Bakhuis, Wouter

Betser, Lea

Bogers, Ad J.J.C.

Gossot, Dominique

Maat, Alexander P.W.M.

Mahtab, Edris A.F.

Sadeghi, Amir H.

Seguin-Givelet, Agathe

Siregar, Sabrina

Susa, Denis

NARCIS 

Translobar venous drainage management in (sub)lobar resections: Virtual 3-dimensional planning and surgical technique

EUR Research Repository

THORACIC: LUNG CANCER: SURGICALTECHNIQUETranslobar venous drainage management in (sub)lobarresections: Virtual 3-dimensional planning andsurgical techniqueWouter Bakhuis, MD,MSc,a Lea Betser,MD,b Amir H. Sadeghi, MD, PhD,a Dominique Gossot, MD, PhD,bDenis Susa, MD, PhD,c Alexander P. W. M. Maat, MD,a Sabrina Siregar, MD, PhD,aAd J. J. C. Bogers, MD, PhD,a Agathe Seguin-Givelet, MD, PhD,b,d and Edris A. F. Mahtab, MD,aRotterdam and Roosendaal, The Netherlands, and Paris and Bobigny, FranceFrom the aDepartment of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands; bSur-gery Department, Institut Montsouris, Institut du Thorax Curie Montsouris, Paris, France; cBravis Hospital,Roosendaal, The Netherlands; and dParis 13 University, Sorbonne Paris Cite, Faculty of Medicine SMBH, Bo-bigny, France.Supported by the Koers23 grant, Erasmus Medical Center, The Netherlands.Disclosures: Drs Sadeghi andMahtab are both coinventors of the virtual reality-based technology (PulmoVR) pre-sented in this article. All other authors reported no conflict of interest.The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handing manu-scripts for which they have a conflict of interest. The editors and reviewers of this article have no conflict ofinterest.Drs Bakhuis, Seguin-Givelet, and Mahtab contributed equally to this article.IRB/ERB number MEC-2020-0702, date of approval October 19, 2020.Written informed consent was obtained from all patients.Received for publication Oct 18, 2022; revisions received March 6, 2023; accepted for publication March 10,2023; available ahead of print April 17, 2023.Address for reprints: Edris A. F. Mahtab, MD, Department of Cardiothoracic Surgery, Erasmus University Med-ical Center, Room Rg-629, Dr Molewaterplein 40, 3015 GD Rotterdam, The Netherlands (E-mail: e.mahtab@erasmusmc.nl).JTCVS Techniques 2023;19:128-312666-2507Copyright 2023 The Author(s). Published by Elsevier Inc. on behalf of The American Association for ThoracicSurgery. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).https://doi.org/10.1016/j.xjtc.2023.03.021Lateral 3D visualization of right-sided interlobarvein between segment 2 and 6.CENTRAL MESSAGETo emphasize the importance ofthorough preoperative planning,5 cases with translobar venousdrainage of the right lung,observed during 3-dimensionaland virtual reality visualization aredescribed.Most of the currently available knowledge of bronchovas-cular anatomy is based on cadaver studies.1 However, bron-chovascular anatomy is highly variable, advocating the termpatient-specific anatomy instead of anatomical variation.2With innovative visualization techniques such as virtual3-dimensional (3D) modeling and immersive virtual reality(VR), patient-specific anatomy can be visualized withmore detail and accuracy than through conventional2-dimensional computed tomography (2D-CT) images.In our centers, we have adopted novel 3D/VR technolo-gies (Pulmo3D, Visible Patient, and PulmoVR) to preoper-atively analyze patient-specific anatomy for pulmonaryresections. Over the past few years, we have faced severalcases in which there was a right-sided translobar venousdrainage in patients undergoing (sub)lobar resection. Inthis article, we aim to describe the importance of a thoroughpreoperative planning strategy and surgical technique toeither spare or selectively ligate these translobar veins.3D MODELING ROUTINE, CASE PRESENTATION,AND SURGICAL TECHNIQUEVR/3D-based planning, using PulmoVR and Pulmo3D,has been used since 2020 in Erasmus Medical Center andBravis Hospital, and Visible Patient has been used since128 JTCVS Techniques c June 20232016 in the Institut du Thorax Curie Montsouris for all seg-mentectomies, as described elsewhere.3,4 Five patient caseswith translobar venous drainage of the right lung were iden-tified. Written informed consent was obtained from all pa-tients. The study was approved by the medical ethicalcommittee of the Erasmus Medical Center (MEC-2020-0702).Case 1 was a 70-year-old woman with a histologicallyproven adenocarcinoma, cT1a N0 M0, in segment 3 of theright upper lobe (RUL). A segment 3 resection was planned.Standard CT scan showed that both fissures were absent inthe right lung (Figure 1, A). During VR visualization, an in-terlobar vein between segment 2 and segment 6 draininginto the superior pulmonary vein (SPV) was observed(Figure 1, B). During surgery, the aberrant drainage wasconfirmed and the vein was spared, after opening of theFIGURE 1. Two-dimensional computed tomography (2D-Ct), virtual reality, and 3-dimensional visualization of cases 1 and 2. A, Case 1: 2D-CT. B, Pul-mo3D, lateral view. C, Intraoperative representation of interlobar vein V6/2 (white arrow points to interlobar vein V6/2). D, Case 2: 2D-CT. E, PulmoVRlateral view. F, Pulmo3D, lateral view of translobar vein of S6 (white arrow points to translobar vein V6). A, Artery; B, bronchus; V, vein; RUL, right upperlobe; S, segment.Thoracic: Lung Cancer: Surgical Techniquehorizontal fissure by bluntly dissecting a tunnel between theSPV’s and the horizontal fissure (Figure 1, C).Case 2 was a 74-year-old patient with a cT2b N0 M0adenocarcinoma in the RUL. Standard CT raised the suspi-cion (due to fissural crossing of a venous structure) ofvenous drainage of segment 6 into the SPV (Figure 1, D),which was confirmed by PulmoVR/Pulmo3D visualization(Figure 1, E and F). A lobectomy was performed. To spareV6, first, the horizontal fissure was opened with endosta-plers similarly to the previous case, by creating a tunnel be-tween the SPV and the horizontal fissure. After that, theRUL veins were ligated selectively and V6 was spared.Case 3 was a 30-year-old woman who was referred for asingle metastasis in segment 10 of the right lower lobe. Abasal segmentectomy was planned. 2D-CT (Figure 2, A)and 3D-planning (Figure 2, B) demonstrated that segment2 was mainly drained by a retrobronchial vein, which wasthe upper tributary of the inferior pulmonary vein (IPV).This vein could be spared by approaching the IPV veinfrom the dorsal hilum (Figure 2, C). After identificationand isolation of V2 and V6, the remaining basal veinswere ligated.Case 4 was a 70-year-old patient whowas admitted for anadenocarcinoma cT2a N0 M0 located in segment 3 andinvading the middle lobe through the fissure. A superior bi-lobectomywas indicated. 2D-CT suggested a translobar ret-robronchial vein of segment 2 (Figure 2, D), confirmed by3D visualization (Figure 2, E). During surgery, the veincoming from segment 2 and crossing posteriorly the inter-medial bronchus perpendicularly was confirmed(Figure 2, F). This vein was also identified by a dorsalapproach of the hilum, and subsequently clipped to preserveother IPV tributaries.Case 5 was a 73-year-old man who presented with a30-mm ground glass opacity in the right apical segment.Because primary non–small cell lung cancer cT1c N0 M0JTCVS Techniques c Volume 19, Number C 129FIGURE 2. Two-dimensional computed tomography (2D-CT) and 3-dimensional and intraoperative views of retrobronchial veins in cases 3, 4, and 5. Case3: 2D-CT (A), dorsal view (B), and intraoperative (C) representation of retrobronchial vein of the right upper lobe (RUL) into the inferior pulmonary vein(IPV). Case 4: 2D-CT (D), Pulmo3D, dorsal-medial view (E), and intraoperative (F) view of translobar vein V2. Case 5: 2D-CT (G), dorsal view (H), andintraoperative (I) view of retrobronchial V2 to IPV (black arrow (A) and white arrow (B-I) indicate translobar vein V2). V, Vein; RUL, right upper lobe; IPV,inferior pulmonary vein; RLL, right lower lobe; SPV, superior pulmonary vein; SBV, superior basal vein; IBV, Inferior basal vein;ULB, upper lobe bronchus;LLB, lower lobe bronchus.Thoracic: Lung Cancer: Surgical Techniquetumor was suspected, a segment 1 and 2 segmentectomywas planned. 3D visualization showed a right single (com-mon ostium) pulmonary vein with direct branching of a ret-robronchial vein draining segment 2 (Figure 2, H). One130 JTCVS Techniques c June 2023anteriorly located SPVwas draining segment 1 and segment3. Dorsal approach of the hilum provided a clear view onV2, which could selectively be clipped for the segment 1and 2 segmentectomy (Figure 2, I).Thoracic: Lung Cancer: Surgical TechniqueCONCLUSIONSOver the past few years, an increasing number of morecomplex sublobar resections have been performed. This rai-ses the need to thoroughly analyze the bronchovascularanatomy pre-operatively to avoid unforeseen circumstancesduring the procedure. Bronchovascular anatomy can be as-sessed more easily compared with standard CT based on 3Dmodeling of patient-specific lung anatomy. In these cases,possible congestion of the venous drainage of the remaininglung lobes/segments could be prevented. In the literature,venous drainage of segment 6 into the SPV, as seen in pa-tients 1 and 2, was observed in approximately 1.5%.2Drainage of segment 2 into the IPV was described in1.9%.5 Single right pulmonary vein drainage is very rare,and incidence is unknown.Experienced consequences of ligation of translobarvenous structures depend on the size of the ligated vein.One of the authors had experienced 1 case of translobarvein ligation, resulting in some venous congestion in thelung parenchym. Patient had no symptoms, but congestionremained visible on follow-up CT scans. On the otherhand, we experienced venous congestion after lung trans-plantation, which did show a lung lobe that resembleddecompensation. During reoperation, the lung lobe washepatized and very fragile. Eventually, this can cause lung(lobe) ischemia if persistent.References1. Boyden EA, Scannell JG. An analysis of variations in the bronchovascular patternof the right upper lobe of 50 lungs. Am J Anat. 1948;82:27-73. https://doi.org/10.1002/aja.10008201032. Nagashima T, ShimizuK, Ohtaki Y, Obayashi K, Nakazawa S,Mogi A, et al. Anal-ysis of variation in bronchovascular pattern of the right middle and lower lobes ofthe lung using three-dimensional CTangiography and bronchography.Gen ThoracCardiovasc Surg. 2017;65:343-9. https://doi.org/10.1007/S11748-017-0754-43. Sadeghi AH, Maat APWM, Taverne YJHJ, Cornelissen R, Dingemans A-MC,Bogers AJJC, et al. Virtual reality and artificial intelligence for 3-dimensionalplanning of lung segmentectomies. JTCVS Techniques. 2021;7:309-21. https://doi.org/10.1016/j.xjtc.2021.03.0164. Seguin-Givelet A, GrigoroiuM, Brian E, Gossot D. Planning andmarking for thor-acoscopic anatomical segmentectomies. J Thorac Dis. 2018;10:S1187. https://doi.org/10.21037/JTD.2018.02.215. Nagashima T, Shimizu K, Ohtaki Y, Obayashi K, Kakegawa S, Nakazawa S, et al.An analysis of variations in the bronchovascular pattern of the right upper lobe us-ing three-dimensional CT angiography and bronchography. Gen Thorac Cardio-vasc Surg. 2015;63:354-60. https://doi.org/10.1007/S11748-015-0531-1JTCVS Techniques c Volume 19, Number C 131

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Translobar venous drainage management in (sub)lobar resections:Virtual 3-dimensional planning and surgical technique

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Translobar venous drainage management in (sub)lobar resections: Virtual 3-dimensional planning and surgical technique

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