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Department of Surgery, Duke University Medical Center, Durham, North Carolina
* Address correspondence to Dr DAmico, 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 |
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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 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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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 |
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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 |
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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 |
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