Ann Thorac Surg 2007;83:1913-1914
© 2007 The Society of Thoracic Surgeons
How To Do It
Convenient and Improved Method to Distinguish the Intersegmental Plane in Pulmonary Segmentectomy Using a Butterfly Needle
Mitsuhiro Kamiyoshihara, MDa,*,
Seiichi Kakegawa, MDa,
Yasuo Morishita, MDb
a Department of General Thoracic Surgery, Maebashi Red Cross Hospital, Maebashi, Gunma, Japan
b Department of Thoracic Visceral and Organ Surgery, Gunma University School of Medicine, Maebashi, Gunma, Japan
Accepted for publication June 22, 2006.
* Address correspondence to Dr Kamiyoshihara, Department of General Thoracic Surgery, Maebashi Red Cross Hospital, 3-21-36 Asahi-Cho, Maebashi, Gunma, 371-0014 Japan (Email: m-kamiyoshihara{at}maebashi.jrc.or.jp).
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Abstract
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In the traditional method of segmentectomy, the plane between segments where removal is to occur is demarcated by inflating the normal lung, while keeping the segment to be removed airless. Our method, the opposite of convention, involves inflating only the involved segment by instilling oxygen through a butterfly needle into the bronchus subtending the segment. This saves time and therefore benefits the patient.
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Introduction
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Since Churchill and Belsey [1] reported lingula segmentectomy of the left upper lobe for the treatment of bronchiectasis, pulmonary segmentectomy has been adopted by many general thoracic surgeons to preserve lung parenchyma. Unlike the interlobar fissure, accurate recognition of the intersegmental plane is difficult, because the intersegmental fissure is rarely seen. In most methods, to distinguish the intersegmental plane the lung is ventilated. We propose a convenient and improved technique with a butterfly needle to distinguish the intersegmental plane.
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Technique
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After deflating the lung, pulmonary arterial branches and veins to the segment are defined, ligated and divided (Fig 1). The bronchus is isolated and encircled. The proximal segmental bronchus is either divided or temporarily controlled with a right-angled clamp. A 23-guage butterfly needle is inserted into the distal portion of the bronchus (Fig 2), and through an extension tube oxygen flow (1 L) is instilled, resulting in expansion of the affected segment that can now be removed using cautery or stapling (Fig 3). The raw surface may be covered with an absorbable sealing material, polyglycolic acid felt (PGAF: Neoveil (sheet type) [Igaki Medical Planning Co, Ltd, Kyoto, Japan]), to prevent air leak.
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Fig 1. Operative procedure shows the following: (A) inflated lobe, (B) deflated lobe and a butterfly needle, (C) clamping the proximal segmental bronchus, inserting a butterfly needle into the distal bronchus, inflating only the affected segment with oxygen through the butterfly needle, and (D) severing the intersegmental plane easily.
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Fig 2. The target segmental bronchus is clamped, and a 23-guage butterfly needle is inserted into the distal portion of the bronchus.
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Fig 3. Through a butterfly needle, 1 L of oxygen flow is instilled, resulting in expansion of the affected segment, which can now be removed using cautery.
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Comment
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The traditional method of distinguishing the intersegmental plane is by clamping the affected bronchus and having the anesthesiologist inflate the remaining lung. However, expansion of the normal lung may obscure the operative area, especially when limited incisions are used.
Two variations of our approach where the affected segment is kept inflated while the normal lung is deflated have been described. Tubota [2] described clamping the affected bronchus while the lung was inflated and allowing the remaining normal lung to deflate. Matsuoka and colleagues [3] described the anesthesiologist selectively inflating the affected bronchus using a bronchofiberscope positioned in the bronchus and the segment inflated using Jet-ventilation (HFO Jet Ventilator, Mera, Tokyo).
We believe our method is easier and simpler as it is under the surgeon’s control. It saves time and therefore benefits the patient. The technique has not worked in 1 patient with severe emphysematous change; here the plane was not readily identified. Potential pitfalls include anomalous bronchial anatomy and air embolism if the pulmonary artery branch is inadvertently punctured.
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References
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- Churchill ED, Belsey R. Segmental pneumonectomy in bronchiectasis, the lingula segment of the left upper lobe Ann Surg 1939;109:481-499.[Medline]
- Tubota N. An improved method for distinguishing the intersegmental plane of the lung Surg Today 2000;30:963-964.[Medline]
- Matsuoka H, Nishio W, Sakamoto T, Harada H, Yoshimura M, Tsubota N. Selective segmental jet injection to distinguish the intersegmetnal plane using jet ventilation Jpn J Thorac Cardiovasc Surg 2003;51:400-401.[Medline]
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Abstract
Introduction
