ObjectiveTo analyze the learning curve of Da Vinci robotic segmentectomy. MethodsCumulative sum analysis (CUSUM) was used to analyze the learning curve of Da Vinci robotic segmentectomy performed by the General Hospital of Northern Theater Command from February 2018 to December 2020. The learning curve was obtained by fitting, and R2 was used to judge the goodness of fitting. The clinical data of patients in different stages of learning curve were compared and analyzed. Results The first 50 patients who received Da Vinci robotic segmentectomy were included, including 24 males and 26 females, with an average age of 61.9±10.6 years. The operation time decreased gradually with the accumulation of operation patients. The goodness of fitting coefficient reached the maximum value when R2=0.907 (P<0.001), CUSUM (n) =0.009×n3−0.953×n2+24.968×n−7.033 (n was the number of patients). The fitting curve achieved vertex crossing when the number of patients reached 17. Based on this, 50 patients were divided into two stages: a learning and improving stage and a mastering stage. There were statistical differences in the operation time, intraoperative blood loss, postoperative drainage volume, number of lymph node dissection, postoperative catheter time, postoperative hospital stay, and postoperative complications between the two stages (P<0.05). ConclusionIt shows that the technical competency for assuring feasible perioperative outcomes can be achieved when the cumulative number of surgical patients reaches 17.
Lung cancer, as one of the malignant tumors with the fastest increasing morbidity and mortality in the world, has a serious impact on people's health. With the continuous advancement of medical technology, more and more medical methods are applied to lung cancer screening, which has gradually increased the detection rate of early lung cancer. At present, the standard operation for the treatment of early non-small cell lung cancer (NSCLC) is still lobectomy and mediastinal lymph node dissection. There is a growing trend to use segmentectomy for the treatment of early stage lung cancer. Anatomical segmentectomy not only removes the lesions to the maximum extent, but also preserves the lung function to the greatest extent, and its advantages are also obvious. This article reviews the progress of anatomical segmentectomy in the treatment of early NSCLC.
ObjectiveTo analyze the feasibility, advantages and disadvantages of the fluorescence method and the inflation-deflation method in defining the intersegmental plane during thoracoscopic lung segmental resection.MethodsFrom February to October 2018, 60 patients underwent thoracoscopic anatomical segmentectomy in Thoracic Surgery Department of Nanjing Chest Hospital, with 28 males and 32 females, aged from 25 to 82 years. Three-dimension computed tomography bronchography and angiography was used to reconstruct pulmonary vessels, bronchus and virtual intersegmental plane. Among them, 20 patients used the fluorescence method to define the intersegmental plane, and the other 40 patients used the traditional inflation-deflation method to define the intersegmental plane.ResultsFluorescent injection of indocyanine green (ICG) showed a clear intersegmental line with a duration sufficient to complete the label. With the fluorescence method, the intersegmental plane occurrence time was significantly shortened (10.75±3.78 s vs. 988.00±314.24 s, P<0.001) and had satisfactory repeatability. The lungs did not need to be inflated, which was convenient for the operation. And the operation time was shortened (108.75±31.28 min vs 138.00±32.47 min, P=0.002). No obvious ICG injection-related concurrency symptoms was found.ConclusionCompared with the traditional inflation-deflation method, the fluorescence method can display the intersegmental line quickly, accurately and clearly, reduce the difficulty of surgery, shorten the operation time, and provide reliable technical support for thoracoscopic anatomical segmentectomy. The fluorescence is a safe and effective method that is worthy of clinical application.
Abstract： The principles of 2010 National Comprehensive Cancer Network（NCCN） clinical practice guidelines in non-small cell lung cancer address that anatomic pulmonary resection is preferred for the majority of patients with non-small cell lung cancer and video-assisted thoracic surgery (VATS) is a reasonable and acceptable approach for patients with no anatomic or surgical contraindications. By reviewing the literatures on general treatment, pulmonary segmentectomy, pulmonary function reserve, and the anatomic issue of early stage non-small cell lung cancer surgery, the feasibility and reliability of thoracoscopic pulmonary segmentectomy are showed.
ObjectiveTo analyze the effect of indocyanine green (ICG) fluorescence dual-visualization technique on evaluating tumor margins during the thoracoscopic segmentectomy. MethodsA total of 36 patients who underwent thoracoscopic anatomical segmentectomy using ICG fluorescence dual-visualization technique in our hospital from December 2020 to June 2021 were retrospectively included. There were 15 males and 21 females aged from 20 to 69 years. The clinical data of the patients were retrospectively analyzed. ResultsThe ICG fluorescence dual-visualization technique clearly showed the position of lung nodules and the plane boundary line between segments during the operation. There was no ICG-related complication. The average operation time was 98.6±21.3 min, and the average intraoperative bleeding amount was 47.1±35.3 mL, the average postoperative drainage tube placement time was 3.3±2.8 d, the average postoperative hospital stay was 5.4±1.8 d, and the average tumor resection distance was 2.6±0.7 cm. There was no perioperative period death, and one patient suffered a persistent postoperative air leak. ConclusionThe ICG fluorescence dual-visualization technique is safe and feasible for evaluating the tumor margins during thoracoscopic segmentectomy. It simplifies the surgical procedure, shortens the operation time, ensures sufficient tumor margins, and reserves healthy pulmonary parenchyma to the utmost extent, providing reliable technical support for thoracoscopic anatomical segmentectomy.
ObjectiveTo investigate the clinical effect of 3D computed tomography bronchial bronchography and angiography (3D-CTBA) and guidance of thoracoscopic anatomic pulmonary segmentectomy by Mimics software system. MethodsA retrospective analysis was performed on patients who underwent thoracoscopic segmentectomy in the Department of Thoracic Surgery of Affiliated People's Hospital of Jiangsu University from June 2020 to December 2022. The patients who underwent preoperative 3D-CTBA using Materiaise's interactive medical image control system (Mimics) were selected as an observation group, and the patients who did not receive 3D-CTBA were selected as a control group. The relevant clinical indicators were compared between the two groups. ResultsA total of 59 patients were included, including 29 males and 30 females, aged 25-79 years. There were 37 patients in the observation group, and 22 patients in the control group. The operation time (163.0±48.7 min vs. 188.8±43.0 min, P=0.044), intraoperative blood loss [10.0 (10.0, 20.0) mL vs. 20.0 (20.0, 35.0) mL, P<0.001], and preoperative puncture localization rate (5.4% vs. 31.8%, P=0.019) in the observation group were better than those in the control group. There was no statistically significant difference in the thoracic tube placement time, thoracic fluid drainage volume, number of intraoperative closure nail bin, postoperative hospital stay, or postoperative air leakage incidence (P>0.05) between the two groups. ConclusionFor patients who need to undergo anatomical pulmonary segmentectomy, using Mimics software to produce 3D-CTBA before surgery can help accurately identify pulmonary arteriovenous anatomy, reduce surgical time and intraoperative blood loss, help to determine the location of nodules and reduce invasive localization before surgery, and alleviate patients' pain, which is worthy of clinical promotion.
Objective To evaluate the effectiveness and safety of indocyanine green fluorescence method versus modified inflation-deflation method for thoracoscopic anatomic segmentectomy. Methods CNKI, Wanfang Database, China Biomedical Literature Database, Web of Science, Cochrane Library, EMbase, PubMed, Clinicaltrials.gov, were searched from 1 January 2000 to 1 May 2023, and controlled studies between indocyanine green fluorescence and modified inflation deflation method in thoracoscopic segmentectomy were collected. Meta-analysis was performed using Stata14MP and RevMan5.4. Results A total of 10 articles, including 1 156 patients, were identified. In thoracoscopic anatomic segmentectomy, indocyanine green fluorescence method had an advantage over modified inflation deflation method. The total incidence of postoperative complications decreased (OR=0.51, 95%CI 0.36 to 0.71, P<0.0001). The incidence of air leaks decreased (OR=0.50, 95%CI 0.31 to 0.80, P=0.004), the operation time shortened (MD=−25.81, 95%CI −29.78 to −21.84, P<0.00001), the length of postoperative hospital stays shortened (MD=−0.98, 95%CI −1.57 to −0.39, P=0.001), the rate of clear displaying for intersegmental boundary line increased (OR=5.79, 95%CI 2.76 to 12.15, P<0.00001). The difference was statistically significant. Conclusion Compared with modified inflation deflation method, indocyanine green fluorescence method can quickly and clearly display the intersegmental boundary line, reduce the difficulty of surgery, shorten the operation time, reduce the length of postoperative hospital stay, and provide reliably technical support for thoracoscopic anatomic segmentectomy. It is an effective and safe method, which is worthy of extensive application.
Whether anatomical segmentectomy can replace lobectomy in the treatment of early-stage lung cancer remains controversial. A large number of studies have been conducted for decades to explore whether pulmonary segmentectomy can treat early-stage lung cancer, which is actually to explore the indications of intentional segmentectomy. With the development of scientific researches, it is found that many characteristics affect the malignancy of lung cancer, and the different grades of each characteristic affect the prognosis of patients. It is worth exploring whether different surgical approaches can be used for early-stage lung cancer with different characteristics and different grades. This article reviews the literature and studies to discuss the advances in indications of segmentectomy for early-stage lung in terms of tumor size, consolidation-to-tumor ratio, pathological classification and tumor location, respectively. The objective of this review is to help thoracic surgeons to objectively and scientifically select the surgical method according to the clinical characteristics of early-stage lung cancer.
Abstract： Objective To investigate the application of a silicone guiding tube for endoscopic linear stapling device in complete video-assisted thoracoscopic lobectomy and segmentectomy，so as to improve the safety and efficiency of manipulating the endoscopic linear stapling device. Methods We retrospectively analyzed clinical data of 178 patients with peripheral non-small cell lung caner and 26 patients with benign lung lesions who underwent surgical resection in First Affiliated Hospital of Nanjing Medical University from October 2009 to December 2011. There were 85 males and 119 females with their average age of 62±11 years. A total of 172 patients underwent complete video-assisted thoracoscopic lobectomy and 32 patients underwent segmentectomy. We designed a silicone guiding tube to facilitate the use of endoscopic linear stapling device. With the help of the tube， a1l pulmonary arteries， veins， bronchus and interlobar fissure involved were managed with endoscopic linear stapling devices. Results Three patients （1.47%）underwent conversion to thoracotomy because of dense lymph node adhesion， and all other complete video-assisted thoracoscopic surgeries were successfully performed. There was no blood vessel injury， severe postoperative complications or perioperative death. The use rate of the tube was 95.6% （303/317）， 66.9% （115/172）， 22.7% （39/172） and 78.5% （255/325） in pulmonary arteries， veins， bronchus and interlobar fissure stapling for lobectomy respectively， and 94.4% （34/36）， 77.3% （17/22）， 25.0% （8/32）， 33.1% （45/136） in pulmonary arteries， veins， bronchus and interlobar fissure stapling for segmentectomy respectively. For lobectomy， a total of 986 staples were used with an average of 5.7 staples for each patient， the average operative time was 192.5±54.0 min and average intraoperative blood loss was 118.1±104.1 ml. For segmentectomy， a total of 226 staples were used with an average of 7.1 staples for each patient， the average operative time was 193.7±37.4 min and average intraoperative blood loss was 60.9±78.0 ml. Conclusion Using a silicone guiding tube can facilitate the application of endoscopic linear stapling device， shorten the learning curve of complete video-assisted thoracoscopic lobectomy and segmentectomy， and improve the safety， convenience and economical efficiency of endoscopic linear stapling device.
Objective To verify the feasibility and accuracy of the "lung surface intersegmental constant proportion landmarks", developed by our center, in identifying intersegmental planes during pulmonary segmentectomy. MethodsWe prospectively enrolled the patients who planned to receive thoracoscopic segmentectomy in West China Hospital of Sichuan University and The Third People's Hospital of Chengdu from September 2021 to October 2021. We took a relatively objective and feasible method, intravenous injection of indocyanine green, in identifying intersegmental planes as standard control. We intraoperatively judged the consistency between "lung surface intersegmental constant proportion landmarks" and intravenous injection of indocyanine green in identifying intersegmental planes. We discerned main landmarks of intersegmental plane by the constant proportion segment module, which was built based on the "lung surface intersegmental constant proportion landmarks", as well as distinguished the planes with discrepant fluorescence by peripheral intravenous indocyanine green injection. When the distance between the landmarks determined by the "ung surface intersegmental constant proportion landmarks" and the segmental boundaries displayed by indocyanine green fluorescence staining was ≤1 cm, the landmarks were judged to be consistent with the planes with discrepant fluorescence. As long as one of the landmarks was judged to be consistent, the method was considered to be feasible and accurate. Results A total of 21 patients who underwent thoracoscopic segmentectomy were enrolled, with 5 male and 16 female patients. The median age was 55 years, ranging from 34 to 76 years. A total of 11 patients received left-side surgery, while 10 patients received right-side surgery. In the operations of 21 pulmonary segmentectomies, at least one intersegmental landmark determined by the "lung surface intersegmental constant proportion landmarks" was consistent with the intersegmental plane determined by indocyanine green fluorescence staining in each patient. ConclusionThe intersegmental landmarks determined by the "lung surface intersegmental constant proportion landmarks" are consistent with that determined by indocyanine green fluorescence staining. The method of "lung surface intersegmental constant proportion landmarks" is feasible and accurate in identifying intersegmental planes during pulmonary segmentectomy.