Thoracoscopic Lung Segmentectomy Based On Three-dimensional Computed Tomography Simulation For Undetectable Tumors
Hirohisa Kato, Hiroyuki Oizumi, Jun Suzuki, Akira Hamada, Kenta Nakahasi, Takayuki Sasage, Mitsuaki Sadahiro.
Yamagata University,Faculty of Medicine, Yamagata, Japan.
Objective: Recently, the number of surgeries for intraoperative undetectable tumors has increased; however, whether these tumors can be precisely resected in thoracoscopic segmentectomy is unknown. We investigated whether three-dimensional (3-D) computed tomography (CT) simulation can be used successfully during thoracoscopic segmentectomies. Methods: Between March 2005 and November 2017, 133 patients (60 men and 73 women; mean age: 66.3±10.6 years; mean tumor size: 1.4±0.5 cm) underwent thoracoscopic anatomic segmentectomy without tumor markings for nonpalpable and visually undetectable tumors. The patients were diagnosed as having lung cancer (n=110), metastatic lung tumors (n=14), or benign tumors (n=9). Multidetector CT images were recorded with 1-mm data slices. Workstations and a client viewer were used preoperatively and during surgery. Pleurography and arteriovenous reconstruction were performed using a 3-D surface- and volume-rendering method (Figure). On the basis of the CT reconstruction, the segment containing the tumor was first identified as a targeted segment on the CT image in the horizontal, coronal, and sagittal planes. Subsequently, the tumor and pulmonary vessels of the targeted segment were recognized on the 3-D image. The design of resection with sufficient surgical margins was planned concerning intersegmental veins etc. When simple segmentectomy alone would yield insuficient surgical margins, segmentectomy combined with adjacent subsegmentectomy was planned. Intersegmental planes were identified by referring to the 3-D CT simulation and the inflation-deflation line created with the selective bronchial closure after lung inflation. Results: In all the cases, surgeons processed the 3-D image reconstruction within 5 min and identified the tumor on the 3-D image. Eighty-five, 34, and 14 patients underwent segmentectomy, subsegmentectomy, and segmentectomy combined with adjacent subsegmentectomy, respectively. The overall surgical time (median [range]) was 186 min (71-425 min); bleeding volume, 51 mL (0-882 mL); drainage duration; 1 day (1-13 days); and length of postoperative hospital stay, 6 days (3-21 days). Complications occurred in 13 patients (9.8%), but none were severe. The ratio of accurate resection was 98.5%. No recurrences occurred during the mean follow-up period of 58.3 months (range, 1-145 months). Conclusions: 3-D CT simulation and the inflation-deflation line can aid in the resection of undetectable tumors during thoracoscopic lung segmentectomy.
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