Uniportal VATS Anatomic Right Basal Segmentectomy (S7-10)

Anatomic sublobar resections have been used primarily for benign pulmonary lesions, lung metastases, and early stage lung cancer. There are many recent studies that support the oncological results of anatomic sublobar resections compared to lobectomy in terms of recurrence and overall survival [1-8]. In addition, the procedure’s performance through minimally invasive procedures is possible by experienced teams [9, 10]. The authors present a sublobar resection performed for a 50-year-old woman who was diagnosed with a 2.5 cm diffuse ground glass opacity adenocarcinoma in the right basal segments (Figure 1) that was identified during chronic asthma follow-up.Preoperative studies ruled out nodal or distant involvement. A lung function test presented significant limitation, with an estimated postoperative DLCO near 30% after right lower lobectomy. Given the tumor characteristics, the absence of lymph node involvement, and the functional limitation, the authors decided to perform an anatomic segmentectomy of the basal segments (S7 + S8 + S9 + S10) through a uniportal video-assisted thoracoscopic (VATS) approach.The authors began the procedure by making a 3.5 cm incision in the sixth intercostal space. A lymphadenectomy was performed in stations 12, 11, 10, 9, 8, 7, and 4R for intraoperative analysis. After confirmation of no nodal involvement, the major fissure was dissected, identifying the pulmonary artery and its branches to the basal segments and for segment 6 (S6). The common arterial branch for the basal segments was dissected and then divided using an endostapler. The inferior pulmonary vein was dissected, progressing distally until the vein of S6 was identified and the authors clearly found the division with the basal venous trunk. Then, the authors divided the basal venous trunk using an endostapler. The posterior fissure was completed with a stapler, identifying the venous branch for S6 from anterior and posterior in order to ensure its preservation.The inferior lobar bronchus was dissected to the distal sublobar divisions, and the bronchus for the basal segments (B7-10) was dissected and divided with an endostapler after adequate ventilation of S6 was assured. Before this step, the authors also performed bronchoscopic evaluation of distal bronchial divisions. No intraoperative or postoperative complications were recorded. The chest tube was removed, and the patient was discharged home on postoperative day two. The final diagnosis was lepidic adenocarcinoma without nodal involvement (T2bN0M0).ConclusionThe performance of anatomic segmentectomies through minimally invasive approaches as uniportal VATS is safe and feasible.ReferencesTraibi A, Grigoroiu M, Boulitrop C, et al. Predictive factors for complications in anatomical pulmonary segmentectomies. Interact Cardiovasc Thorac Surg. 2013;17(5):838-844.Martin-Ucar AE, Nakas A, Pilling JE, West KJ, Waller DA. A case-matched study of anatomical segmentectomy versus lobectomy for stage I lung cancer in high-risk patients. Eur J Cardiothorac Surg. 2005;27(4):675-679.Date H, Andou A, Shimizu N. The value of limited resection for “clinical” stage I peripheral non-small cell lung cancer in poor-risk patients: comparison of limited resection and lobectomy by a computer-assisted matched study. Tumori. 1994;80(6):422-426.Okada M, Yoshikawa K, Hatta T, Tsubota N. Is segmentectomy with lymph node assessment an alternative to lobectomy for non-small cell lung cancer of 2 cm or smaller? Ann Thorac Surg. 2001;71(3):956-961.Watanabe T, Okada A, Imakiire T, Koike T, Hirono T. Intentional limited resection for small peripheral lung cancer based on intraoperative pathologic exploration. Jpn J Thorac Cardiovasc Surg. 2005;53(1):29-35.Campione A, Ligabue T, Luzzi L, et al. Comparison between segmentectomy and larger resection of stage IA non-small cell lung carcinoma. J Cardiovasc Surg (Torino). 2004;45(1):67-70.Keenan RJ, Landreneau RJ, Maley RH, et al. Segmental resection spares pulmonary function in patients with stage I lung cancer. Ann Thorac Surg. 2004;78(1):228-233.Dziedzic R, Zurek W, Marjanski T, et al. Stage I non-small-cell lung cancer: long-term results of lobectomy versus sublobar resection from the Polish National Lung Cancer Registry. Eur J Cardiothorac Surg. 2017;52(2):363-369.Galvez C, Lirio F, Sesma J, Baschwitz B, Bolufer S. Single-incision video-assisted thoracoscopic surgery left-lower lobe anterior segmentectomy (S8). J Vis Surg. 2017;3:114.Gonzalez Rivas, Lirio F, Sesma J. Uniportal anatomic combined unusual segmentectomies. J Vis Surg. 2017;3:91.解剖性亚肺叶切除术（anatomic sublobar resection）最初主要应用于良性肺部病变、肺转移瘤及早期肺癌的治疗。近年来多项研究证实，相较于肺叶切除术（lobectomy），解剖性亚肺叶切除术在肿瘤复发率与总生存期层面的肿瘤学疗效相当[1-8]。此外，经验丰富的手术团队可通过微创路径完成该术式[9,10]。 本文报告1例50岁女性患者的亚肺叶切除术病例：该患者因慢性哮喘随访期间，于右肺基底段发现直径2.5cm的弥漫性磨玻璃密度腺癌（图1）而就诊。术前检查已排除淋巴结及远处转移。肺功能检查提示显著通气受限，预估行右下肺叶切除术后的一氧化碳弥散量（DLCO）仅为正常值的30%左右。结合肿瘤特征、无淋巴结受累及肺功能受限情况，术者决定采用单孔胸腔镜辅助手术（video-assisted thoracoscopic surgery, VATS）路径，为患者实施基底段（S7+S8+S9+S10）解剖性肺段切除术。 术者首先于第6肋间做3.5cm切口作为手术入路。术中对12、11、10、9、8、7及4R组淋巴结进行清扫（lymphadenectomy）并送检术中冰冻病理分析。确认无淋巴结转移后，术者解剖并游离肺主裂，显露肺动脉及其基底段分支与第6段（S6）动脉分支。游离基底段总动脉干后，使用内镜缝合器（endostapler）予以离断。随后解剖下肺静脉，向远端分离直至识别出S6静脉，明确其与基底静脉干的分界后，使用内镜缝合器离断基底静脉干。使用缝合器完成后裂游离，同时辨认S6静脉的前后分支以确保其得以完整保留。将下叶支气管向远端亚肺叶分支处游离，在确认S6通气良好后，解剖并离断基底段支气管（B7-10），使用内镜缝合器完成切断。在此步骤前，术者还通过支气管镜对远端支气管分支进行了评估。 术中及术后均未出现并发症。术后第2日拔除胸腔引流管，患者顺利出院。最终病理诊断为鳞屑样腺癌，无淋巴结受累（T2bN0M0）。 结论：通过单孔VATS等微创路径实施解剖性肺段切除术安全且可行。 参考文献： [1] Traibi A, Grigoroiu M, Boulitrop C, et al. 解剖性肺段切除术并发症的预测因素. 交互式心血管与胸外科杂志. 2013;17(5):838-844. [2] Martin-Ucar AE, Nakas A, Pilling JE, West KJ, Waller DA. 高危患者Ⅰ期肺癌解剖性肺段切除术与肺叶切除术的病例匹配研究. 欧洲心胸外科杂志. 2005;27(4):675-679. [3] Date H, Andou A, Shimizu N. 高危患者“临床”Ⅰ期外周非小细胞肺癌有限切除术的价值：计算机匹配研究对比有限切除术与肺叶切除术. 肿瘤学杂志. 1994;80(6):422-426. [4] Okada M, Yoshikawa K, Hatta T, Tsubota N. 直径≤2cm非小细胞肺癌的淋巴结评估肺段切除术是否可替代肺叶切除术？. 胸外科年鉴. 2001;71(3):956-961. [5] Watanabe T, Okada A, Imakiire T, Koike T, Hirono T. 基于术中病理探查的小外周肺癌意向性有限切除术. 日本胸心血管外科杂志. 2005;53(1):29-35. [6] Campione A, Ligabue T, Luzzi L, et al. 肺段切除术与更大范围切除术治疗ⅠA期非小细胞肺癌的对比. 心血管外科杂志（都灵）. 2004;45(1):67-70. [7] Keenan RJ, Landreneau RJ, Maley RH, et al. 肺段切除术可保留Ⅰ期肺癌患者的肺功能. 胸外科年鉴. 2004;78(1):228-233. [8] Dziedzic R, Zurek W, Marjanski T, et al. Ⅰ期非小细胞肺癌：波兰国家肺癌登记处肺叶切除术与亚肺叶切除术的长期结果. 欧洲心胸外科杂志. 2017;52(2):363-369. [9] Galvez C, Lirio F, Sesma J, Baschwitz B, Bolufer S. 单切口胸腔镜辅助左肺下叶前段切除术（S8）. 可视化外科杂志. 2017;3:114. [10] Gonzalez Rivas, Lirio F, Sesma J. 单孔解剖性联合异常肺段切除术. 可视化外科杂志. 2017;3:91.