MMCTS
(June 26, 2008). doi:10.1510/mmcts.2007.003137
Copyright © 2008 European Association for Cardio-thoracic Surgery
Procedure
Totally endoscopic anatomic pulmonary segmentectomies
Dominique Gossot*,
Costin Radu,
Mohamed Sadok Boudaya and
Pierre Magdeleinat
Thoracic Department, Institute Mutualiste Montsouris, 42 Bd Jourdan, 75014 Paris, France
* Corresponding author: Tel.: +33-1-5661-6214; fax: +33-1-5661-6247. dominique.gossot{at}imm.fr
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Summary
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Although some series of video-assisted major pulmonary resections have been reported, very few series of totally endoscopic lobectomies have been published and – to our knowledge – none of totally endoscopic anatomic segmentectomies. We have recently performed five anatomic segmentectomies using this approach. The video demonstrates the main steps of the procedure, based on the recordings of three different operations: a lingulectomy, a left basilar segmentectomy and a resection of the right lower lobe superior segment.
Key Words: Segmentectomy • Thoracoscopy • VATS
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Introduction
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Anatomic segmentectomies are usually indicated for benign lesions or for metastasis when the goal is resecting the lesion while sparing parenchyma. According to some recent works, they may also outcome favorably with lobectomies for stage I non-small cell lung carcinomas (NSCLC) [1, 2]. The tendency to extend the indications of anatomic segmentectomies may match the trend to use more and more video-assisted surgery in selected patients [3, 4]. Some series of video-assisted segmentectomies have been published but – to our knowledge – totally endoscopic anatomic segmentectomies have not been reported. By totally endoscopic, we mean that no access incision is used and that the whole dissection is conducted using only endoscopic instruments and video display (Schematic 1). Based on our experience of totally endoscopic lobectomies [5], we have recently performed a totally endoscopic anatomic segmentectomy (TEAS) in five patients. The technique is described herein. We will limit the topic to the resection technique. The lymphadenectomy, which is similar to the one performed for lobectomies, will not be described.
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Schematic 1 Schematic illustration of a totally endoscopic segmentectomy. One or two additional 3-mm or 5-mm trocars may be necessary.
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Technique
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General aspects
The procedure is performed under general anesthesia with split ventilation. Patients are positioned in lateral decubitus as for a thoracotomy with the arm hanging down. Contrary to open or video-assisted procedures where the surgeon stands at the patient's back, the surgeon may move from back to front, as for some steps of the operation, the video perspective is more natural from the front. Two high definition (HD) monitors are used and the endoscope is placed on a mechanical scope holder. All procedures are performed using a deflectable scope housing a CCD at its tip (LTF, Olympus, Tokyo, Japan – MMCTSLink 163) and connected to a HD camera (HDTV) (Exera II, Olympus, Tokyo, Japan – MMCTSLink 164) providing a 1080 horizontal lines resolution.
Only endoscopic instruments are used. These are inserted through 3–5 trocars, according to the necessity of dissection or exposure. Depending on the type of inserted instruments, their diameter ranges from 3 mm (for micro-instruments) to 15 mm (for retrieval bag). The control of large vessels is done with endostaplers while the hemostasis of small caliber vessels is done with either clips or ultrasonic shears. The 3-mm instruments are used for some specific tasks or for improving exposure. No access incision is used. At completion of the pulmonary resection, the specimen is placed into an endobag and retrieved through one of the port sites that is enlarged on a 3-cm length.
Steps
1. Fissure division
Opening the fissure to approach the branches of the pulmonary artery is sometimes one of the most challenging steps of the procedure, especially if it is partly fused (Video 1).
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Video 1 Division of a partly fused fissure between the right lower lobe and upper lobe. This requires a cautious dissection to avoid any bleeding or oozing that could compromise a clear vision on vascular supply (resection of the superior segment of the right lower lobe).
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The main concern is that opening and dissecting the fissure may provoke some minor oozing that can be troublesome during a thoracoscopic operation where the operative field must remain as dry as possible to keep an optimal vision. One of the keys of a bloodless dissection is to progress step by step, from the periphery to the hilum. The thin part of the fissure is divided with ultrasonic shears (SonoSurg, Olympus, Tokyo, Japan) (Video 2) or electrothermal bipolar shears (LigaSure, Valleylab Inc., USA – MMCTSLink 166) (Video 3).
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Video 2 Division of the external part of the fissure using ultrasonic shears (SonoSurgTM, Olympus). As the fissure gets thicker, stapling is advisable (resection of the basilar segment of the left lower lobe).
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Video 3 Division of the external part of the fissure using electrothermal bipolar shears (LigasureTM, Valleylab) (lingulectomy).
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For the inner and thick part of the fissure, stapling is required. This usually requires that the inner part of the vascular elements has been at least identified or, better, isolated. Dissection is conducted from the periphery to the hilum with blunt tip scissors until the pulmonary artery is reached (Video 4). The inner part of the fissure can be stapled at this stage, or later, once the arterial supply has been controlled (Video 5). The dissection and division of the fissure can be difficult because its length can be up to 15 cm, so that a sharp vision on both of its extremities with a direct viewing telescope is almost impossible. A deflectable tip thoracoscope is of great help during this step because it allows keeping a bird's eye view on the whole fissure throughout the dissection.
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Video 4 Dissection and opening of the fissure using blunt tip scissors connected to electrocautery (lingulectomy).
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Video 5 Division of the internal part of the fissure using an endostapler (lingulectomy).
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2. Segmental arteries
The lobar artery is dissected and exposed. It can be taped. The segmental branches are dissected. They can be taped to facilitate exposure and then clipped and divided. Two to three clips are applied (Video 6).
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Video 6 Dissection and division of the segmental artery (lingulectomy). Only the inner aspect of the pulmonary artery has been exposed. Note that a mild oozing from a tear of a lymph node is temporarily packed with a resorbable gauze (SurgicelTM, Johnson & Johnson – MMCTSLink 168). The artery is dissected, taped, clipped and severed.
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3. Segmental veins
Although some surgeons do not find it necessary to isolate the roots of the pulmonary veins, since they can be divided during the stapling of the parenchyma at the end of the dissection, we prefer dissecting and isolating the segmental branches of the vein because it will help in handling the parenchyma by giving more freedom. The exposure of the inferior pulmonary vein necessitates dividing the pulmonary ligament, which is achieved using a hook connected to electrocautery (Video 7). The main vein is exposed and its branches are progressively dissected using a combination of blunt tip scissors and a 5-mm endopeanut. Small branches can be divided using ultrasonic scissors and larger branches are clipped (Videos 8 and 9, Photo 1).
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Video 7 Division of the pulmonary ligament, which is exposed using a 3-mm grasping forceps, using an electrocautery hook. This allows approaching the inferior aspect of the left inferior pulmonary vein (resection of the basilar segment of the left lower lobe).
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Video 8 Dissection of the segmental branches of the left inferior pulmonary vein (resection of the basilar segment of the left lower lobe), using blunt tip scissors, endopeanuts (to force the parenchyma back) and dissector. Small branches are divided using ultrasonic shears while larger branches are clipped.
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Video 9 Division of the lingular vein using ultrasonic scissors (lingulectomy).
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Photo 1 Close-up view of the inferior pulmonary vein after dissection and clipping of the basilar vein (resection of the basilar segment of the left lower lobe).
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4. Segmental bronchus
The lobar bronchus is visualized and the segmental division is then dissected and exposed (Video 10). This step may require caution and patience because of peribronchial lymph nodes that can be accidentally torn, leading to troublesome oozing. If necessary, the segmental bronchus is occluded with a clamp to check reventilation before stapling (Photo 2 and Video 11). Because the pass between the bronchus and the parenchyma is narrow, loading the bronchus in the stapler jaws is difficult (Video 12). A guide is necessary to drive the stapler jaws without excessive friction and force. We use a small diameter silicone suction tube whose base is connected to the stapler tip [6] (Video 13).
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Video 10 Dissection of the lobar bronchus and of its intersegmental division (lingulectomy).
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Photo 2 5-mm endoscopic clamp for clamping the bronchus and/or the parenchyma (resection of the superior segment of the right lower lobe).
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Video 11 The segmental bronchus is occluded using a 5-mm clamp to test reventilation of the parenchyma (lingulectomy).
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Video 12 This sequence demonstrates that the endostapler tip is too bulky and cannot be passed smoothly behind the segmental bronchus. A guide must be used (lingulectomy).
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Video 13 Use of silicone tube to guide the endostapler jaw behind the segmental bronchus, which is then stapled (lingulectomy).
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5. Intersegmental plane
Once the segmental bronchus has been stapled, the lung is gently reventilated using low pressure and small volumes and the parenchyma of the intersegmental plane is clamped using a 5-mm clamp (Storz, Tuttlingen, Germany) (Video 14). Identification of the intersegmental plane may require multiple and tedious maneuvers for inflation and deflation of the parenchyma. Once determined, landmarks are made on the intersegmental plane using electrocautery (Video 15, Photo 3) and the endostapler is then applied (Video 16).
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Video 14 Reventilation. The segmental bronchus has been stapled and the lung is reventilated to find out the correct intersegmental plane (lingulectomy). A 5-mm clamp is applied to compress the parenchyma.
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Video 15 Once the intersegmental plane has been determined, landmarks are made using diathermy dots (resection of the superior segment of the right lower lobe).
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Photo 3 After temporary clamping of the segmental bronchus, the lung is reventilated. Dots are marked on the intersegmental line using electrocautery (resection of the superior segment of the right lower lobe).
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Video 16 Division of the intersegmental plane using a 60-mm endostapler with 4.8 mm staples (lingulectomy).
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6. Specimen extraction
The specimen is placed into an endobag and extracted through the most anterior port that is enlarged to a 3-cm length, which is sufficient for the retrieval of a pulmonary segment (Video 17). The cosmetic result at one month can be seen on Photo 4.
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Video 17 The specimen is placed into an endobag. The most anterior port is enlarged to allow for extraction (lingulectomy).
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Photo 4 Cosmetic result at one month after a TEAS for carcinoid tumor in an overweight female patient. Small white arrows=ports. Large white arrow=port and chest tube. Large black arrow=port and specimen extraction.
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7. Drainage
A single chest tube is placed through one of the ports and connected to water-seal. The lung is reinflated under saline to check the absence of air leak (Video 18). Its removal is decided according to the usual rules, i.e. no air leakage and output inferior to 150 cc per day.
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Video 18 A single chest tube is placed after extraction of the specimen (resection of the basilar segment of the left lower lobe).
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Results
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Out of the 80 totally endoscopic major pulmonary resections performed in our unit, five were segmentectomies. Patient characteristics, type of segmentectomy and results are summarized in Table 1. The average duration of operation, calculated skin-to-skin, as entered in the operating room database was 172 min (range: 92–240). The average intraoperative blood loss was 62 ml (range: 0–200). There was no postoperative complication.
Chest tube duration ranged from 2 to 5 days (mean: 3). Postoperative hospital stay ranged from 3 to 5 days (mean: 4). No late clinical or radiological complication was noticed. Final pathological diagnoses are reported in Table 1. For the two patients who underwent a resection of the superior segment of the right lower lobe for NSCLC and a lingulectomy for a carcinoid tumor, the number of resected lymph nodes was respectively 14 and 18.
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Discussion
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The larger series of video-assisted segmentectomies comprises 68 patients, and has recently been reported by Schuchert et al. for the treatment of stage I NSCLC [2]. Their technique includes a 4-cm access incision with ‘avoidance of a rib-spreader’ and no detail is given on the type of instrumentation and video imaging. In the series of Okada et al. [7], the median length of the utility incision is 65 mm (range: 40–120). As described by the authors, this is a hybrid technique using mainly conventional instrumentation and direct vision through the utility incision. Atkins et al. have reported a series of 48 thoracoscopic segmentectomies, mainly for NSCLC [1]. Although there are few technical details in the paper, one assumes that the technique is actually video-assisted since there is only one access incision and a 1-cm incision, most likely for the scope. In addition, their reported blood loss is 280±200 ml, which is not compatible with a pure endoscopic technique that requires a dry operative field. A case-report dealing with an anatomic lingulectomy for invasive aspergillosis was reported by Whitson but the technique is not detailed.
It seems that a totally endoscopic technique has only been done for lobectomies using dedicated endoscopic instrumentation and a 100% monitor display [5, 8, 9]. Shigemura et al. have shown that this technique takes significantly longer than a video-assisted approach but the blood loss is significantly less and the results compare favorably with open and VATS techniques, in terms of resected lymph nodes and survival [8].
In this preliminary experience, we have not found TEAS to be more difficult than lobectomies, except for the division of the intersegmental plane. This step may require multiple reventilation of the lung that hampers the vision and is time-consuming. The recently described technique using jet ventilation selectively directed to the burdened bronchus under bronchofiberscopy seems appealing [7].
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Footnotes
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 Disclosures of potential conflicts of interest: All items mentioned in this article were purchased by our institution on the basis of the market. The deflectable endoscope was provided free of charge by Olympus for evaluation. No funding was given and the authors have no financial support from this company. 
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References
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- Atkins BZ, Harpole DH Jr, Mangum JH, Toloza EM, D'Amico TA, Burfeind WR Jr. Pulmonary segmentectomy by thoracotomy or thoracoscopy: reduced hospital length of stay with a minimally-invasive approach. Ann Thorac Surg 2007;84:1107–1113.[Abstract/Free Full Text]
- Schuchert MJ, Pettiford BL, Keeley S, D'Amato TA, Kilic A, Close J, Pennathur A, Santos R, Fernando HC, Landreneau JR, Luketich JD, Landreneau RJ. Anatomic segmentectomy in the treatment of stage I non-small cell lung cancer. Ann Thorac Surg 2007;84:926–933.[Abstract/Free Full Text]
- McKenna RJ Jr, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1100 cases. Ann Thorac Surg 2006;81:421–426.[Abstract/Free Full Text]
- Onaitis MW, Petersen RP, Balderson SS, Toloza E, Burfeind WR, Harpole DH Jr, D'Amico TA. Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients. Ann Surg 2006;244:420–425.[CrossRef][Medline]
- Gossot D, Stern JB, Girard P, Caliandro R, Raynaud C, Debrosse D, Magdeleinat P. Full thoracoscopic lobectomies and segmentectomies for benign and metastatic condition. Rev Mal Resp 2008;51:50–58.
- Ito N, Suda T, Inoue T, Yasui S, Suzuki Y, Taniguchi Y, Ishiguro K, Ohgi S. Use of a soft silicone tube guide for an automatic suture device in video-assisted lung lobectomy. J Thorac Cardiovasc Surg 2005;130:931–932.[Free Full Text]
- Okada M, Mimura T, Ikegaki J, Katoh H, Itoh H, Tsubota N. A novel video-assisted anatomic segmentectomy technique: selective segmental inflation via bronchofiberoptic jet followed by cautery cutting. J Thorac Cardiovasc Surg 2007;133:753–758.[Abstract/Free Full Text]
- Shigemura N, Akashi A, Nakagiri T, Ohta M, Matsuda H. Complete versus assisted thoracoscopic approach: a prospective randomized trial comparing a variety of video-assisted thoracoscopic lobectomy techniques. Surg Endosc 2004;18:1492–1497.[CrossRef][Medline]
- Shiraishi T, Shirakusa T, Miyoshi T, Hiratsuka M, Yamamoto S, Iwasaki A. A completely thoracoscopic lobectomy/segmentectomy for primary lung cancer – technique, feasability and advantages. Thorac Cardiovasc Surg 2006;54:202–207.[CrossRef][Medline]
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Summary
Introduction
