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Supplement: The Minimally Invasive Thoracic Surgery Summit

Thoracoscopic Segmentectomy: Technical Considerations and Outcomes

Department of Surgery, Duke University Medical Center, Durham, North Carolina

^_* Address correspondence to Dr D’Amico, Duke University Medical Center, Box 3496, Durham, NC 27710 (Email: damic001{at}mc.duke.edu).

Presented at the Minimally Invasive Thoracic Surgery Summit, New York, NY, June 8–9, 2007.

	Introduction

Top Introduction General Strategy for... Specific Thoracoscopic Segmental... Experience With Thoracoscopic... Comment References

 
Minimally invasive strategies in the management of primary and secondary pulmonary malignancies are evolving. Thoracoscopic lobectomy is defined as the anatomic resection of an entire lobe of the lung, using a videoscope and an access incision, without the use of a mechanical retractor and without rib-spreading [1–5]. The anatomic resection includes individual dissection and stapling of the involved pulmonary vein, pulmonary artery, and bronchus, as well as appropriate management of the mediastinal lymph nodes, as would be performed with thoracotomy. Thoracoscopic segmentectomy refers to minimally invasive sublobar anatomic resection of single or multiple bronchopulmonary segments [6]. Potential advantages of the minimally invasive technique include decreased postoperative pain, faster return to full activity, shorter chest tube duration, shorter length of stay, preserved pulmonary function, fewer overall postoperative complications, and improved compliance with adjuvant chemotherapy compared with lobectomy done with open thoracotomy [1–6].

Lobectomy is considered the standard of care for operable patients with completely resectable clinical stage I non-small cell lung cancer [7]. Sublobar anatomic resection, or segmentectomy, has been proposed for selected patients with marginal pulmonary function and for patients with resectable central pulmonary metastases. The potential advantage of segmentectomy compared with lobectomy is preservation of pulmonary function; the potential advantage compared with wedge resection is improved oncologic outcome [7]. Reported experience with thoracoscopic segmentectomy is limited. This review describes the techniques used for thoracoscopic segmentectomy and the clinical results with this procedure.

	General Strategy for Thoracoscopic Segmentectomy

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The standard segmentectomies performed with this technique include lingula-sparing left upper lobectomy, lingulectomy, superior segmentectomy, and basilar segmentectomy. Other individual segmental resections, such has posterior or anterior upper lobe segmentectomy, are feasible but less commonly performed.

The technique for thoracoscopic segmentectomy uses the fundamentals of thoracoscopic lobectomy previously reported [2, 3]. In brief, this technique uses only 2 incisions: a 1-cm camera port incision in the seventh or eighth intercostal space in the posterior axillary line and a 4-cm access incision in the fifth or sixth intercostal space anteriorly. This approach is suitable for any lobar or sublobar thoracoscopic resection, despite anatomic variations from patient to patient, as well as differential location of the various anatomic area of interest. The conversion rate when this technique is used for thoracoscopic lobectomy is less than 2% [1–3].

Once thoracoscopic access is established, full exploration is undertaken to exclude unresectablity, such as pleural carcinomatosis or other evidence of metastatic disease. For each anatomic sublobar resection, the segmental pulmonary vein of interest is the first hilar structure of interest. To improve access to the hilum, division of the pleura at the pleural–parenchymal reflection is performed with a linear endoscopic stapler, adding length to the hilum and exposing the vein for staple ligation. Subsequent dissection is dependent on the specific segment(s) of interest (described subsequently). Parenchymal resection is then performed with the stapling device. Identification of the segmental borders for parenchymal division may be enhanced with temporary pulmonary reinflation; however, the visible venous anatomy of the exposed segments, including the segment being removed and the adjacent segment being preserved, will also guide this process.

	Specific Thoracoscopic Segmental Resections

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Lingula-Sparing Upper Lobectomy
This segmentectomy is performed by beginning the dissection in the anterior hilum. Subsequent dissection will be facilitated by extending the pleural division cranially (as described previously) and completing the circumferential pleural division of the hilum from the superior pulmonary vein to the posterior aspect of the major fissure (working clockwise around the hilum). After the left upper lobe branches of the left superior pulmonary vein are divided, dissection of the anterior and apical arterial branches is begun. The space between these arterial branches and the upper lobe bronchus is developed, with hilar lymph node resection as needed. After the anterior and apical arterial branches are stapled, dissection of the left upper lobe bronchus is performed at the bifurcation with the lingular bronchus. The bronchus is then encircled, stapled, and divided. If present, a posterior arterial branch is then stapled as well. Parenchymal division is performed as previously described.

Lingulectomy
Thoracoscopic segmental resection of the lingula is performed in a manner similar to right middle lobectomy [2, 3]. The lung is retracted posteriorly, and the lingular vein is exposed. After the lingular vein is stapled and divided, dissection of the upper lobe bronchus is undertaken at the bifurcation of the lingular bronchus, which is stapled and divided. The major fissure is then opened, beginning anteriorly, exposing the lingular arterial branch(es), which can then be stapled and divided. Parenchymal division is performed as previously described.

Superior Segmentectomy
Although thoracoscopic superior segmentectomy may be initiated with dissection of the segmental artery in the major fissure, the preferred approach is to avoid the fissure. The segmental vein is visualized from the posterior aspect, after dividing the inferior pulmonary ligament and the posterior pleural reflection. Visualization is improved by rotating the operative table forward and retracting the lung anteriorly. After division of the superior segmental vein, the segmental bronchus is exposed and stapled. The superior segment artery is then stapled and divided, followed by the fissure and parenchyma.

Basilar Segmentectomy
The basilar segments of the inferior pulmonary vein are approached from the inferior direction, after dividing the inferior pulmonary ligament. Once the vein is ligated, the segmental artery and the segmental bronchus may be approached. The artery is approached first, through the oblique fissure, and it is stapled, with attention to preserving the superior segment artery. Finally, the segmental bronchi are stapled last, at their confluence.

	Experience With Thoracoscopic Segmentectomy

Top Introduction General Strategy for... Specific Thoracoscopic Segmental... Experience With Thoracoscopic... Comment References

 
Although the use of thoracoscopic lobectomy has increased in the past several years, there are few references to thoracoscopic segmentectomy in the literature [6, 8–10]. Houck and colleagues [10] reported the technical issues involved with the performance of lingular-sparing left upper lobectomy in a series of 11 patients. A retrospective review of prospectively collected data for 77 consecutive segmentectomy patients was recently reported [6]. In this study, preoperative, intraoperative, and postoperative variables for 48 patients undergoing thoracoscopic segmentectomy (TS) were compared with 29 patients undergoing open segmentectomy. Baseline demographics were similar between groups. Indications for pulmonary resection included 39 patients with non-small cell lung cancer (NSCLC), 30 with central pulmonary metastases, and 8 with benign diagnoses, including bronchiectasis and other infectious processes, congenital abnormalities, and bronchial adenoma.

In this series, no thoracoscopic cases required conversion to open procedures. Operative times, estimated blood loss, and chest tube duration were similar between groups. Outcomes were also similar, except that hospital length of stay was significantly shorter among thoracoscopic segmentectomy patients (6.8 ± 6 days vs 4.3 ± 3 days; p = 0.03). Thirty-day mortality was 6.9% (2 of 29) for the open segmentectomy group compared with 0% for the TS group.

	Comment

Top Introduction General Strategy for... Specific Thoracoscopic Segmental... Experience With Thoracoscopic... Comment References

 
The experience of Atkins and colleagues [6] and Houck and colleagues [10] demonstrates that thoracoscopic lobectomy is safe and feasible. Also demonstrated is an acceptable rate of postoperative complications for thoracoscopic segmentectomy, similar to the complication profile of the open segmentectomy group in this study [6] and consistent with other published data for open segmentectomy [11, 12]. This study also addresses the potential advantages of the thoracoscopic approach that are associated with the reduced hospital length of stay, which is consistent with previous studies comparing thoracoscopic lobectomy with the conventional procedure. [2, 5, 13–19]. Furthermore, demonstration of the feasibility of thoracoscopic segmentectomy reinforces the concepts that minimally invasive strategies are effective and versatile and that these approaches provide successful completion of technically difficult procedures.

Ideal conditions for thoracoscopic segmentectomy include patients with NSCLC and marginal pulmonary function, such as a patient with upper lobe–dominant emphysema and a small tumor in the lower lobe, amenable to sublobar resection. Other appropriate clinical scenarios include patients with granulomatous lung disease or central pulmonary metastases, which would be effectively managed with a sublobar anatomic resection.

The technique for thoracoscopic segmentectomy described in this report has been demonstrated to be successful [6]; however, other techniques, such as the use of alternative port incisions or the approach of all of the hilar vessels through the fissure, might also be reasonable. Similarly, the use of blunt dissection to complete the parenchymal resection is also feasible thoracoscopically, although stapled parenchymal division is favored.

It remains to be established whether thoracoscopic segmentectomy is an appropriate procedure for patients with NSCLC who would tolerate lobectomy. This concept may be addressed by a study conducted by the Cancer and Leukemia Group B (CALGB 14053), a phase III randomized trial of lobectomy vs sublobar resection (either thoracoscopic or open) for small (2 cm) NSCLC. As lung cancer screening becomes more prevalent, the identification of small tumors, including subcentimeter lesions, may lead to increased performance of segmentectomy, and the thoracoscopic approach should be considered.

	References

Top Introduction General Strategy for... Specific Thoracoscopic Segmental... Experience With Thoracoscopic... Comment References

 

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