Ten-Year Outcome and Development of Virtual-Assisted Lung Mapping in Thoracic Surgery.

Virtual-assisted lung mapping (VAL-MAP) is a preoperative bronchoscopic multispot dye-marking technique used in sublobar lung resection of barely palpable lung nodules. This review summarizes the history and outcomes of the VAL-MAP procedure. VAL-MAP was developed in 2012, and long-term outcomes of lung resection using VAL-MAP have recently been verified. Problems associated with conventional VAL-MAP include a prerequisite of post-mapping computed tomography (CT), occasional inability to see dye marks during surgery, and infrequent resection failure due to deep resection margins; various techniques have been developed to address these issues. VAL-MAP using electromagnetic navigation bronchoscopy with on-site adjustment can omit post-mapping CT. The use of indocyanine green in VAL-MAP has increased the success rate of marking detection during surgery without causing additional complications. VAL-MAP 2.0-a three-dimensional mapping technique that involves the intrabronchial placement of a microcoil-has increased the accuracy of sublobar resection, particularly for deeply located tumors. Although these promising new techniques have some limitations, they are beneficial for sublobar lung resection.

Virtual-assisted lung mapping using dual staining with indocyanine green and indigo carmine enhanced marking detectability.

Background: Virtual-assisted lung mapping (VAL-MAP) is a preoperative bronchoscopic multispot dye-marking procedure to facilitate sublobar lung resection for unidentifiable lung nodules. To increase detectable markings, we performed VAL-MAP using dual staining (VAL-MAP DS) with indocyanine green (ICG) and indigo carmine. This study was designed to evaluate the efficacy and safety of the modified technique. Methods: We retrospectively reviewed the records of patients who underwent VAL-MAP DS. Twenty patients with 27 lesions underwent 72 VAL-MAP DS markings. We investigated the overall detectable marking rate, visible marking rate, successful resection rate, and complications. Results: The overall detectable marking rate, thanks to both ICG and indigo carmine, tended to be higher than the indigo carmine visible marking rate (95.7% vs. 85.5%, P=0.08). The successful resection rate with sufficient margins was 92.0%. There were no adverse events related to the use of ICG. ICG markings of the lungs of patients with a history of smoking more than 50 pack-years tended to be visible, but the staining was too extensive compared with the staining in patients who smoked less or not at all (58.8% vs. 0.0%, P<0.001). Conclusions: VAL-MAP DS is likely be efficacious and safe in enhancing the detectability of markings. This bronchoscopic technique should be considered as one of the optimal preoperative marking methods in thoracic surgery.

Latest update about virtual-assisted lung mapping in thoracic surgery.

Virtual-assisted lung mapping (VAL-MAP) is a preoperative bronchoscopic multi-spot dye-marking technique using virtual images developed to assist in navigational lung resection. The technique of VAL-MAP has been shown to be safe and effective surgical assistive tool for performing pulmonary sublobar resections. The technique is applicable for treating multiple small pulmonary lesions that are hardly palpable including ground glass nodules (GGNs). It also may help shorten surgical duration in wedge resection cases. Electromagnetic navigation bronchoscopy (ENB) may eliminate the need for post-mapping computed tomography (CT) scans in logistically challenged situations. In the most recent, multicenter prospective single-arm study, conventional VAL-MAP had reasonable efficacy for obtaining good surgical margin in pulmonary sublobar resections, although the successful resection rate did not reach the primary goal most significantly due to deep resection margins. The technique of VAL-MAP in combination with microcoil may be the next step to acquire better surgical margins.

The AMAGAMI technique: an easy technique to achieve precise stapling in thoracoscopic segmentectomy.

The "AMAGAMI" or "incomplete grasping" technique is used to adjust the location of the lung while gently grasping the lung tissue with a stapler. Thoracoscopic segmentectomy requires precise but complex stapling, while the surgical view and the number of available instruments are limited. In the AMAGAMI technique, instead of moving the stapler to the targeted position of the lung tissue, an unlocked stapler is used to hold the lung tissue at an easily accessible position, and the lung tissue can then be slid to the ideal resection line using forceps. To use the AMAGAMI technique effectively, "standing stitches" are very helpful in enabling visualization of the ideal resection lines. Standing stitches are placed along intersegmental lines that have been determined based on the information provided by virtual-assisted lung mapping (VAL-MAP) or other marking techniques; these stiches are usually placed at the corner of the targeted segment and in-between if necessary. Monofilament suture is used for standing stitches, and about 1 cm lengths are left to enable later visualization. As these stitches stick out of the lung surface even when viewed from a tangential angle, the direction of stapling is easily visualized in thoracoscopic surgery. These techniques are particularly useful in challenging segmentectomy requiring complex staple lines, such as S10 segmentectomy, and in surgery with limited instrumental access, such as uniportal thoracoscopic surgery.

Virtual-assisted lung mapping (VAL-MAP) shortened surgical time of wedge resection.

BACKGROUND: The detection of extremely small lung tumors has increased with the development of computed tomography. Resection of such tumors by thoracoscopy is often hindered due to the unclear location of the tumor. Various methods of preoperative determination of such lesions have been attempted, but without marked success. Here we used virtual-assisted lung mapping (VAL-MAP) to perform surgical resection of small lung lesions. METHODS: We selected patients with pulmonary tumors that we anticipated to be difficult to identify during thoracoscopy and/or decide the resection line for sub-lobar lung resection. The wedge resections in the VAL-MAP group were compared to a group of patients who underwent wedge resection without VAL-MAP in 2013. RESULTS: Surgery duration was significantly shorter in the VAL-MAP group (average: 76.4 min) than in the 2013 group (average: 108.6 min; P=0.000451), although the VAL-MAP group (average major axis: 9.6 mm) had smaller tumors (P=0.000032) and more pure ground-glass opacities (GGOs) (P=0.0000919) than the 2013 group (average major axis: 16.6 mm). CONCLUSIONS: The findings of this study indicate that VAL-MAP is efficacious. In particular, VAL-MAP resulted in a shorter surgery duration and has expanded the indications of resectable lesions.

Thoracoscopic stapler-based "bidirectional" segmentectomy for posterior basal segment (S10) and its variants.

Thoracoscopic segmentectomy for the posterior basal segment (S10) and its variant (e.g., S9+10 and S10b+c combined subsegmentectomy) is one of the most challenging anatomical segmentectomies. Stapler-based segmentectomy is attractive to simplify the operation and to prevent post-operative air leakage. However, this approach makes thoracoscopic S10 segmentectomy even more tricky. The challenges are caused mostly from the following three reasons: first, similar to other basal segments, "three-dimensional" stapling is needed to fold a cuboidal segment; second, the belonging pulmonary artery is not directly facing the interlobar fissure or the hilum, making identification of target artery difficult; third, the anatomy of S10 and adjacent segments such as superior (S6) and medial basal (S7) is variable. To overcome these challenges, this article summarizes the "bidirectional approach" that allows for solid confirmation of anatomy while avoiding separation of S6 and the basal segment. To assist this approach under limited thoracoscopic view, we also show stapling techniques to fold the cuboidal segment with the aid of "standing stiches". Attention should also be paid to the anatomy of adjacent segments particularly that of S7, which tends to be congested after stapling. The use of virtual-assisted lung mapping (VAL-MAP) is also recommended to demark resection lines because it flexibly allows for complex procedures such as combined subsegmentectomy such as S10b+c, extended segmentectomy such as S10+S9b, and non-anatomically extended segmentectomy.

Bilateral segmentectomies using virtual-assisted lung mapping (VAL-MAP) for metastatic lung tumors.

BACKGROUND: Virtual-assisted lung mapping (VAL-MAP) has been used not only in wedge resection but also in segmentectomy for hardly palpable lung nodules. We herein report a case of bilateral segmentectomy using VAL-MAP with chronological change of pulmonary function test results. CASE PRESENTATION: A 50-year-old female was found to have a colorectal cancer with pulmonary nodules in both sides of the lungs considered as synchronous lung metastases. After sigmoidectomy for primary cancer and chemotherapy, treatments for small nodules in both sides of the lungs were planned. Most nodules were small and supposed to be impalpable. We performed thoracoscopic segmentectomy of right S8 with the aid of VAL-MAP and, after 2 months, combined subsegmentectomy of left S8a and 9a and wide wedge resection of left S8b with the aid of VAL-MAP. All nodules suspected of lung metastases were successfully resected with adequate margins, and the decrease in pulmonary function was minimal compared with predicted postoperative forced vital capacity (FVC) and forced expiratory volume (FEV) 1.0 calculated by the numbers of subsegments. CONCLUSIONS: Bilateral segmentectomies of small impalpable metastatic tumors were performed successfully with the aid of VAL-MAP.