Research Article
Single Port Thoracoscopic Anatomic Segmentectomy: Three-Year Experience
Zhibo Chang* and Jun-Qiang Fan
Department of Thoracic Surgery, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
*Corresponding author: Zhibo Chang, Department of Thoracic Surgery, The Second Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
Published: 13 Jul, 2018
Cite this article as: Chang Z, Fan J-Q. Single
Port Thoracoscopic Anatomic
Segmentectomy: Three-Year
Experience. Clin Surg. 2018; 3: 2015.
Abstract
Objective: To evaluate the safety and feasibility of single port thoracoscopic anatomic segmentectomy
in the treatment of pulmonary diseases.
Methods: Clinical data of 161 consecutive patients undergoing single port thoracoscopic anatomic
segmentectomy from May 2014 to June 2017 were retrospectively analyzed.
Results: There were 51 male and 110 female, aged 57.76 years on average (28-85 years). The mean
operation time was 130 (35-280) min. The mean intraoperative hemorrhage volume was 47.5 (5-
400) ml. The mean postoperative extubation time was 3.16 (1-9) d. The mean postoperative length of
hospital stay was 4.63 (2-20) d. One case was switched to open surgery intraoperatively. No patient
died during postoperative 30 d. Among them, 134 patients underwent simple segmentectomy, 15
receiving combined segmentectomy, 8 undergoing segmentectomy combined with lobectomy and 4
receiving sub-segmentectomy. Among them, 153 patients were diagnosed with non-small cell lung
cancer and 8 with benign lung diseases. The incidence of postoperative complications was 6.8%
mainly including pulmonary air leakage and pulmonary infection.
Conclusion: Single port thoracoscopic anatomic segmentectomy is a safe and feasible approach for
lung diseases. Single port thoracoscopic anatomic segmentectomy combined with systematic lymph
node dissection or sampling serves as one of the options for the treatment of early lung cancer.
Keywords: Single port; Thoracoscopy; Anatomic pulmonary segmentectomy
Introduction
In 1939, Churchill and Belsey [1] first applied segmentectomy to treat bronchiectasis. In 1973, it was first applied for the treatment of lung cancer [2]. Recently, multiple retrospective studies have demonstrated that the recurrence rate of malignant tumors and long-term survival rate do not significantly differ between anatomic pulmonary segmentectomy and lobectomy in the treatment of stage I lung cancer [3-5,15]. In recent years, single-port thoracoscopy is an emerging endoscopic technique. Current researches have suggested that compared with the multi-port thoracoscopy, single-port thoracoscopy yields similar clinical efficacy whereas induces less surgical trauma and faster postoperative recovery [6,7]. In our hospital, single-port thoracoscopic resection of the pulmonary lobe and segment and sleeve-shaped surgery have been performed. From May 2014 to June 2017, clinical data of 161 patients undergoing single port thoracoscopic anatomic segmentectomy were retrospectively analyzed to evaluate the safety and feasibility in the treatment of lung diseases.
Subjects and Methods
Subjects
From May 2014 to June 2017, single port thoracoscopic anatomic segmentectomy was
conducted in 161 cases. Relevant clinical data included gender, age, preoperative comorbidities,
preoperative examinations, operation time, intraoperative hemorrhage volume, quantity of lymph
node dissection, postoperative drainage, and postoperative length of hospital stay, postoperative
complications, postoperative pathological status and 30-d postoperative mortality rate. Among 161
patients undergoing thoracoscopic anatomic segmentectomy, 51 cases were male and 110 female,
aged 57.76 years (28-85 years) on average.
Methods
Preoperative preparation: Routine preoperative examinations included electrocardiogram,
lung function test and enhanced chest CT scan. In partial patients,
three dimensional CT reconstruction was performed to identify the
incidence of anatomical changes of the vessels and bronchia in the
target segment. The patients initially diagnosed with lung cancer
received routine head MRI and systemic radionuclide bone imaging
or PET-CT to exclude the possibility of extra-pulmonary metastasis.
Surgical methods: All patients underwent double-lumen
endotracheal intubation under general aneasthesia, lung ventilation
on the normal side in a lateral decubitus position. A 3-4 cm
incision was created in the 4th or 5th intercostal space between
anterior axillary line and midaxillary line. Electrocautery hook and
harmonic scalpel (Johnson & Johnson, USA) were utilized to isolate
the vein, artery and bronchia of the target segments and incisional
closure was conducted by the endoscopic linear stapling device.
The Electrocautery hook, harmonic scalpel or stapling device was
utilized to process the planes between lung segments. The follow
items should be cautioned intraoperatively. First, adequate incisional
margins should be guaranteed. The incisional margin should be >2
cm or exceed the diameter of malignant tumors. If the incisional
margins were insufficient, combined segmentectomy or pulmonary
lobectomy should be performed. Second, the middle mediastinum,
lung hilus, inter-lobe, inter-segment lymph nodes, target segments
and incisional margins were prepared for frozen pathological section.
If the lymph nodes were positive, the scheduled segmentectomy
should be substituted by lobectomy.
Figure 1
Figure 1
Routine CT medical examination of a 44-year-old female revealed
a mix 6mm GGO nodule within the right S6.
Figure 2
Figure 2
Osirix was utilized for three dimensional reconstruction of the
pulmonary artery, vein and bronchia. The A6, B6 and V6a are showed.
Results
The distribution of the resected pulmonary segments in
161 patients undergoing single port thoracoscopic anatomic
segmentectomy was illustrated in Table 1. Among 161 cases, 8 were
benign and 153 were malignant. The pathological outcomes were
illustrated in Table 2. Among 161 surgeries, the mean operation
time was 130 (35-280) min. The mean intraoperative hemorrhage
volume was 47.5 (5-400) ml. No case received intraoperative and
postoperative blood transfusion. The mean postoperative of thoracic
drainage time was 3.16 (1-9) d. The mean postoperative length of
hospital stay was 4.6 (2-20) d. Relevant results among different types
of surgeries were illustrated in Table 3. The apicoposterior segment
of the left upper lung, the lingular segment of the left upper lung and
the basal segment of the lower lobe were included into the simple
segmentectomy group for statistical analysis.
In this study, the incidence of postoperative complications was
6.8%, illustrated in Table 4. No patient died at postoperative 30 d.
Figure 3a
Figure 3a
This patient had two vessels of A6, when the fissure between S2
and S6 was cut, the first A6 was exposed.
Figure 3b
Figure 3c
Discussion
Thoracoscopic segmentectomy was reported in 1993 for the
first time. Raviaro et al. [8] from Italy reported the first case of
thoracoscope-assisted small incision segmentectomy worldwide. In
2004, total thoracoscope-assisted segmentectomy was first applied to
treat lung cancer [9]. At present, single-port thoracoscopic anatomic
segmentectomy has been gradually introduced at home and abroad.
In this investigation, the inclusion criteria comply with international
guidelines and standards.
The following indications should be strictly met: 1. Those aged>75
years; Those cannot tolerate lobectomy due to poor cardiopulmonary
function or other complications (compromised resection). 2. Those
with peripheral lung nodes ≤2 cm in diameter. At least one of the
characteristics should be met: simple adenocarcinoma in situ,
ground glass-like opacity (GGO) ≥ 50% detected by CT scan and
the node doubling time ≥ 400 d by imaging diagnosis. 3. Those
with solitary metastatic tumors or benign lesions which do not
necessarily require lobectomy (relatively large lesions, deep lesions
or the lesions constrained to the pulmonary segment); 4. Those with
a medical history of pneumonectomy or multiple intra-pulmonary
lesions which should be resected by multiple cycles of surgeries. The
lung function should be retained as possible. Multiple carcinomas
(compromised surgery).
Precise anatomy of the target pulmonary segments can be
performed during anatomic pulmonary segmentectomy. In this study,
the enrolled patients received routine preoperative chest contrastenhanced
CT scan. For a majority of cases, Deep Insight software or
Osirix software was utilized for three dimensional reconstructions
of the pulmonary artery, vein and bronchia. Partial lesions adjacent
to intersegmental fissure were localized by CT-guided lung mass
puncture. During the early stage of research, Hookwire needle was
used for localization and metal spring coil was utilized during the
late stage of the study [16]. The latter technique yields mild injury,
mitigates the pain, is well tolerated and properly fixed. Figure 1-3
show one example of lung cancer that was resected via single port
thoracoscopic anatomic segmentectomy.
Selection of surgical incisions: during the early stage of research,
the incisions were created in the 4th intercostal space between anterior
axillary line and the midaxillary line during the surgery of the upper
lobe of the left lung. During the surgeries of other lung lobes, the
incisions were made in the 5th space between intercostal anterior
axillary line and the midaxillary line. The 4th intercostal incisions
allows for convenient processing of the anterior artery at the apex
of the left upper lung. Along with the maturation of the surgical
technologies, the surgical incisions have been gradually transited
and fixed to the 5th intercostal site during routine lung surgery. This
position is located at the middle point between the upper and lower
fissure and the oblique fissure, which allows for convenient access to
each position and anatomical structure within the thoracic cavity.
Processing of anatomical structures: Pulmonary segments
possess respective bronchia, pulmonary artery and vein, constantly
accompanied by deformity and changes. However, the lung tissues
between two lung segments are connected without anatomic isolation
plane. Comparatively, the morphology of pulmonary artery and
bronchia is almost stable with slight variations. The pulmonary artery
was accompanied by the bronchia, which can be mutually referenced.
Combined with preoperative CT scan and three dimensional
reconstructions, the tissues in the target segments can be identified
and determined. The main branches of the pulmonary segmental veins
stretch among the pulmonary segments, which are known as intersegmental
veins accompanied with intra-segmental veins stretching
within the pulmonary segments and among the sub-segments. When
processing pulmonary segmental veins, intra-segmental veins should
be cut off and inter-segmental veins stretching between the target
segment and adjacent pulmonary segments should be preserved as
possible. If the inter-segmental veins could not be identified, the
target segments of each inter-segmental vein should be isolated to the
distal end. After the inter-segmental interface was determined, intersegmental
veins along with lung parenchyma were excised to avoid
injury and misdiagnosis.
In this study, the following approaches were adopted to determine
the inter-segmental phones: first, lung insufflation: the lung was
insufflated after the clamping of the bronchia of the target segments
to determine the unaffected pulmonary segments; Second, collapse
of the insufflated lung: the lung was insufflated initially, followed by
unilateral lung ventilation after the bronchia of the target segments
were clamped. The other pulmonary segments were collapsed,
which formed boundaries with the insufflated target lung segments.
Throughout this process, it was recommended to utilize pure oxygen
for lung insufflation because the exchange and absorption rates of
oxygen were higher than those of nitrogen. Use of pure oxygen could
reduce the collapse speed of the other pulmonary segments. Third,
bronchial injection method: initially, the lung tissues were collapsed,
the bronchia of the target segments were excised, and subsequently
a syringe was used to inflate the bronchia of the target segments to
expand the lung tissues; Fourth, if the lung tissue boundaries of the
target segments could not be determined by using the methods above,
the lung tissues of the target segments could be excised according to
the anatomical position of preoperative reconstruction outcomes.
Processing of inter-segmental plane: first, electro-scalpel and
harmonic scalpel were used to incise the inter-segmental interface.
Second, stapling device was utilized to incise the inter-segmental
interface. Third, both two methods were adopted. Ohtsuka T et al.
[12] comparatively analyzed the electro-scalpel and electro-scalpel
combined with stapling device and demonstrated that the incidence
of postoperative pulmonary air leakage was increased and the
surgical expense was decreased in the electro-scalpel alone group
compared with the combined group. No statistical significance was
noted in the loss of lung function, postoperative indwelling time
and length of hospital stay between two groups. Tao H statistically
compared the stapling device with electro-scalpel combined with
stapling device and revealed no statistical significance in the loss of
lung function between two approaches [11]. In this study, electroscalpel,
harmonic scalpel and stapling device were collectively utilized
to process the inter-segmental plane. Under normal circumstances,
electro-scalpel and harmonic scalpel were used to process the tissues
adjacent to the lung hilus, and stapling device was utilized for the
tissues surrounding visceral peritoneum. For individual cases, merely
one of the electro-scalpel, harmonic scalpel and stapling device was
utilized. Nevertheless, the effect of different methods upon the time
of postoperative pulmonary air leakage and long-term lung function
remains to be elucidated. Pleural suture or pravastatin + biological
glue was performed to treat the air leakage of the inter-segmental
plane after isolation. Saito H et al. [13] retrospectively analyzed these
two approaches in 133 patients and concluded that pleural suture was
superior in terms of postoperative pulmonary air leakage and could
shorten the air leakage time. No statistical significance was observed
in the lung function at postoperative 1 and 6 months between two
approaches. In this study, pleural suture or pravastatin + biological
glue was adopted based upon specific circumstances. Pleural suture
was mainly adopted for severe air leakage, whereas pravastatin +
biological glue was chosen for slight air leakage or air leakage adjacent
to the pulmonary segmental root.
In this study, pulmonary segmentectomy alone was adopted in a
majority of patients, and combined pulmonary segmentectomy and
pulmonary segmentectomy in combination with lobectomy were
performed in a minority of cases. Pulmonary segmentectomy alone
basically covered all types of common lung segments. All patients
successfully completed the surgery and recovered. The operation
time, intraoperative hemorrhage volume, postoperative extubation
time and postoperative length of hospital stay were the least in
the pulmonary segmentectomy group, whereas the most in the
segmentectomy combined with lobectomy group, which were almost
consistent with the quantity of intraoperative structural treatment
and trauma size.
During the late stage of this study, sub-segmentectomy was
performed in 5 cases. Four patients underwent sub-segmentectomy
alone including 3 sub-segmentectomy of the apicoposterior
segment of the left upper lung and 1 sub-segmentectomy of the
anterior segment of the left upper lung. Another case received
sub-segmentectomy of the lingular segment combined with the
apicoposterior segment of the left upper lung, who was included
into the combined segmentectomy group. Sub-segmentectomy
was selected after careful consideration and full preparation. First,
surgical experience was accumulated after daily surgery and over 100
segmentectomy. Second, sub-segmentectomy was gradually applied
along with the development of minimally invasive surgery. In this
study, we chose patients with early-stage lesions which were limited to
specific sub-pulmonary segments. Prior to sub-segmentectomy, three
dimensional reconstruction was performed to identify anatomical
lung structures and localize the lesions. Intraoperative procedures of
sub-segmentectomy were almost identical to those of segmentectomy,
in which the artery, bronchia and intra-segmental vein could be
precisely excised. All cases successfully completed the surgery and
recovered. The operation time, intraoperative hemorrhage volume,
postoperative extubation time and postoperative length of hospital
stay were superior to those in the pulmonary segmentectomy alone
group.
Intraoperative hemorrhage, switch to open surgery and
postoperative complication: in this investigation, 2 patients
presented with pulmonary arterial injury and hemorrhage. One case
received endoscopic vascular repairing and the other was switched
to open surgery. Approximately 5.5% of the patients suffered from
postoperative complications including pulmonary air leakage,
pneumohypoderma and chylothorax, which were healed after active
treatment. Compared with non-single port thoracoscopic technique,
the incidence rates of intraoperative hemorrhage, switch to open
surgery and postoperative complications were not increased.
Taken together, single-port thoracoscopic technique is
relatively mature, safe and feasible and inclined to become the
mainstream technique. We consider that any anatomic pulmonary
segmentectomy can be accomplished under single-port thoracoscope.
There are several limitations to be acknowledged. The sample size
is relatively small due to strict criteria of surgical indications. The
follow-up time is short. The random control group is lacking. The
conclusion obtained from this investigation remains to be validated
by subsequent research with large sample size.
Table 1
Table 2
Table 3
Table 4
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