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J Thorac Cardiovasc Surg 2007;133:753-758
© 2007 The American Association for Thoracic Surgery
General Thoracic Surgery |
a Department of Thoracic Surgery, Hyogo Medical Center for Adults, Akashi City, Hyogo
b Department of Anesthesiology, Hyogo Medical Center for Adults, Akashi City, Hyogo
c Department of Radiology, Fukui Medical University, Yoshida, Fukui, Japan.
Received for publication August 26, 2006; revisions received October 22, 2006; accepted for publication November 2, 2006. * Address for reprints: Morihito Okada, MD, PhD, Department of Thoracic Surgery, Hyogo Medical Center for Adults, Kitaohji-cho13-70, Akashi City 673-8558, Hyogo, Japan. (Email: morihito1217jp{at}aol.com).
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Abstract |
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Methods: Under bronchofiberscopy, jet ventilation is selectively applied to the burdened bronchus to develop an anatomic plane between the inflated segment to be resected and the deflated area to be preserved. From April 2004 to June 2006, 52 consecutive patients with a clinical T1 N0 M0 peripheral cancer 2 cm or smaller underwent video-assisted segmental resection called hybrid VATS segmentectomy in which electrocautery with no stapler was used to divide the intersegmental plane detected by selective jet ventilation.
Results: Complete resection was achieved in all patients. The median operative time and bleeding during the operation were 155 minutes (range 85-225 minutes) and 60 mL (range 10-210 mL), respectively. The complication rate was 13.5% (7/52), and the most common was concerning air leak. The median duration of postoperative air leak and chest tube drainage was 1 day and 3 days, respectively. There were no in-hospital deaths. There was one case of mediastinal lymph node recurrence and another of metastasis to the brain although there was no case of local recurrence in the surgical margin area.
Conclusions: A novel video-assisted segmentectomy technique for lung cancer is clinically useful. Selective segmental inflation provides an obvious intersegmental plane quickly and easily, allowing a real margin distance in the ventilated segment. Despite the minimally invasive approach, since only the segment to be resected and not the entire lobe is expanded, an appropriate surgical view is possible.
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Introduction |
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in 1939 and had been performed since then in many patients with an infectious disease such as tuberculosis and in selected patients with non–small cell lung carcinoma (NSCLC). However, in the past few decades the frequency of this procedure has considerably decreased because of the advent of antibiotic agents for infections, the improvement of sanitary conditions, the outcome of the randomized study by the Lung Cancer Study Group,2 demonstrating that sublobar resections including wedge resections resulted in higher rate of local recurrence than did lobectomy in patients with stage IA NSCLC, and the escalating incidence of nonanatomic stapled wedge resection. Consequently, most recent residency programs of thoracic surgery do not include segmentectomy as an obligatory procedure, but several expert thoracic surgeons have advanced that segmentectomy is important as a basic surgical technique and should not be forgotten by current-generation thoracic surgeons.3-7
In concordance with the explosive increase of early detected small-sized NSCLCs through the development of radiographic tools and the widespread practice of screening,8 we have been aggressively performing radical segmentectomy with lymph node assessment not only in high-risk patients but also in good-risk patients with clinical stage IA tumors 2 cm or smaller.9-12 Lately, we have used a new method to detect the intersegmental plane in segmentectomy that involves selective jet ventilation under bronchofiberscopy. With this method the segment to be removed can be inflated while keeping the segments to be preserved without air. This technique is completely opposite to the conventional method and allows the clear visualization of the intersegmental line between the segment to be resected and the one to be preserved. We can see the real surgical margin in the inflated segment and can get a good surgical field even through video-assisted thoracic surgery (VATS) without having to make an effort to suppress the other segments and lobes with an instrument. In addition, dissection of the anatomic intersegmental plane by electrocautery but not by staple reduces local failure at the margin, one of the unfavorable recurrent patterns, and makes the preserved adjacent segments fully expansive to obtain maximum pulmonary function. In this study, we describe this novel technique through hybrid VATS approach13 in detail and evaluate its clinical utility.
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Materials and Methods |
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More recently, the main access has been opened with a wound retractor made of silicone rubber with no rib spreading. It is crucial to note that the skin incision must be extended without hesitation if the surgeon has difficulty with the surgical view. We favor a backhand grip, holding 30-cm-long scissors (model 101-8098-30; Mayo-Harrington; Stille, Sweden) for sharp dissection, lengthy needle holders, and forceps upside-down. Pleural lavage cytology is examined immediately after the introduction of a thoracoscope to check the subclinical tumor dissemination.14
Recognition of the intersegmental plane is accomplished by differential inflation with jet ventilation. After the segmental bronchi are isolated, an anesthesiologist puts a 3.5-mm bronchofiberscope through the double-lumen tube into the orifice of the targeted segmental bronchus. The tip of the bronchofiberscope is recognized at the surgical field because the surgeon can see the light of the tip and lead it to the suitable place of the targeted bronchus, in which high-frequency oscillation is started (40 Hz, working pressure 2 kg/cm2, HFO Jet Ventilator; Mera, Tokyo, Japan). The diseased segment is inflated while the preserved segments appear collapsed, and a line is formed between the inflated and the deflated lung parenchyma, evidencing the anatomic intersegmental plane.11 This technique allows the development of a defined plane without air transmission through collateral ventilation, unlike the conventional method. After jet ventilation fills the targeted segment, the distal site of the bronchus is tied to keep the segment inflated, and the proximal site to the tie is transected, leaving a stump of sufficient length so that closure will not occlude other segmental orifices. When more than one segment is to be removed, the surgeon can selectively insert the tip of the fiberscope into each segmental bronchus and inflate one segment after the other. At the central portion around the hilum, the intersegmental plane is approached along the intersegmental vein, and at the peripheral site electrocauterization is used along the inflation-deflation line. With a commercially available fibrin sealant (Bolheal; Chemo-Sero Therapeutic Institute, Kumamoto, Japan), composed of fibrinogen and thrombin and an absorbable polyglycolic acid felt (Neoveil; Japan Medical Planning Co, Kyoto, Japan), the raw surface of the remaining lung prevents air leakage after cutting by cautery. Only when the lung is emphysematous can the surgeon use staplers for dividing the intersegmental plane to keep air leak to a minimum. Since a margin greater than the tumor diameter, that is, at least 2 cm of healthy lung tissue, is required, the resection line can be placed on the segment adjacent to the affected one, or portions of a few adjacent segments or subsegments can be extirpated (Figure 1). Sampling or dissection of segmental, lobar, hilar, and mediastinal lymph nodes followed by frozen-section analysis is mandatory to decide the applicability of segmentectomy. In patients with intentional indication for radical segmentectomy, lobectomy should be performed instead when the surgical margin is judged to be imperfect or any lymph node is found to be diseased. Routinely, the chest is drained with a single chest tube under water seal, which is inserted through the incision initially established for the thoracoscope.
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Surgical–pathologic staging was performed according to the New International Staging System for Lung Cancer.16 Each patient provided his or her informed written consent based on the protocol approved by the institute’s review board before the operation. After the operation, every patient was basically evaluated at 3-month intervals for the first 2 years and at 6-month intervals thereafter. |
Results |
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Discussion |
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have resulted in an amazing increase of early detection of ever-smaller NSCLCs that possibly have a more indolent biologic behavior, such as bronchioloalveolar carcinoma. The trend has rapidly been changing clinical practice in thoracic surgery and, accordingly, many surgeons have without doubt become concerned over the unified treatment with whole lobectomy for these small peripheral cancers. Removing a relatively large volume of healthy lung tissue may result in a poorer quality of postoperative life, a higher frequency of operative morbidity, and fewer possibilities to additionally have a second or even a third NSCLC resected, for which these patients would survive long enough to be at risk. Recently, several authors have reported that sublobar resection was not inferior to lobectomy concerning the prognosis of selected patients with a small-sized NSCLC.9-12,17-20
The Lung Cancer Study Group study showed a higher occurrence of local recurrence after sublobar resection,2 and we noted that their series included a high proportion of wedge resections in the sublobar resection group (32.8%, 40/122) for tumors up to 3 cm in diameter; thus we think that the predominance of wedge resection might have influenced the frequency of local recurrence. In contrast, the percentage of wedge resections was 11.5% (30/260) in our previous report,12 which targeted tumors up to 2 cm. If the indication had been limited to tumors of 2 cm or smaller and if segmentectomy, which could improve the treated margin, had commonly been used, the frequency of local recurrence could have been lower.9-12,17,18 Additionally, we are afraid that the more frequent application of wedge resection might lead to a lower assessment of lymph nodes, leading to a potential understaging of the disease, contrary to segmentectomy, which allows the inspection of the status of regional lymph nodes. We believe that segmentectomy is anatomic resection and should be completely distinguished from nonanatomic wedge resection. Nowadays, segmental resections are hardly being performed and the procedure has become unfamiliar to many thoracic surgeons. Particularly when intentionally planning a radical sublobar resection, the surgeon must overcome the great temptation to perform an easier wedge resection. The development of stapling devices has made huge wedge resection without regard to anatomic planes an almost overwhelming alternative to segmentectomy, despite warnings that the distortion of the stapled residual lobe might lead to pleural complications such as empyema and fistula and loss of lung function. Segmentectomy also allows an optimal resection of suspicious small-sized deep-seated lesions with safe surgical margins, since adopting diagnostic lobectomy for a potential underlying malignancy must be avoided.
In general, segmentectomy is technically trickier than lobectomy, requiring deep 3-dimensional knowledge of the relevant bronchoarterial relationships and possible anomalies of arterial branches. Sharp dissection by scissors accurately and quickly exposes the segmental hilar structures. Habitually, the arterial branches are initially divided, allowing identification of the segmental bronchus, which is the most reliable landmark of a segment because of its rare anomaly. The ligation of segmental vein is best performed last, after the intersegmental plane has been outlined, as the venous drainage might not be actually apparent. Identification of the intersegmental plane, which basically exists in lobes (Figure 2), is performed by differential inflation, in which the diseased segment is selectively inflated by jet ventilation and thus demarcated, quickly producing an inflation–deflation line. It is a great advantage to accurately define the real margin distance provided in an inflated diseased segment and to limit expansion to only the selected segment, not to the entire lobe, for obtaining an appropriate surgical field in this era of VATS. Generally, the reverse procedure is used; occlusion of the segmental bronchus in an airless whole lung is followed by expansion of the lung. Collateral ventilation through Kohn’s pores will often fill the diseased segment owing to the positive air pressure used in this method, which accordingly fails to outline the inflation-deflation line. The main cause of the failure is relatively strong positive pressure, which is required to inflate the whole lung. In contrast, the pressure of jet ventilation is absolutely weak to selectively inflate only the targeted segment. During jet ventilation the surgeon can see the gradual inflation of the targeted segment, adjust the pressure of the jet ventilation under his or her direct vision, and stop the jet ventilation at the time of complete inflation before air flows into the collateral ventilation. Intriguingly, the intersegmental plane is approached along the inflation-deflation line at the peripheral site while the intersegmental vein is a landmark at the central portion around the hilum. Although sparing the intersegmental veins that delineate the perimeter of a bronchopulmonary segment and drain contiguous segments, and consequently preserving the venous drainage of adjacent segments, is a requirement of segmental resection to keep the full function of the adjacent segments, the surgeon should not hesitate to remove the intersegmental vein when the margin from the tumor is considered insufficient.
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