Risk of Death From Other Diseases in Lung Cancer Patients After Sublobar Resection Versus Lobectomy.

BACKGROUND AND OBJECTIVES: A recent Japanese phase three clinical trial for lung cancer suggested a possible advantage of segmentectomy over lobectomy in terms of death from other diseases. This study aimed to compare the risk of death from other diseases based on surgical procedures in lung cancer patients without recurrence. METHODS: We retrospectively reviewed 2121 patients without disease recurrence after curative resection for lung cancer at our institution. Patient characteristics and overall survival were compared between sublobar resection and lobectomy. RESULTS: The sublobar group (n = 595) had a significantly higher proportion of women, non-smokers, patients without comorbidities, patients with a history of other cancers, and patients with earlier-staged disease when compared with the lobectomy group (n = 1526). The overall survival was significantly longer in the sublobar group than in the lobectomy group (p = 0.0034). After adjusting for background characteristics in an analysis of 488 patients, the overall survival had a trend to be longer in the sublobar group than in the lobectomy group (p = 0.071). CONCLUSIONS: Our results suggested that the risk of death from other diseases was potentially higher after lobectomy than after sublobar resection. Although several clinical factors could influence the results, these results may support the benefit of sublobar resection, assuming that the curability of both procedures is similar.

Open thoracotomy versus VATS versus RATS for segmentectomy: a systematic review & Bayesian network meta-analysis.

BACKGROUND: Recent trials suggest that more conservative resections such as segmentectomy are non-inferior to more radical approaches. Most segmentectomy can be safely performed using video-assisted thoracoscopic surgery (VATS). The clinical benefits of robotic-assisted thoracoscopic surgery (RATS) remain unclear. We aimed to perform a systematic review evaluating the outcome of open thoracotomy, VATS, and RATS for segmentectomy. METHODS: A systematic database search was conducted of original articles exploring the outcome of open versus VATS versus RATS segmentectomy in PubMed, EMBASE and SCOPUS. The primary outcome was 30-day mortality. Secondary outcomes were hospital readmission, air leak, and post-operative pneumonia respectively. RESULTS: 11 studies were included with a total patient sample size of 7280. There were no differences between the three approaches in terms of 30-day mortality, hospital readmission, air leak, and post-operative pneumonia. CONCLUSION: There are no significant differences between the three approaches in the clinical outcomes measured. While our analysis demonstrates the potential benefits of RATS, it is important to note that the steep learning curve associated with this technique may impact its wider adoption and efficacy in the community. Further randomised control studies are required to compare the short and long terms results of VATS and RATS approaches.

Three-Dimensional Holographic-Guided Robotic Lung Segmentectomy for Deep Pulmonary Nodules: Technique and Initial Results.

Background: Diagnosis and treatment of small and isolated lung nodules remain challenging issues. Purpose: The aim of this article is to report the technique of real-time navigation using holographic reconstruction technology combined with a robot assisted thoracic surgery (RATS) platform for lung resection in patients with small deep nodules.Research Design: The pre-surgery 3D planning was based on the chest CT scan. The reconstruction was uploaded to a head-mounted display for real-time navigation during mini invasive robot assisted surgery performed with an open console platform. We evaluated this technique with the success rate of diagnosis, the operative time and the post-operative course.Study Sample: This technique was performed in 6 patients (4 female, mean age 65 years) to date.Results: The precision of the head-mounted display based localization system was effective in all cases without the need of open conversion. The mean diameter of the nodules was 8 mm (6-9). The diagnosis was a lung cancer (n = 5) and tuberculoma (n = 1). The mean operative time was 125 min (100-145). The mean hospital stay was 2.5 days (1-3).Conclusions: In conclusion, the intraoperative navigation using the 3D holographic assistance was an helpful tool for mini invasive RATS lung segmentectomy without the need of preoperative localization.

Indocyanine green fluorescence identification of the intersegmental plane by the target segmental vein-first single-blocking during thoracoscopic segmentectomy.

BACKGROUND: Innovative attempt to explore the feasibility and accuracy of using indocyanine green fluorescence (ICGF) to identify the intersegmental plane by the target segmental veins preferential ligation during thoracoscopic segmentectomy. METHODS: A retrospective analysis was conducted on clinical data of 32 consecutive patients who underwent thoracoscopic segmentectomy with intersegmental plane identification using both ICGF and inflation-deflation method after target segmental veins prioritized blocking at Nanjing Chest Hospital from December 2022 to June 2023. Preoperative three-dimensional reconstruction was used to identify the target segment and the anatomical structure of the arteries, veins, and bronchi. After ligating the target segmental veins during surgery, the first intersegmental plane was immediately identified and marked with an electrocoagulation device using an inflation-deflation method. Subsequently, the second intersegmental plane was determined using the ICGF method. Finally, the consistency of the two intersegmental planes was evaluated. RESULTS: All the 32 patients successfully completed thoracoscopic segmentectomy without ICG-related complications and perioperative death. The average operation time was (98.59 ± 20.72) min, the average intraoperative blood loss was (45.31 ± 35.65) ml, and the average postoperative chest tube removal time was (3.5 ± 1.16) days. The average postoperative hospital stay was (4.66 ± 1.29) days, and the average tumor margin width was (26.96 ± 5.86) mm. The intersegmental plane determined by ICGF method was basically consistent with inflation-deflation method in all patients. CONCLUSION: The ICGF can safely and accurately identify the intersegmental plane by target segmental veins preferential ligation during thoracoscopic segmentectomy, which is a beneficial exploration and important supplement to the simplified thoracoscopic anatomical segmentectomy.

Complex segmentectomy for non-palpable small lung cancer adjacent to the incomplete interlobar fissure using radiofrequency identification.

Pulmonary segmentectomy for small non-palpable tumors, such as lung cancer or pulmonary metastasis, is challenging owing to possible insufficient surgical margins. Particularly, extensive segmentectomy beyond the second lobe may be required to obtain a sufficient surgical margin for a tumor adjacent to an incomplete interlobar fissure. Radiofrequency identification (RFID) marking systems have proven beneficial for detecting small lung tumors during surgery. Herein, we present two representative cases of complex segmentectomy (left-side video-assisted thoracoscopic extended S8 + S9 segmentectomy and left-side robot-assisted thoracoscopic extended S1+2 b + c segmentectomy) for small lung cancer adjacent to an incomplete interlobar fissure. Extensive segmentectomy was avoided, and preservation of lung parenchyma was feasible using an RFID system. The patients could undergo segmentectomy safely with a sufficient surgical margin. In conclusion, an RFID system facilitates secure and safe precise segmentectomy while minimizing the resected pulmonary volume.

Risk factors for locoregional relapse after segmentectomy: Supplementary analysis of the JCOG0802/WJOG4607L trial.

INTRODUCTION: The JCOG0802/WJOG4607L trial revealed superior overall survival in segmentectomy to lobectomy for small-peripheral non-small-cell lung cancer. However, locoregional relapse (LR) is a major issue for segmentectomy. An ad hoc supplementary analysis aimed to determine the risk factors for LR and the degree of advantages of segmentectomy based on primary tumor sites. METHODS: Participants in multi-institutional and intergroup, open-label, phase 3 randomized controlled trial in Japan were enrolled from August 10, 2009, to October 21, 2014. Risk factors for LR after segmentectomy and clinical features following the primary tumor site were investigated. RESULTS: Of 1105 patients, 576 and 529 underwent lobectomy and segmentectomy, respectively. The primary tumor site for segmentectomy was the left upper division, left lingular segment, left S6, left basal segment, right upper lobe, right S6, or right basal segment. Multivariable analysis in the segmentectomy group revealed that pure-solid appearance on thin-section computed tomography (odds ratio 3.230; 95% confidential interval [CI] 1.559-6.690; p = 0.0016), margin distance less than the tumor size (odds ratio 2.682; 95% CI 1.350-5.331; p = 0.0049), and male sex (odds ratio: 2.089; 95% CI: 1.047-4.169; p = 0.0366) were significantly associated with LR. Patients with left lingular segment tumors (odds ratio 4.815; 95% CI 1.580-14.672) tended to experience LR more frequently than those with left upper division tumors, although primary tumor sites were not statistically significant. CONCLUSIONS: Thin-section computed tomography findings and margin distance are important factors to avoid LR in segmentectomy.

Robotic thoracic surgery: lessons learned from the first 1,000 procedures.

Introduction: The aim of this study was to evaluate the impact of the thoracic robotic approach in a high-volume center regarding procedures and clinical outcomes after 1,000 procedures. Methods: In a single-center subset of the Epithor® database, a prospective cohort database of French thoracic surgery, we analyzed procedural characteristics and clinical outcomes from February 2014 to April 2023. A surgical technique for lung surgery was conducted with a four-arm closed chest with the port access approach and vascular sewing and knotting were preferred over stapling. Statistical analysis was performed using the Chi-2 test for discontinuous variables and the Mann-Whitney-Wilcoxon test for continuous variables. Tests were considered significant for a p-value <0.05. Results: Robotic thoracic surgery was used in anatomical lung resection in 85% of the cases. Over the study period, 1,067 patients underwent robotic surgery, of which 509 had lobectomies and 391 segmentectomies. In the segmentectomy group vs. lobectomy group we observed a shorter length of stay (9 ± 7 vs. 7 ± 5.6 days, p < 0.001), a shorter surgery time (99 ± 24 vs. 116 ± 38 min, p < 0.001) a lower conversion rate (n = 2 vs. n = 17, p = 0.004), and a lower complication rate (28% vs. 40%, p = 0.009, mainly Clavien-Dindo II, 18% and 28%, respectively). For cancer treatment surgery, we found more previous cancer in the segmentectomy group (48% vs. 26%, p < 0.001). We also observed a progressive change of lobectomy vs. segmentectomy from 80%/20% to 30%/70% over the 9 years. Discussion: A robotic platform is an appropriate tool to perform anatomical lung resection and especially to develop a safe and systematic approach to lung-sparing sub-lobar resection.

The advantages of preoperative 3D reconstruction over 2D-CT in thoracoscopic segmentectomy.

Performing a pulmonary segmentectomy is a complex process, with precise localization of pulmonary nodules and recognition of intraoperative anatomical variations posing significant challenges. This study aims to assess the advantages of preoperative three-dimensional reconstruction (3D-RE) in thoracoscopic segmentectomy. The study, at Fujian Medical University Cancer Hospital, analyzed data from segmentectomy patients from January 2016 to February 2022. It compared 3D-RE and two-dimensional computed tomography (2D-CT) preoperative scans, focusing on perioperative complications within30 days to identify any differences. This investigation encompassed a total of 265 instances, with 148 belonging to the 3D-RE group and 117 aligned with the 2D-CT group. The 3D-RE group showed reduced intraoperative blood loss and shorter postoperative hospital stays (P < 0.001). They also had higher rates of lymph node sampling and combined subsegmentectomy and segmentectomy procedures (P < 0.01). Postoperative complications, particularly pneumonia and lung fistula, were lower in the 3D-RE group (P = 0.041). The rates of minimally invasive adenocarcinoma (MIA) and invasive adenocarcinoma (IAC) were significantly higher in the 3D-RE group, while adenocarcinoma in situ (AIS) and benign cases were less common (P = 0.006). Surgical duration, chest tube duration, chest drainage volume, surgery complexity, and pathological diagnoses showed no significant differences between the groups. Utilization of preoperative 3D-RE holds potential to minimize both intraoperative and postoperative complications, thereby enhancing the safety and feasibility of undertaking segmentectomy procedures.

Mediastinal lymph node dissection in segmentectomy for peripheral c-stage IA (≤2 cm) non-small-cell lung cancer.

OBJECTIVE: Although recent trials on intentional segmentectomy have made mediastinal lymph node dissection (MLND) mandatory, the necessity of MLND in segmentectomy remains uncertain. We conducted a retrospective study to evaluate the necessity of MLND in segmentectomy for patients with peripheral stage IA (≤2 cm) non-small cell lung cancer. METHODS: Of the 5222 surgical cases for non-small cell lung cancer from 3 institutions between 2010 and 2021, 1457 patients met the JCOG0802 trial eligibility criteria. Initially, we analyzed 574 patients who underwent lobectomy with MLND to identify preoperative risk factors for cN0-pN2 occurrence (cohort 1). Subsequently, we evaluated the relationship between these factors and the cumulative postoperative recurrence in 390 patients who underwent segmentectomy (cohort 2). RESULTS: In cohort 1, risk factors for cN0-pN2 occurrence were consolidation-to-tumor ratio = 1.0 and maximum standardized uptake value ≥2.0. When classifying patients into 3 groups (group A, without any factors, group B, with either factor, and group C, with both factors), the occurrence of cN0-pN2 was significantly greater in group C than in the other groups (0.9%, 3.4%, and 8.4%, respectively, P = .005). When classifying patients in cohort 2 using the classification identified in cohort 1 (117, 131, and 142 were categorized into group A, group B, and group C, respectively), the 5-year cumulative incidence of recurrence rate was significantly greater in group C than in others (2.0%, 2.0%, and 15.9%, respectively, P < .001). CONCLUSIONS: MLND is unlikely to be beneficial in intentional segmentectomy for patients with tumors showing consolidation-to-tumor ratio <1.0 and maximum standardized uptake value <2.0.

Enhancing identification of early-stage lung adenocarcinomas through solid component analysis of three-dimensional computed tomography images.

OBJECTIVES: As the role of segmentectomy expands in managing early-stage lung adenocarcinoma, precise preoperative assessments of tumor invasiveness via computed tomography become crucial. This study aimed to evaluate the effectiveness of solid component analysis of three-dimensional (3D) computed tomography images and establish segmentectomy criteria for early-stage lung adenocarcinomas. METHODS: This retrospective study included 101 cases with adenocarcinoma diagnoses, with patients undergoing segmentectomy for clinical stage 0 or IA between 2012 and 2017. The solid component volume (3D-volume) and solid component ratio (3D-ratio) of tumors were calculated using 3D computed tomography. Additionally, based on two-dimensional (2D) computed tomography, the solid component diameter (2D-diameter) and solid component ratio (2D-ratio) were calculated. The area under the receiver-operating characteristic curve (AUC) was calculated for each method, facilitating predictions of mortality and recurrence within 5 years. The AUC of each measurement was compared with those of invasive component diameter (path-diameter) and invasive component ratio (path-ratio) obtained through pathology analysis. RESULTS: The predictive performance of 3D-volume did not differ significantly from that of path-diameter, whereas 2D-diameter exhibited less predictive accuracy (AUC: 3D-volume, 2D-diameter, and path-diameter: 0.772, 0.624, and 0.747, respectively; 3D-volume vs. path-diameter: p = 0.697; 2D-diameter vs. path-diameter: p = 0.048). Results were similar for the solid component ratio (AUC: 3D-ratio, 2D-ratio, path-ratio: 0.707, 0.534, and 0.698, respectively; 3D-ratio vs. path-ratio: p = 0.882; 2D-ratio vs. path-ratio: p = 0.038). CONCLUSION: Solid component analysis using 3D computed tomography offers advantages in prognostic prediction for early-stage lung adenocarcinomas.

Contribution of fluorescence imaging to thoracoscopic anatomical segmentectomy: a multicenter propensity matching analysis.

Background: Thoracoscopic anatomical segmentectomy is increasingly recognized for managing early-stage lung cancer. However accurately identifying intersegmental planes (ISPs), especially in complex lung segments, remains challenging. In comparison to conventional methods, fluorescence imaging represents a novel solution. This study aimed to examine the potential benefits of fluorescence imaging in single-port thoracoscopic anatomical segmentectomy. Methods: A multicenter (three regional hospitals), retrospective, comparative analysis was conducted using data from 402 consecutive patients who underwent single-port thoracoscopic anatomical segmentectomy from June 2020 to December 2022. The cohort included 191 patients treated with the fluorescence method and 211 patients treated with the modified inflation-deflation method. Among the cohort, 130 patients were placed in the simple segmentectomy group and 272 in the complex segmentectomy group. Propensity score matching (PSM) was used to adjust for baseline differences between the fluorescence and modified inflation-deflation subgroups in the complex segmentectomy group. Perioperative outcomes were compared between the groups. Results: In the simple segmentectomy group, no significant differences were observed between the fluorescence and modified inflation-deflation methods regarding segmental resection time, intraoperative blood loss, postoperative chest tube drainage and duration, postoperative pain, length of hospital stay, complication rate, or hospital costs. In the complex segmentectomy group, however, fluorescence imaging significantly shortened segmental resection time (69.37±28.22 vs. 78.80±34.66 min; P=0.03), while reducing intraoperative blood loss (P=0.046); and improving visual analogue scale (VAS) pain scores on the first postoperative day (P=0.006). Both methods demonstrated comparable safety and oncologic effectiveness. Conclusions: Fluorescence-guided single-port thoracoscopic anatomical segmentectomy demonstrated comparable perioperative safety and effectiveness to the modified inflation-deflation technique while offering advantages, such as shorter segmental resection time, for complex segmentectomies.

Conversion Therapy to Transplant or Surgical Resection in Patients with Unresectable Hepatocellular Carcinoma Treated with Boosted Dose of Yttrium-90 Radiation Segmentectomy.

BACKGROUND/OBJECTIVES: The aim of this study was to assess the efficacy of boosted dose yttrium-90 radioembolization (TARE) as a modality for conversion therapy to transplant or surgical resection in patients with unresectable hepatocellular carcinoma (HCC). METHODS: In this single-center retrospective study, all patients with a diagnosis of HCC who were treated with boosted dose TARE (>190 Gy) between January 2013 and December 2023 were reviewed. Treatment response and decrease in tumor size were assessed with the RECIST v1.1 and mRECIST criteria. Milan and University of California, San Francisco (UCSF), criteria were used to determine transplant eligibility, and Barcelona Clinic Liver Cancer (BCLC) surgical resection recommendations were used to evaluate tumor resectability. RESULTS: Thirty-eight patients with primary HCC who were treated with boosted dose TARE were retrospectively analyzed. The majority of the patients were Child-Pugh A (n = 35; 92.1%), BCLC C (n = 17; 44.7%), and ECOG performance status 0 (n = 25; 65.8%). The mean sum of the target lesions was 6.0 cm (standard deviation; SD = 4.0). The objective response rate (ORR) was 31.6% by RECIST and 84.2% by mRECIST. The disease control rate (DCR) was 94.7% by both RECIST and mRECIST. Among patients outside of Milan or UCSF, 13/25 (52.0%, Milan) and 9/19 (47.4%, UCSF) patients were successfully converted to within transplant criteria. Of patients who were initially unresectable, conversion was successful in 7/26 (26.9%) patients. CONCLUSIONS: This study provides further real-world data demonstrating that boosted-dose TARE is an effective modality for conversion of patients with unresectable HCC to transplant or resection.

Oncologic outcomes after minimally invasive segmentectomy or lobectomy in patients with hypermetabolic clinical stage IA1-2 non-small cell lung cancer.

Objective: To evaluate the oncologic outcome of patients with hypermetabolic tumors resected by segmentectomy or lobectomy. Methods: This was a retrospective analysis of all consecutive patients with peripheral clinical stage IA1-2 non-small cell lung cancer (January 2017-June 2023) who underwent resection by segmentectomy or lobectomy in a single center. A hypermetabolic tumor was defined as a tumor with a positron emission tomography (PET) maximum standardized uptake value >2.5. Propensity score case-matching analysis was used to generate 2 balanced groups of patients with hypermetabolic tumors operated by segmentectomy or lobectomy. Four-year overall survival (OS), event-free survival (EFS), and cancer-specific survival were compared between the matched groups. Results: A total of 164 segmentectomies and 234 lobectomies were analyzed. There were 91 (55%) hypermetabolic tumors in the segmentectomy group versus 178 in the lobectomy group (76%), P < .001. The comparison of the matched groups with hypermetabolic tumors showed a better 4-year OS after lobectomy compared with segmentectomy (lobectomy 87%; 95% confidence interval [CI], 76-93; segmentectomy, 67%; 95% CI, 49-80; P = .029). The 4-year EFS appeared to have a better trend after lobectomy (77%; 95% CI, 65-85) compared with segmentectomy (58%; 95% CI, 39-72), P = .088. The 4-year cancer-specific survival, however, was similar between the matched groups (lobectomy, 95%; 95% CI, 86-98 vs segmentectomy, 94%; 95% CI, 78-99, P = .79). Conclusions: Early-stage peripheral hypermetabolic tumors are associated with poorer oncologic outcomes compared with less PET-avid tumors. Despite poorer OS and EFS after segmentectomy likely caused by cancer-unrelated deaths, cancer-specific survival in this high-risk group was similar after lobectomy or segmentectomy. In well-selected patients, a high PET maximum standardized uptake value should not be considered a contraindication to segmentectomy.

Robotic anatomical resection for hepatocellular carcinoma located within segment 7 using the Glissonean approach.

Worldwide use of robotic-assisted hepatectomy has increased dramatically over the past two decades. The role of robotic liver surgery is still controversial, especially with respect to its long-term oncological outcomes in treating early-stage hepatocellular carcinoma (HCC). The Glissonean approach is a fundamental technique for anatomical resection using open and laparoscopic liver surgery. To our knowledge, there have been few reports on purely robotic anatomical segmentectomy 7 for HCC using the Glissonean approach have been described. The present study describes the technical details and surgical outcomes of totally robotic segmentectomy 7 using the Glissonean approach. Fourteen patients with HCC limited to segment 7 underwent segmentectomy 7 from January 2019 through April 2023 in our hospital. The surgical techniques, peri-operative, and oncological outcomes were analyzed. Purely robotic anatomical segmentectomy 7 using the Glissonean approach was safe and feasible with the technology described herein in all of the 14 patients. The peri-operative and oncological outcomes were better and/or comparable with those of other similar hepatic resections using open approach and/or laparoscopic approach. The median follow-up time was 18 months. Intrahepatic recurrence occurred in 2 (14.3%) patient within one year following surgery. The 3-year overall survival rate was 81%. Although technically challenging, the purely robotic segmentectomy 7 could be performed safely and simultaneously with oncological radicality using the Glissonean approach.

Combined segmentectomy: S1 + S3, right upper lobe.

A particular challenge in minimally invasive pulmonary segmentectomy arises in the presence of a lesion close to a neighbouring segment. In this case, avoiding a lobectomy while ensuring complete resection with adequate margins may require the resection of two adjacent segments in the form of a bisegmentectomy. A combined segmentectomy of the S1 and S3 segments of the right upper lobe is readily performed through an anterior multiport thoracoscopic approachis systematic and straightforward, maximizing exposure while minimizing the extent of dissection.

Routine conventional leak test is not required for robotic major pulmonary resections.

OBJECTIVE: We retrospectively evaluated whether or not conventional air leak testing is necessary in robotic major pulmonary resections. METHODS: After excluding patients who received 2 or more days of postoperative drainage for chylothorax or excessive pleural effusion, 578 patients who underwent major pulmonary resection using minimally invasive approaches between February 2019 and November 2023 at our institution were included in this study. All patients were divided into two groups including thoracoscopic (n = 471) and robotic (n = 107) approaches. Conventional air leak testing was performed in all patients in the thoracoscopic approach but not in the robotic approach. After propensity score matching of patient backgrounds between the two groups, perioperative outcomes were compared (n = 100 each). The primary endpoint was the rate of drain removal on postoperative day (POD) 2 or later. In addition, factors associated with drain removal on POD 2 or later in the robotic group were identified. RESULTS: The rate of drain removal at POD 2 or later was not significantly different between the two groups (p = 0.011). Multivariable analysis to identify factors associated with drain removal at POD2 or later in the robotic approach showed that sealant application (p = 0.002) and lobectomy (vs. segmentectomy, p = 0.034) were significantly associated. CONCLUSIONS: In conclusion, even in the absence of air leak testing, a robotic approach for major lung resections can result in a drain removal rate on the day of surgery or POD1 that is comparable to a conventional thoracoscopic approach. However, it may be useful in selected patients requiring sealant placement or undergoing lobectomy.

Optimal planning and management strategies for minimally invasive lung segmentectomies: an international Delphi consensus report.

OBJECTIVES: CALGB140503/JCOG0802 RCTs comparing lobectomy with sublobar resection in stage IA NSCLC have confirmed the non-inferiority of segmentectomy. Additional insight is needed to improve preoperative work-up and intraoperative strategies to increase safety and promote the dissemination of minimally invasive segmentectomy (MIS). A Delphi panel study assessed the level of consensus among surgeons for the planning and management of MIS. METHODS: Twenty-one expert lung surgeons represented academic institutions, major teaching hospitals, and community hospitals from Europe, North America, and Asia. A 3-round Delphi methodology was used to analyse the answers of each panellist. Recognizing that questions with fewer response options have a higher consensus probability due to limited variability, weighted consensus thresholds were modified based on the number of response options. RESULTS: The 21 panellists responded to all 3 rounds of questions. Based on the most robust consensus (94.4%), 3D chest CT reconstructions are recommended only when planning complex segmentectomies. Surgeons should perform 3D reconstructions chest CT scans (consensus = 83.3%). The most effective and safest technique is image-guided VATS in a hybrid operating room (consensus = 83.3%). Dyes with intravenous administration are the safest technique for identifying the intersegmental plane during MIS (consensus = 72.2%). Augmented/mixed reality will probably not immediately help reduce perioperative complications (consensus = 72.2%). CONCLUSIONS: This Delphi consensus supports 3D reconstructions and preoperative pulmonary nodule localization before complex MIS. These recommendations should be considered when allocating resources to improve MIS's safety and oncologic efficacy for patients with small, early-stage lung cancers.

Risks of segmentectomy for interstitial pneumonia with diffuse pulmonary ossification.

An 84-year-old man with a history of progressive interstitial pneumonia presented to our department with lung cancer (cT2aN0M0-IB) in right S6. Moreover, computed tomography revealed progressive diffuse pulmonary ossification in the bilateral lower pulmonary lobes. S6 segmentectomy was performed via video-assisted thoracoscopic surgery. It was difficult to divide the intersegmental plane using a stapler because of severe fibrosis and pulmonary ossification with bone marrow formation. Pulmonary ossification may be an important finding for surgical planning because of severe fibrosis or inflammation associated with severe lung condition. We suggest that the surgical indications and approaches for such cases should be reconsidered because pulmonary ossification can be associated with severe lung conditions.

A robotic left S6 and S1/2c segmentectomy using the lung-inverted approach.

In pulmonary segmentectomy, the dominant pulmonary arteries are traditionally divided at the fissure. However, this approach sometimes leads to inadvertent injury to the pulmonary artery and prolonged air leak when the fissure is fused. To overcome these problems, by taking advantage of the good visualization provided by robotic surgery, we have adopted the lung-inverted approach without fissure dissection for segmentectomy. We have successfully performed a robotic left S6 and S1+2c segmentectomy using the lung-inverted approach. In addition to a good postoperative course, the console time was 57 minutes, which was considered relatively short. This approach may have contributed to the short operating time because it did not require repeated rotation of the lung. A clear understanding of the anatomy was required to perform this approach properly, because each branch of the pulmonary vessels and bronchi was treated inverted at the hilum. A preoperative 3-dimensional computed tomography broncho-angiographic scan was considered useful because it allowed us to recognize the relative positions of the dominant pulmonary vessels, the bronchi and other structures that were preserved.

The application of indocyanine green fluorescence imaging to determine intersegmental plane during thoracoscopic segmentectomy: A meta-analysis and systematic review.

To investigate whether the application of intravenous indocyanine green fluorescence imaging(ICG-FI) had advantage in intersegmental plane visualization and perioperative outcome than using traditional inflation-deflation method(control group) in thoracoscopic segmentectomy. We searched PubMed, Embase, Cochrane Library, EMBASE, Wanfang Database, VIP Database, and CNKI Database to include comparative studies focusing on the comparisons of ICG-FI and control, up to December 2022. We used standard mean differences (SMD, continuous variables) or risk ratios (RR, categorical variables) with their corresponding 95 % confidence interval (CI) were used to assess pooled effects. This analysis was conducted according to the PRISMA guideline. Total, seven published studies with 905 patients (ICG-FI group n = 428, control group n = 477) were included for further analysis. The ICG-FI group was significantly associated with less bleeding during the surgery (SMD = -0.23,95 % CI: -0.08∼-0.38, P < 0.05), shorter surgery time (SMD = -0.87, 95 % CI: -1.75∼-0.17, P < 0.05) and intersegmental boundary line (IBL) presentation time (SMD = -4.50, 95 % CI: -4.97∼-4.07, P < 0.01). The ICG-FI group had shorter postoperative hospitalization time (SMD = -0.18, 95 % CI: -0.34∼-0.03), P < 0.05), and the drainage duration (SMD = -0.18, 95 % CI: -0.34∼-0.03,P < 0.05) than that in the control group. The ICG-FI group also showed the less postoperative complications (RR = 0.75, 95 % CI: 0.64-0.88). There were no significant differences in the number of lymph node resection. No significant publication bias were found in this analysis. Compared with inflation-deflation method, application of ICG-FI in thoracoscopic segmentectomy could reduce operation time, IBL presentation time, length of hospital stay, intraoperative blood loss, and overall complication incidence.