Tips and advantages of thoracoscopic S9, 10 segmentectomy through a pulmonary ligament approach

Background:

There are increasing opportunities to perform lung segmentectomy for small lung cancers and metastatic lung tumors. Among them, for tumors present in lower lobe S9 or 10, basal segmentectomies (BS) or S9, S10 segmentectomies are usually selected. Although S9 or 10 segmentectomies are expected to preserve respiratory functions, they are more difficult than basal segmentectomies, because the segmental vessels and bronchi are deeper from interlober fissures, and it is necessary to be divided lung parenchyma deeply. In such a situation, from our institute, new surgical approach, named pulumnonary ligament approach (PLA) was reported (J Thorac Cardiovasc Surg. 2015; 149: 937 – 9). The points of this technique are as follows. (1) Because approach only from the pulmonary ligament, separation of interlober fissure is not necessary. (2) Completely opposite to interlober approach, cut or ligation of branches are in the order of segmental veins, bronchi, and arteries. (3) Easy to divide an intersegmental plane using an intersegmental septum, which is a physiological intersegmental plane in the extension of a pulmonary ligament. On the other hand, the respiratory functional advantages assumed in this technique were not examined.

Material and method:

We retrospectively reviewed of 51 patients who underwent PLA or BS between June 2006 and December 2017.

Result:

35 patients received PLA and 16 patients received BS. Postoperative respiratory function (FVC, %FVC, FEV1.0, %FEV1.0) was significantly preserved in the PLA group compared to the BA group. There was no difference between the two groups regarding local recurrences and distant metastasis.

Conclusion:

PLA showed no significant difference in perioperative and postoperative outcomes, and respiratory function was significantly preserved compared with BS. Therefore, PLA for tumors present in S9 or S10 is considered to be a reasonable option. On the other hand, during PLA operation, all segmental branches of vessels and bronchi should be identified from the bottom of lungs, so it is important to understand segmental anatomies of each patients. Therefore, preoperative 3D simulation and intraoperative 3D navigation are useful to prevent misidentification of branches.

Also, I will show the surgical tips of PLA and practice of 3D simulation on the video.