 1-size-fits-all method is not feasible. Based on the published evidence, 6 main methods were reported, each with its pros and cons: inflation-deflation technique, selective resected segmental inflation, systemic injection of indocyanine green, injection of endobronchial dye, 3-dimensional simulation using multidetector computed tomography and virtual-assisted lung mapping. In conclusion, ISP demarcation is mandatory to achieve a high rate of success of thoracoscopic segmentectomy, and it is very helpful in surgical planning, especially when preoperative multidetector computed tomography and 3-dimensional reconstructions are routinely performed

How to improve the precision of closed chest sublobar resections.

Abstract: Despite carcinological results awaiting validation, sublobar resections (SLRs) are of increasing interest due to the progressive change in tumour profile and to their lower morbidity when compared to lobectomies. However, this morbidity remains too high in comparison to non-surgical alternatives. Decreasing the complication rate requires greater precision. We present here the different ways to improve the accuracy of the different steps of these interventions: (I) performing these procedures via a closed chest approach; (II) knowing as much as possible about segmental anatomy and studying mapping; (III) performing an intraoperative examination on the intersegmental lymph nodes and on resection margins; (IV) using a preoperative or intraoperative marking method to determine the intersegmental plane (ISP); (V) stapling ISP, an imperfect method but that currently represents the least bad compromise between accuracy and safety

Unplanned Procedures During Thoracoscopic Segmentectomies.

BACKGROUND Thoracoscopic sublobar resections (TSLRs) are gaining popularity, but are challenging. However, despite technical difficulties, the reported rate of adverse events, complications, and unplanned procedures is low. To understand this paradox, we have studied our series of TSLRs. METHODS We reviewed our prospective and intention-to-treat database on videothoracoscopic anatomical resections and extracted all planned thoracoscopic segmentectomies from January 2007 to July 2016. Intraoperative and postoperative data were analyzed. Unplanned procedures were defined as a conversion into thoracotomy or an unplanned additional pulmonary resection. RESULTS During the study period 284 thoracoscopic anatomical segmentectomies were performed in 280 patients. There were 124 men and 156 women with a mean age of 64 years (range, 18 to 86 years). Indication for segmentectomy was a proven or suspected non-small cell lung carcinoma in 184 patients, suspected metastasis in 51 patients, and benign lesion in 49 patients. In total, 23 patients had an unplanned procedure (8%). There were 10 unplanned thoracotomies (9 conversions and 1 reoperation; 3.1%) mainly for vascular injuries, and 15 unplanned additional resections (5.1%) distributed among oncological reasons (n = 7), per operative technical issues (n = 6) and postoperative adverse events (lingular ischemia, n = 2). Considering only the 235 patients operated on for cancer, the unplanned additional pulmonary resection rate for an oncological reason was 3%. CONCLUSIONS Although lower than for thoracoscopic lobectomies, the rate of unplanned procedure during TSLRs is of concern. It could most likely be reduced by technical refinements, such as a better preoperative planning

Oncological results of full thoracoscopic major pulmonary resections for clinical Stage I non-small-cell lung cancer.

OBJECTIVES The full thoracoscopic approach to major pulmonary resections is considered challenging and controversial as it might compromise oncological outcomes. The aim of this work was to analyse the results of a full thoracoscopic technique in terms of nodal upstaging and survival in patients with non-small-cell lung carcinoma (NSCLC). METHODS All patients who underwent a full thoracoscopic major pulmonary resection for NSCLC between 2007 and August 2016 were analysed from an 'intent-to-treat' prospective database. Overall survival and disease-free survival were estimated using the Kaplan-Meier curves and comparisons in survival using the log-rank test. RESULTS A total of 648 patients met the inclusion criteria, of whom 621 patients had clinical Stage I and 27 had higher stages (16 oligometastatic patients were excluded from the analysis, 11 cT3 or cT4). The mean follow-up was 34.5 months. There were 40 conversions to thoracotomy (6.3%). Thirty-day or in-hospital mortality was 0.95%. Complications occurred in 29.3% of patients. On pathological examination, 22.5% of clinical Stage I patients were upstaged. Nodal upstaging to N1 or N2 was observed in 15.8% of clinical Stage I patients. Five-year overall survival of the whole cohort was 75% and was significantly different between clinical Stages IA (76%) and IB (70.9%). For tumours <2 cm, no significant difference in overall survival was found for the segmentectomy group compared to the lobectomy group: 74% versus 78.9% (P = 0.634). CONCLUSIONS Long-term survival is not compromised by a full thoracoscopic approach. Our results compared favourably with those of video-assisted techniques

Thoracoscopic Right Apicoposterior Segmentectomy

<p>S2 and S1+2 segmentectomies are frequently indicated, as the location of a tumor or a nodule in S2 or at the border between S2 and S1 is not unusual. Preserving S3 rather than performing an upper lobectomy has two advantages: it spares respiratory function, and S3 is a large segment that occupies the pleural cavity and prevents reexpansion issues that can be encountered after an upper lobectomy, as illustrated in Video 1 and Figure 1.<br></p><p>The technique the authors describe is based on a thoracoscopic fissure-first approach whose rational and basics have been reported (1, 2). This technical description is based on an experience of 63 right S1+2segmentectomies out of a series of 375 thoracoscopic segmentectomies that have been performed at the authors' institution. Knowledge of anatomical landmarks and anatomical variations is a prerequisite to feeling secure during these procedures (3).<br></p><p>Learn more at: https://www.ctsnet.org/article/thoracoscopic-right-apicoposterior-segmentectomy</p