Lung segmentectomy assisted by highly selective independent segmental ventilation

doi:10.21203/rs.3.rs-86696/v1

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Case report

Lung segmentectomy assisted by highly selective independent segmental ventilation

https://doi.org/10.21203/rs.3.rs-86696/v1

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Journal Publication

published 15 Apr, 2021

Read the published version in Journal of Cardiothoracic Surgery →

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Background: The identification of targeted intersegmental plane and resection with adequate surgical margin is one of the crucial steps in anatomical pulmonary segmentectomy, and improvements are still needed.

Case presentation: Three cases of intersegmental plane identification using highly selective independent segmental ventilation during segmentectomy are reported. All cases required the cooperation with anaesthesiologist who is able to perform segmental ventilation and double confirmation of branch of segmental bronchus by surgeon. The surgical procedure provides a direct visualization of spare segment inflation and saving time in deflation by the conventional residual segment inflation method.

Conclusions: Highly selective independent segmental ventilation can be considered a suitable option for the pulmonary intersegmental plane identification, which could be universally used for lung segmentectomy.

Cardiac & Cardiovascular Systems

Cardiothoracic Surgery

Segmentectomy

highly selective independent segmental ventilation

VATS

intersegmental plane identification

Precise intersegmental plane identification is a crucial step in anatomical segmentectomy, which is a surgical procedure aiming at curation of small and early lung cancer and sparing of lung function. Traditional approaches include high-frequency ventilation [1], indocyanine green injection [2] and infrared thoracoscopy [3], these techniques are demanding for time of lung collapse, pharmaceutical materials and special camera. Therefore, a more simpler and efficiency way of intersegmental plane identification is required.

With the advance of anaesthesiologic technique, lung ventilation reaches a segmental level. With specialized instruments and proper intubation technique, direct inflation of target lung segment is possible. We report on three successful cases of intersegmental plane identification assisted by using highly selective independent segmental ventilation during segmentectomy. Here, we described our highly selective independent segmental ventilation method for intersegmental plane identification.

This ventilation technique was approved by the Institutional Review Board and the Ethics Committee of Nanfang Hospital, Southern Medical University.

Three patients, 52, 78, and 60 years old, respectively, were admitted because of small nodule with less than 3 cm was found in computed tomography between April 2018 and May 2018. All patients met the indication of pulmonary segmentectomy. The VATS procedures included: the lateral basal and posterior basal segments of right lower lung (S9 + 10), the apical, posterior and anterior segments of left upper lobe (S1 + 2 + 3), and the apical and posterior segment of left upper lobe (S1 + 2). All segmentectomies were done by single-direction thoracoscopic segmentectomy [4–6].

For ventilation, all the patients were excluded from tracheal and bronchial variation preoperatively. The highly selective independent segmental ventilation approach started at the time of intubation during general anaesthesia, marking a preset site. Two experienced anaesthesiologists performed the identification and visualization of the target segment. Following the management of segmental artery and vein, intersegmental plane identification is required. At the moment, the 5F Arndt pediatric endobronchial blocker (Cook Medical, Bloomington, USA) entered the preset site guiding by fiberoptic bronchoscopy (FOB) and inserted into the orifice of segmental bronchi of independent-ventilated pulmonary segment (Fig. 1a-b). After reconfirmation by the light of FOB in VATS dark vision (Fig. 1c) and the endo-stapler was clamped at the targeted segmental bronchi, 100% oxygen flowed at 3-5L/min was ventilated by anaesthesiologist (Fig. 1d-f). The independent pulmonary segments were subsequently inflated without ventilation of remaining pulmonary lobe. After the triple confirmation and marking of intersegmental plane, the endo-stapler (Endo GIA™ 60 mm Articulating Medium/Thick Reload with Tri-Staple Technology Purple Cartridge, COVIDIEN Medical, USA) is then introduced and divided the segmental bronchi and the segmental border. The lymph node dissection was then performed.

We successfully performed 3 segmentectomies with highly selective independent segmental ventilation. There is no ventilation associated complication after surgery, patients were discharged with uneventful recovery course. The technique of quick and accurate identification of the plane of the lung segment is of particularly importance in segmental resection. The conventional method of is inflation and deflation technique. The shortcoming of this method is the identification of the target bronchus highly depends on the subjective judgment of the surgeon and the waiting time for deflation is long. Other identification techniques for intersegmental plane were descriped in previous study. The technique of ultrafine fiber bronchoscopy with high-frequency bronchial ventilation (40 Hz, 2 kg / cm²) at target segment was purposed by Okada [7]. Misaki et.al. visualized intersegmental junction under infrared thoracoscopy when intravenously injection of indocyanine green (ICG; 3.0 mg / kg) is done after ligation of the target segmental artery. Oh et.al. reported a method of injection of ICG (25 mg dissolved in 50 mL of saline) at the distal peripheral bronchus after the target segment bronchus was controlled [2]. The disadvantages of this method are the use of specific special equipment or drugs.

Highly selective lung segment ventilation is an anesthesia-surgical technique that combines the proficiency of bronchoscope, ventilator and thoracoscopy under the close cooperation between the surgeon and the anesthesiologist. The trinity of segmental bronchus identification by bronchoscope, bronchoscope light source under dark vision of VATS, and inflation of remaining segment not affecting other pulmonary lobe ensures the safety of precise resection of target lung segment. Compared with traditional ventilation, our highly selective independent segmental ventilation does not ventilate the remaining pulmonary lobe, avoiding waiting time for lung collapse and not blocking the surgical field. When compared with traditional bronchoscope-guided high-frequency ventilation, our endobronchial blocker was inserted into the orifice of remaining segmental bronchus, which can effectively prevent potential damage to the endobronchial blocker, and the bronchoscope. The equipment in this technique is conventional consumables, no special video equipment or dye is required. Therefore, this technology can accurately and quickly locate the stereoborder of target lung segment, which is expected to shorten the operation time of the lung segment resection and improve efficiency of intersegmental plane identification.

To our knowledge, this is the first case series of pulmonary segmentectomy assisted by highly selective independent segmental ventilation. Because of the simplicity of this technique, we purposed that the universal use could be feasible for resection of pulmonary segments and the efficacy of this method should be estimated in a larger clinical trial.

FOB: fiberoptic bronchoscopy

ICG: indocyanine green

VATS: video-assisted thoracoscopic surgery

Ethics approval and consent to participate

This ventilation technique was approved by the Institutional Review Board and the Ethics Committee of Nanfang Hospital, Southern Medical University. Written informed consent was obtained from the patients for publication of this technical procedure.

Consent for publication

Consent for publication was obtained from presented patients.

Availability of data and materials

All images supporting the technique of this article is included within the article. We could provide surgical videos with patients’ consent.

Competing interests

We declare no competing interests.

Funding

The work was supported by the Science and Technology Planning Project of Guangdong Province (2016A020215120), and the Research Initiative Fund of Southern Hospital 2018 (C1051325). The work was partially supported by the Major Science and Technology Planning Project of Guangdong Province (2017B020226005) and the National Natural Science Foundation of China (81902319).

Authors' contributions

KC C and XS S suggested the method and drafted the manuscript. KC C, XS S, XG L, D L, Z N, H W performed the surgeries. J Y and JY C performed the anaesthesia procedures. XS S, JX Z and Z N contributed to editing and revising the manuscript. All authors read and approved the final manuscript.

Acknowledgements

Refer to the Funding section.

Okada M, Tsutani Y, Ikeda T, Misumi K, Matsumoto K, Yoshimura M, Miyata Y: Radical hybrid video-assisted thoracic segmentectomy: long-term results of minimally invasive anatomical sublobar resection for treating lung cancer. Interactive cardiovascular and thoracic surgery 2012, 14(1):5-11.
Oh S, Suzuki K, Miyasaka Y, Matsunaga T, Tsushima Y, Takamochi K: New technique for lung segmentectomy using indocyanine green injection. The Annals of thoracic surgery 2013, 95(6):2188-2190.
Misaki N, Chang SS, Gotoh M, Yamamoto Y, Satoh K, Yokomise H: A novel method for determining adjacent lung segments with infrared thoracoscopy. The Journal of thoracic and cardiovascular surgery 2009, 138(3):613-618.
Liu L, Che G, Pu Q, Ma L, Wu Y, Kan Q, Zhuge X, Shi L: A new concept of endoscopic lung cancer resection: Single-direction thoracoscopic lobectomy. Surgical oncology 2010, 19(2):e71-77.
Liu C, Guo C, Lin F, Li C, Pu Q, Ma L, Mei J, Liao H, Zhu Y, Li J et al: [Long term outcomes of patients with stage I lung cancer treated by single-direction video-assisted thoracoscopic surgery lobectomy or segmentectomy]. Zhonghua wai ke za zhi [Chinese journal of surgery] 2015, 53(10):742-746.
Cai K, Wu H, Ren P, Cai R, Xiong G, Wang H: Unidirectionally progressive resection of lower right lung cancer under video-assisted thoracoscopy. J Thorac Dis 2013, 5 Suppl 3:S310-314.
Okada M, Koike T, Higashiyama M, Yamato Y, Kodama K, Tsubota N: Radical sublobar resection for small-sized non-small cell lung cancer: a multicenter study. The Journal of thoracic and cardiovascular surgery 2006, 132(4):769-775.

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Journal Publication

published 15 Apr, 2021

Read the published version in Journal of Cardiothoracic Surgery →

Editorial decision: Major revision
08 Mar, 2021
Review #2 received at journal
14 Jan, 2021
Review #1 received at journal
11 Jan, 2021
Reviewer #2 agreed at journal
03 Jan, 2021
Reviewer #1 agreed at journal
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Reviewers invited by journal
03 Oct, 2020
First submitted to journal
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Submission checks completed at journal
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You are reading this latest preprint version

Lung segmentectomy assisted by highly selective independent segmental ventilation

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