Anatomical distribution and clinical significance of translobar bronchi, arteries, and veins hidden in the interlobar fissure.

Background: The interlobar bronchovascular structures hidden in the incomplete interlobar fissures (IFs) are often inadvertently transected during pulmonary resections, which could inevitably lead to accidental injury and potentially compromise the function of the preserved area. A thorough examination of the anatomical distribution of translobar bronchi, arteries, and veins holds significant clinical importance. Methods: Three-dimensional computed tomography bronchography and angiography (3D-CTBA) data from patients who underwent pulmonary resection between December 2018 and November 2019 were retrospectively analyzed. The translobar bronchi, arteries, and veins were categorized based on their origin and distribution. Surgical results of patients who underwent surgery involving translobar structures were further reviewed. Results: Among the 310 enrolled patients, incomplete IFs (IIFs) were most frequently observed in horizontal fissures (68.7%), followed by right upper oblique fissures (42.3%), left lower oblique fissures (32.6%), left upper oblique fissures (12.9%), and right lower oblique fissures (11.0%). The incidence of bronchovascular structures was significantly higher in IIFs than in complete IFs (CIFs; 85.5% vs. 5.2%, χ2=1,021.1, P<0.001). A total of three subtypes of translobar bronchi, five subtypes of translobar arteries, and 14 subtypes of translobar veins were identified. Primary subtypes of translobar arteries (frequency >5%) included the left A4/5 (18.7%) that branched from A7/8/7+8 and the common trunk of right Asc.A2+A6 (6.1%). Primary subtypes of translobar veins (frequency >5%) included the right V2 draining into inferior pulmonary vein (IPV) (5.8%), the interlobar V3b (58.4%) within horizontal fissures, the right V4/5 draining into V2/3 (26.1%), the left V4/5 draining into IPV (7.4%), the right V6 draining into V2 (38.4%), and the common trunk of left IPV and superior pulmonary vein (SPV; 9.4%). Moreover, 12.0% of translobar arteries and 75.0% of translobar veins were mistransected during anatomical pulmonary resection, resulting in gas-exchanging dysfunction in the preserved territory. Conclusions: Translobar bronchovascular structures exhibited a high incidence and were more commonly present in IIFs. Surgeons should pay increased attention to these structures to prevent accidental injuries during anatomical pulmonary resection.

Noninvasive 3D-CT simulation versus glue injection to localize small pulmonary nodules prior to anatomical segmentectomy: a randomized controlled trial.

OBJECTIVES: This study aimed to investigate whether adding glue injection to three-dimensional computed tomography bronchography and angiography (3D-CTBA) has extra benefits to facilitate anatomical segmentectomy for pulmonary nodules. METHODS: We conducted a randomized controlled trial. The patients undergoing thoracoscopic segmentectomy assisted with 3D-CTBA simulation were enrolled. Then, they were divided into the 3D-CTBA group and the glue-labelling group who received additional computed tomography-guided percutaneous glue (2-octyl cyanoacrylate) injection to label the nodules. The primary outcome was the resection rate of the nodules, and the secondary measures included the operation time, complications and thorax drainage. RESULTS: A total of 173 patients were randomized into the 3D-CTBA group (89 patients) and glue-labelling group (84 patients) between January 2018 and March 2019. Before the segmentectomy, the patients using glue labelling recorded 5 (6.0%) cases of pneumothorax, 2 (2.4%) cases of haemothorax and 1 (1.2%) case of severe chest pain. All the surgical procedure was performed fluently and safely. The resection rate of the nodules was 100% in both groups. Furthermore, these patients demonstrated similar operation time [(141.5 ± 41.9) vs (142.1 ± 38.9) min], estimated blood loss [(111.3 ± 74.0) vs (106.0 ± 63.8) ml], duration of chest tube duration [(5.1 ± 3.0) vs (5.0 ± 3.5) days] and total drainage volume [(872.3 ± 643.1) vs (826.7 ± 806.0) ml], with a P-value of >0.05 respectively. In addition, 6 (7.1%) patients in the glue-labelling group and 6 (6.7%) patients in the 3D-CTBA group reported air leakage (>5 days) and chylothorax. CONCLUSIONS: Noninvasive 3D-CTBA alone is probably sufficient to facilitate anatomical segmentectomy. The additional invasive glue labelling could be avoided in selected patients who undergo intentional segmentectomy. CLINICAL TRIAL REGISTRATION: The trial was registered under the Chinese Clinical Trial Registry (ChiCTR). Identifier: ChiCTR1800018293, https://www.chictr.org.cn/showproj.html?proj=29345.

Application of three-dimensional computed tomography bronchography and angiography in thoracoscopic anatomical segmentectomy of the right upper lobe: A cohort study.

Objective: Three-dimensional computed tomography bronchography and angiography (3D-CTBA) can provide detailed imaging information for pulmonary segmentectomy. This study aimed to investigate the safety and effectiveness of 3D-CTBA guidance of anatomical segmentectomy of the right upper lobe (RUL). Methods: This was a retrospective analysis of anatomical segmentectomy of the RUL at the Thoracic Surgery Department of the Fourth Hospital of Hebei Medical University from December 9, 2013, to June 2, 2021. Preoperatively, all patients underwent contrast-enhanced CT of the chest (to determine the size of the pulmonary nodule) and a lung function test. 3D-CTBA has been performed since 2018; patients with vs. without 3D-CTBA were compared. Segmentectomy was performed according to nodule location. Results: Of 139 patients (46 males and 93 females, aged 21-81 years), 93 (66.9%) completed single segmentectomy, 3 (2.2%) completed single subsegmentectomy, 29 had combined subsegmentectomy, 7 had segmentectomy combined with subsegmentectomy, and 6 had combined resection of two segments. Eighty-five (61.2%) patients underwent 3D-CTBA. 3D-CTBA cases had decreased intraoperative blood loss (67.4 ± 17.6 vs. 73.1 ± 11.0, P = 0.021) and shorter operation time (143.0 ± 10.8 vs. 133.4 ± 20.9, P = 0.001). 3D-CTBA (Beta = -7.594, 95% CI: -12.877 to -2.311, P = 0.005) and surgical procedure (Beta = 9.352, 95% CI: 3.551-15.153, P = 0.002) were independently associated with intraoperative blood loss. 3D-CTBA (Beta = -13.027, 95% CI: -18.632 to 17.422, P < 0.001) and surgical procedure (Beta = 7.072, 95% CI: 0.864-13.280, P = 0.026) were also independent factors affecting the operation time. Conclusion: Preoperative use of 3D-CTBA to evaluate the pulmonary vessels and bronchial branch patterns of the RUL decreased blood loss and procedure time and so would be expected to improve the safety and effectiveness of thoracoscopic segmentectomy.

Clinical significance of the diverse interlobar veins hidden in the upper oblique fissure.

Background: The interlobar veins hidden in the upper oblique fissure (UOF) of the right lung are usually mismanaged cursorily according to the target lobe, which results in accidental injury of the interlobar veins and complications. The detailed classification of interlobar veins based on surgical anatomical analysis is of great clinical significance. Methods: Three-dimensional computed tomography bronchography and angiography (3D-CTBA) reconstructed images of 398 patients from January 2019 to June 2020 were retrospectively analyzed. The interlobar veins in the UOF were observed and classified according to their morphology and distribution. The classification model was further validated in 153 patients who underwent surgery involving dissection of the UOF, and related surgical results were analyzed. Results: The distribution of interlobar veins was diverse, and the general morphology could be divided into 2 main categories and 30 subtypes in the 3D-CTBA images of the 398 patients. Analysis of the 153 patients' surgical data showed that 60 patients suffered from interlobar vein injury. Interlobar veins hidden in an incomplete UOF were the most susceptible to accidental damage (χ2=12.856, P=0.020). A receiver operating characteristic (ROC) curve analysis showed that an interlobar vein diameter larger than 2.4 mm for the oblique fissure interlobar vein type or less than 2 mm for the mediastinal interlobar vein type was associated with a higher risk of injuries (P<0.001). Conclusions: The diversity of interlobar veins and the completeness of the UOF were noteworthy risk factors in surgery involving dissection of the UOF.

Mediastinal basal pulmonary artery identification and classification by three-dimensional reconstruction.

PURPOSE: The primary objective of the present study was to use CT angiography and 3D reconstruction to assess and to classify the mediastinal pulmonary basal segmental arteries. METHODS: We report a particular type of bifurcated left lower pulmonary artery, namely, the "mediastinal basal pulmonary artery" type, which is the first branch from the proximal the left pulmonary artery (LPA) between the left main bronchus (LMB) and the left superior pulmonary vein (LSPV) and proceeding directly into the lower lobe. There are many types of mediastinal basal pulmonary arteries, and these can be classified worldwide in a unified way and format, which will be beneficial for clinical records, annotation and academic exchange. RESULTS: The mediastinal basal pulmonary arteries are described either as "supernumerary" when duplicating or "displaced" when replacing the normal arterial branching pattern of the lower lobe. The displaced type is more frequent than the supernumerary type. There are 12 types of left mediastinal basilar arteries. CONCLUSION: This is the first report to categorize the mediastinal basal pulmonary artery, is the first to suggest a system for mediastinal basal pulmonary artery nomenclature, and creates simplified models for use when planning anatomical segmentectomy. Knowledge and recognition of this rare and special condition may facilitate better diagnosis and treatment of these patients.

Evaluation of combined three-dimensional computed tomography bronchography and angiography with 3D video thoracoscopic surgery in the clinical practice of thoracic surgery / 中华医学教育探索杂志

Objective:To investigate the effects of 3D video thoracoscopic surgery combined with 3D CTBA (three-dimensional computed tomography bronchography and angiography) method in clinical education practice of the undergraduates.Methods:The study included in 60 undergraduate clinical interns from our hospital, and they were randomly divided into the experimental group ( n=30) and control group ( n=30). The teaching content was diagnosis and surgical treatment of lung cancer. The experimental group applied 3D video thoracoscopic surgery combined with 3D CTBA teaching method. The interns studied the anatomy of lung and diagnosis of lung cancer based on the 3DCTBA and visited the operation of lung cancer under 3D thoracoscopy, which enhanced their knowledge of anatomical structure of lung. The control group applied traditional thoracoscopic surgery for lung cancer. Upon termination of clinic practice, all interns were tested with theoretical and clinical knowledge of lung cancer. A questionnaire survey was conducted among them to access the teaching effect. SPSS 18.0 was used for t test and chi-square test. Results:The scores of theory test were not significantly different between two groups. The scores of anatomic and operational knowledge of lung in the experimental group were significantly higher compared with the control group ( P<0.05). Questionnaire result showed that new teaching method could promote the interest in learning, motivated the desire for thoracic surgery, and improved the comprehension of clinical knowledge. More students approved the new teaching method. Conclusion:The new method, 3D video thoracoscopic surgery combined with 3D CTBA, has beneficial effect on clinical interns, which contributes to inspire the motivation and interest of learning and deepen clinic knowledge, and is a promising teaching method worthy of further exploration and application.

A modified system for classifying the bilateral superior pulmonary veins using three-dimensional computed tomography bronchography and angiography images.

BACKGROUND: Identifying the distribution of pulmonary veins with three-dimensional reconstruction images is of great significance for surgical guidance. Existing models neglect the consistency of the bilateral superior pulmonary veins (SPVs) and lack a simple unified classification pattern. This study aimed to analyze the distributional features of bilateral SPVs, based on a cohort of patients undergoing CT examination. METHODS: The three-dimensional computed tomography bronchography and angiography (3D-CTBA) images of 1,520 cases were retrospectively analyzed. The reconstructed images of the right upper lobes were read in 715 cases, and left upper lobes in 805 cases. Through symmetrical analysis, the circulation of main venous branches and the spatial relationships of confluences with adjacent bronchus were compared. RESULTS: The SPVs of bilateral upper lobes showed common distributional features and were divided into three main types. The central vein type, the semi-central vein type, and the non-central vein type accounted for 83.35% [596], 7.84% [56], 8.11% [58] of the 715 cases with right scanning, and 25.71% [207], 62.61% [504], 10.81% [87] of the 805 cases with left scanning, respectively. There were 5 (0.70%) cases with rare variations in the right upper lobe and 7 (0.87%) in the left upper lobe. The attribution of intersubsegmental vein in the posterior segment (V2b) and its position relative to the anterior segmental bronchus (B3) was the basis of classification in the right upper lobe, and the attribution of intersubsegmental vein in the apicoposterior segment (V1+2c) and its position relative to B3 was the basis of classification in the left upper lobe. In this classification system, the branching pattern of the intersegmental vein between the apical segment and the anterior segment (V1b) in the right upper lobe, and the intersegmental vein between the apicoposterior segment and the anterior segment (V1+ 2a) in the left upper lobe were used for subdivision. CONCLUSIONS: Our modified system had a high degree of consistency in classifying SPVs in bilateral upper lobes, thus providing guidance for preoperative and intraoperative procedures.

Analysis of bronchial and vascular patterns in left upper lobes to explore the genesis of mediastinal lingular artery and its influence on pulmonary anatomical variation.

BACKGROUND: For thoracic surgeons, three-dimensional computed tomography bronchography and angiography (3-DCTBA) is a convenient way to analyze pulmonary variations before segmentectomy. Mediastinal lingular artery (MLA) is one of the representative variations. METHODS: The 3-DCTBA data of left upper lobe (LUL) were collected from patients who underwent pulmonary surgery from January 2018 to December 2019. We reviewed the patterns of bronchi and pulmonary vessels and grouped them according to different classifications. RESULTS: Among all the 404 cases of 3-DCTBA, mediastinal lingular artery (MLA) was found in 107 cases (26.49%). The patterns of B3 and the vein in left upper division (LUD) are distinct between mediastinal (M-type) group and interlobar (IL-type) group. The patterns of bronchi and veins in lingular division, as well as the pattern of pulmonary artery in LUD, have no differences between M-type and IL-type groups. CONCLUSIONS: Mediastinal lingular artery is speculated to originate from the variation of B3, and the MLA independently influences the venous pattern in LUD in turn.

Utility of preoperative three-dimensional CT bronchography and angiography in uniportal video-assisted thoracoscopic anatomical lobectomy: a retrospective propensity score-matched analysis.

BACKGROUND: Personalized three-dimensional (3D) reconstruction can help surgeons to overcome technical challenges and variations of pulmonary anatomic structures in the performance of uniportal video-assisted thoracoscopic surgery (UVATS), thus improving the safety and efficacy of the procedure. This study aims to evaluate the utility of preoperative 3D-CT bronchography and angiography (3D-CTBA) with Exoview software in the assessment of anatomical variations of pulmonary vessels, and to analyze short-term surgical outcomes in patients undergoing UVATS lobectomy. METHODS: We retrospectively analyzed the data of 198 consecutive patients who underwent curative UVATS lobectomy between November 2019 and September 2020. The patients were divided into an "Exoview" group (n=53) and a "non-Exoview" group (n=145). We performed 1:1 propensity score matching and compared intraoperative and postoperative outcomes between the two groups. A subgroup analysis of 74 patients who underwent single-direction uniportal lobectomy was also conducted. Aberrant pulmonary vessel patterns related to the surgery were also examined. RESULTS: The operative time in the Exoview group was significantly shorter than that in the non-Exoview group, both before (145.7±33.9 vs. 159.5±41.6 minutes, P=0.032) and after (145.7±33.9 vs. 164.2±41.8 minutes, P=0.014) propensity score matching. The number of mediastinal lymph nodes dissected was higher in the Exoview group than in the non-Exoview group (8.19±6.89 vs. 5.78±3.3, P=0.024) after propensity score matching. Intraoperative blood loss showed a statistical difference between the Exoview and non-Exoview groups (60.4±45.4 vs. 100.8±83.9, P=0.009). Four types of arterial variations and 2 types of venous variations related to the surgery were observed among 8 patients (15%), which have rarely been reported before. CONCLUSIONS: Personalized preoperative 3D-CT bronchography and angiography helped to clearly visualize the pulmonary anatomical structures and could contribute to the safe and efficient performance of UVATS anatomical lobectomy.

VATS right posterior segmentectomy with anomalous bronchi and pulmonary vessels: a case report and literature review.

BACKGROUND: Anatomic variation may increase the difficulty and risk of anatomic segmentectomy. The preoperative three-dimensional computed tomography bronchography and angiography (3D-CTBA) can provide a detailed model of the segmental structure, and contribute to precise and safe segmentectomy. CASE PRESENTATION: This is a case of anomalous bronchi and pulmonary vessels in the right upper posterior segment (RS2). Under the guidance of 3D-CTBA, anatomic RS2 segmentectomy was performed accurately and safely. The postoperative condition was uneventful. CONCLUSIONS: This rare case highlights the importance of 3D-CTBA to guild accurate segmentectomy with anatomic variation.

Three-dimensional computed tomography angiography and bronchography combined with three-dimensional printing for thoracoscopic pulmonary segmentectomy in stage IA non-small cell lung cancer.

BACKGROUND: Compared with lobectomy, the anatomical structure of the lung segment is relatively complex and easy to occur variation, thus it increases the difficulty and risk of precise segmentectomy. The application of three-dimensional computed tomography bronchography and angiography (3D-CTBA) combined with a three-dimensional printing (3D printing) model can ensure the safety of operation and simplify the surgical procedure to a certain extent. We aimed to estimate the value of 3D-CTBA and 3D printing in thoracoscopic precise pulmonary segmentectomy. METHODS: We retrospectively reviewed the clinical data of 65 patients who underwent anatomical segmentectomy at the Affiliated Hospital of Shaoxing University from January 2019 to August 2020. The patients were divided into two groups: a 3D-CTBA combined with 3D printing group (30 patients) and a general group (35 patients). The perioperative data of the two groups were compared. RESULTS: Compared with the general segmentectomy group at the same period in our center, the surgery time of the group guided by 3D-CTBA and 3D printing was significantly shorter. Intraoperative blood loss in the 3D-CTBA and 3D printing group was also apparently lower than in the general group. Hospital stay and postoperative chest tube duration showed no significant differences between the two groups, and neither did postoperative complications such as pneumonia, hemoptysis, arrhythmia, and pulmonary air leakage. CONCLUSIONS: 3D-CTBA combined with 3D printing clearly identifies the precise pulmonary segmental structures, avoids intraoperative accidental injury, reduces intraoperative blood loss, shortens the operation time and improves the safety of thoracoscopic pulmonary segmentectomy in stage IA non-small cell lung cancer (NSCLC).

Clinical application of three-dimensional technique in segmentectomy / 中国胸心血管外科临床杂志

@#More and more relevant research results show that anatomical segmentectomy has the same effect as traditional lobectomy in the surgical treatment of early-stage non-small cell lung cancer (diameter<2.0 cm). Segmentectomy is more difficult than lobotomy. Nowadays, with the promotion of personalization medicine and precision medicine, three-dimensional technique has been widely applied in the medical field. It has advantages such as preoperative simulation, intraoperative positioning, intraoperative navigation, clinical teaching and so on. It plays a key role in the discovery of local anatomical variation of pulmonary segment. This paper reviewed the clinical application of three-dimensional technique and briefly described the clinical application value of this technique in segmentectomy.

Analysis of the variation pattern in left upper division veins and establishment of simplified vein models for anatomical segmentectomy.

BACKGROUND: Three-dimensional computed tomography bronchography and angiography (3D-CTBA) is a powerful tool to analyze pulmonary anatomy. We used 3D-CTBA to analyze variations of the pulmonary veins of the left upper division (LUD) and created a simplified LUD vein model. METHODS: Between January 2019 and October 2019, 124 patients with left-sided pulmonary lesions were admitted and underwent 3D-CTBA prior to surgery. We reviewed the anatomical variations of the LUD veins in these patients using 3D-CTBA images and classified them according to their position in relation to the bronchus. To facilitate this process, the same nomenclature as that used to describe the veins of the right upper lobe (RUL) is used for the LUD. RESULTS: The pattern of LUD veins could be classified into three forms: an anterior + central form, an anterior form and a central form. For the central form, V 1+2 a, V 1+2 b, V 1+2 c and V 1+2 d drained into V. cent. For the anterior form, V 1+2 d drained into V. ant. The anterior + central form could be further classified into three subtypes (V abc, V ab and V a). CONCLUSIONS: This is the first report to categorize the pattern of veins in the LUD. This may facilitate the creation of simplified models for use in pre-operative planning for segmentectomy.

[Assessment of the Accuracy of Modified Inflation-deflation Methods for Distinguishing the Intersegmental Border].

BACKGROUND: For early-stage lung cancer, segmentectomy can get the same oncological benefits as lobectomy. Accurate identification of the intersegmental border is the key to segmentectomy. This study used extended segmentectomy and extended subsegmentectomy to treat lung intersegmental and intersubsegmental ground-glass nodules (GGN) by utilizing modified inflation-deflation methods to distinguish the intersegmental and intersubsegmental borders. The accuracy of modified inflation-deflation methods and the effectiveness of extended resection to guarantee a safe surgical margin were evaluated. METHODS: A retrospective analysis of 83 cases of extended segmentectomy and extended subsegmentectomy was conducted. Preoperative three-dimensional computed tomography bronchography and angiography (3D-CTBA) revealed that nodules were involved in intersegmental or intersubsegmental veins. Based on preoperative three-dimensional reconstruction, the surgery was designed to extendedly remove the dominant lung segment or subsegment with nodules involved. When the dominant lung segment or subsegment could not be identified, the simpler lung segment or subsegment was selected for the resection. After the target vessel and bronchus were cut off during the operation, modified inflation-deflation method was used to determine the border, and a stapler was used to resect the adjacent lung segment or subsegment tissue by 2 cm-3 cm around the inflation-deflation boundary line. Then, the relationship between the inflation-deflation boundary line and the nodule and the width of the surgical margin were measured. Clinical data were collected during the perioperative period. RESULTS: 56 extended segmentectomies and 27 extended subsegmentectomies were performed. The average diameter of pulmonary nodules was (0.9±0.3) cm. There were 79 cases with clearly inflation-deflation boundary lines. The average time needed for the appearance of the lines was (13.6±6.5) min. In 55 cases, the nodules were involved with the inflation-deflation boundary lines. Meanwhile, the remaining 24 cases revealed an average minimum distance of (0.6±0.3) cm between nodules and the boundary lines. The average width of surgical margin was (2.1±0.3) cm in these 79 cases. No deaths or major complications appeared during 30 d after operation. CONCLUSIONS: The modified inflation-deflation method can effectively define the intersegmental and intersubsegmental borders, and guarantee the safe surgical margins of extended segmentectomy and extended subsegmentectomy to treat intersegmental and intersubsegmental small lung tumors.

Assessment of the Accuracy of Modified Inflation-deflation Methods for Distinguishing the Intersegmental Border / 中国肺癌杂志

BACKGROUND@#For early-stage lung cancer, segmentectomy can get the same oncological benefits as lobectomy. Accurate identification of the intersegmental border is the key to segmentectomy. This study used extended segmentectomy and extended subsegmentectomy to treat lung intersegmental and intersubsegmental ground-glass nodules (GGN) by utilizing modified inflation-deflation methods to distinguish the intersegmental and intersubsegmental borders. The accuracy of modified inflation-deflation methods and the effectiveness of extended resection to guarantee a safe surgical margin were evaluated.@*METHODS@#A retrospective analysis of 83 cases of extended segmentectomy and extended subsegmentectomy was conducted. Preoperative three-dimensional computed tomography bronchography and angiography (3D-CTBA) revealed that nodules were involved in intersegmental or intersubsegmental veins. Based on preoperative three-dimensional reconstruction, the surgery was designed to extendedly remove the dominant lung segment or subsegment with nodules involved. When the dominant lung segment or subsegment could not be identified, the simpler lung segment or subsegment was selected for the resection. After the target vessel and bronchus were cut off during the operation, modified inflation-deflation method was used to determine the border, and a stapler was used to resect the adjacent lung segment or subsegment tissue by 2 cm-3 cm around the inflation-deflation boundary line. Then, the relationship between the inflation-deflation boundary line and the nodule and the width of the surgical margin were measured. Clinical data were collected during the perioperative period.@*RESULTS@#56 extended segmentectomies and 27 extended subsegmentectomies were performed. The average diameter of pulmonary nodules was (0.9±0.3) cm. There were 79 cases with clearly inflation-deflation boundary lines. The average time needed for the appearance of the lines was (13.6±6.5) min. In 55 cases, the nodules were involved with the inflation-deflation boundary lines. Meanwhile, the remaining 24 cases revealed an average minimum distance of (0.6±0.3) cm between nodules and the boundary lines. The average width of surgical margin was (2.1±0.3) cm in these 79 cases. No deaths or major complications appeared during 30 d after operation.@*CONCLUSIONS@#The modified inflation-deflation method can effectively define the intersegmental and intersubsegmental borders, and guarantee the safe surgical margins of extended segmentectomy and extended subsegmentectomy to treat intersegmental and intersubsegmental small lung tumors.

Thoracoscopic segmentectomy assisted by three-dimensional computed tomography bronchography and angiography for lung cancer in a patient living with situs inversus totalis: A case report.

BACKGROUND: Situs inversus totalis (SIT) is a rare congenital condition that is characterized by a complete mirror image of the typical arrangement of the thoracic and abdominal viscera. Performing thoracoscopic segmentectomy for a patient with lung cancer and SIT is an extremely skilled and challenging surgical procedure. CASE SUMMARY: A 41-year old woman with a medical history of dextrocardia since childhood was admitted to our hospital with a mixed ground-glass opacity (mGGO) in her left lung field, discovered by computed tomography during her health checkup. In order to facilitate surgical orientation, three-dimensional computed tomography bronchography and angiography (3D-CTBA) was preoperatively carried out. The result of 3D-CTBA was consistent with the diagnosis of SIT and an mGGO in the posterior segment of the left upper lobe (LS2). Surgery was conducted in accordance with preoperative 3D-CTBA and designed surgical procedure, combined with intraoperative navigation. Final pathological examination revealed in situ adenocarcinoma. The patient's postoperative condition was uneventful and no complications were observed. CONCLUSION: We present the first case of lung cancer in a patient with SIT who successfully underwent thoracoscopic segmentectomy assisted by 3D-CTBA. This is a new technique that covers precise confirmation and dissection of targeted structures and intersegmental demarcation, and can help achieve a meticulous anatomical segmentectomy.

Preoperative 3D-CT bronchography and angiography facilitates single-direction uniportal thoracoscopic anatomic lobectomy.

BACKGROUND: Competency in video-assisted thoracoscopic surgery (VATS) lobectomy is estimated to be reached after 50 cases. Preoperative identification of individualized pulmonary vascular drainage is essential for the safe and fluent performance of single-direction uniportal VATS (UVATS) anatomic lobectomy. Digital anatomy models established by three-dimensional computed tomography bronchography and angiography (3D-CTBA) is therefore utilized to accumulate variations of the right upper lobe (RUL) veins, as right upper lobectomy is considered to be the most complicated and challenging procedure. This study aims to investigate the perioperative outcomes and learning curve of single-direction UVATS RUL lobectomy assisted with 3D-CTBA. METHODS: The patients who underwent single-direction intercostal UVATS anatomic RUL lobectomy after 3D-CTBA simulation by the same surgeon at Xuzhou Central Hospital between January 2017 and April 2019 were retrospectively reviewed (3D-CTBA group), and consisted of 99 males and 54 females, with a mean age of 61.6 years, with the variations of the RUL vein being assessed preoperatively. They were further divided into group A (30 cases), B (30 cases), C (30 cases), and D (63 cases), in accordance with the order of surgery. Meanwhile, the first 35 cases of single-direction UVATS RUL lobectomy by another experienced surgeon (after the learning curve of this procedure) who did not use 3D-CTBA was enrolled as a control group. The operation time, intraoperative blood loss, stations and numbers of harvested lymph nodes, the incidence of conversion to multiport VATS or thoracotomy, thoracic tube retention for drainage, complications defined under the Clavien-Dindo system, pain score, and postoperative hospital stay were analyzed. The previous surgical experience of the two surgeons was also evaluated. RESULTS: A significant difference was evident among the 5 groups in terms of age, smoking history, the proportion of neoadjuvant chemotherapy, and T staging of the tumors (P<0.05, respectively). As for the 3D-CTBA group, a total of 29 cases (19.0%) of anomalous RUL posterior segmental pulmonary vein (PV) (V2) drainage were recorded, while the other 124 patients indicated the central type (V2a. Cent.). Of the uncommon RUL V2, they could be further classified into 4 types [V2a. Post. (5/153, 3.3%), VX2a. Ant. (17/153, 11.1%), VXX2a. Ant. (3/153, 2.0%), and nonspecific complicated (4/153, 2.6%)]. Single-direction UVATS lobectomy was performed in every patient successfully. No perioperative mortality, major bleeding, conversion to thoracotomy, the addition of incisions, or 30-day unplanned readmission was recorded. One patient in group B reported an injury of a bronchial artery. All cases had an R0 resection. The operation time of group A (109.8±25.4 min) was significantly longer than that of group B (79.7±11.1 min), C (77.0±12.1 min), D (69.3±16.0 min), and the control (86.1±17.9 min, P<0.001 respectively). Moreover, the operation time of the patients in group B, C, and D was slightly shorter than the control, although without significance (P>0.05, respectively). Furthermore, the duration of chest tube drainage in group A (3.7±2.2 days) was noticeably longer than that in group B (3.0±0.9 days), C (2.7±1.6 days), D (2.6±0.8 days), and the control (2.7±1.6 days, P=0.004 among the groups). Similarly, postoperative hospital stay in group A (3.9±2.3 days) was noticeably longer than that in group B (3.0±1.0 days), C (2.8±1.8 days), D (2.6±0.8 days), and the control (2.8±1.8 days, P=0.002 among the groups). The 5 groups indicated comparable stations and numbers of the harvested lymph nodes, intraoperative blood loss, postoperative total chest drainage volume, incidence of complications, and pain scale on the 14th day after surgery (P>0.05, respectively). CONCLUSIONS: Preoperative 3D-CTBA digital anatomy facilitates the safe and fluent performance of single-direction UVATS anatomic right upper lobectomy, with a learning curve of 30 cases. High-quality trials for better evidence are called for to verify these findings.

Technical process and quality control of precise thoracoscopic lung segmentectomy / 中国胸心血管外科临床杂志

@#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.