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One hundred and fifty-six cases of anatomical pulmonary segmentectomy by uniportal video-assisted thoracic surgery: a 2-year learning experience

One hundred and fifty-six cases of anatomical pulmonary segmentectomy by uniportal video-assisted... Abstract OBJECTIVES Our goal was to explore the outcome of the study and the feasibility for patients of the technique of anatomical pulmonary segmentectomy by uniportal video-assisted thoracic surgery (VATS). METHODS A total of 156 consecutive patients with lung lesions who received anatomical pulmonary segmentectomy by VATS between 2015 and 2016 in our hospital were enrolled. All the subjects had high-resolution, thin-section chest computed tomography (CT) examinations with 3-dimensional reconstruction, a pulmonary function test, abdominal ultrasonography, electrocardiogram and cardiac ultrasonography. The lung lesion was localized before the operation using CT reconstruction or a hookwire to plan the operative method. RESULTS Uniportal VATS pulmonary segmentectomy was successfully completed in 151 (96.8%) patients. Most cases involved the right apical and apical posterior segments and the left trisegment. Only 1 patient had a right middle interior segmentectomy, left upper apical anterior segmentectomy or a right lower posteriolateral segmentectomy, respectively. There were 26 cases of benign lesions (including 17 cases of atypical hyperplasia) and 130 cases of non-small-cell lung cancer. Operation time (146 ± 56 vs 113 ± 32 min), blood loss (63 ± 17 vs 54 ± 13 ml) and complication rates (13.5% vs 5.8%) were obviously lower in 2016 compared with 2015 (P < 0.01). In contrast, the preoperative hookwire localization rate was markedly higher in 2016 compared with 2015. CONCLUSIONS Uniportal VATS anatomical pulmonary segmentectomy is safe and feasible in clinical applications. Compared with the 2- or 3-port method, there were some technical difficulties in the early phase of the learning curve for uniportal VATS that were overcome through a period of practice. Anatomical pulmonary segmentectomy , Uniportal video-assisted thoracic surgery , Lung cancer INTRODUCTION The use of uniportal video-assisted thoracic surgery (VATS) has continued to expand to involve almost all lung cancer resections since the Spanish scholar Gonzalez [1] first performed it in a pulmonary lobectomy in 2011. Compared to traditional multiport VATS, a single incision is enough for uniportal VATS, which minimizes injury to the chest intercostal nerve and has the obvious advantage of reducing postoperative pain [2]. Scholars in Japan and other countries found no significant difference in the efficacy of pulmonary segmentectomy compared to that of pulmonary lobectomy for Stage Ia peripheral lung cancer with a diameter <2 cm, giving rise to the use of pulmonary segmentectomy with VATS [3, 4]. At present, the multiport surgical method (2-, 3- or 4-port method) is mainly used worldwide in the treatment of early stage lung cancer through VATS pulmonary segmentectomy. A limited number of hospitals and doctors perform uniportal VATS pulmonary segmentectomy [5, 6]. The authors changed from the 3-port method to the 2-port method in VATS pulmonary segmentectomy in 2013. Then, in March 2015, we began to perform uniportal VATS pulmonary lobectomy and segmentectomy. This study explored the learning curve and feasibility of the technique by comparing the 52 cases of pulmonary segmentectomy performed in 2015 with the 104 cases performed in 2016. MATERIALS AND METHODS Patients A total of 156 consecutive patients undergoing VATS anatomical segmentectomy at Shanghai Pulmonary Hospital from March 2015 to December 2016 were retrospectively enrolled. All of them had a uniportal segmentectomy initially. Data from eligible patients were obtained from electronic medical records and office clinical records. All the subjects had a high-resolution, thin-section chest computed tomography (CT) examination with 3-dimensional reconstruction, pulmonary function test, abdominal ultrasonography, electrocardiogram and cardiac ultrasonography. The patients who were suspected of having lung cancer were further tested by brain magnetic resonance imaging and emission CT or positron emission tomography-CT to exclude distant metastases. The lung lesion was localized before the operation by CT reconstruction or a hookwire to design the operative method. This study was approved by the ethics committee of Shanghai Pulmonary Hospital. Indication criteria Uniportal VATS pulmonary segmentectomy was used for the following types of cases: (i) benign lung diseases in which wedge resection could be performed and which had ground glass opacities; (ii) T1N0M0 peripheral lung cancer with tumour diameter ≤2 cm; (iii) patients with peripheral lung cancer whose lung function could not tolerate the lobectomy; (iv) ground glass opacities lesions that could not guarantee that the margin would be more than 2 cm by wedge resection; (v) multiple nodules and bilateral surgery. Operative technique The patient was placed on his or her side with double-lumen endotracheal intubation and combined intravenous-inhalation anaesthesia. The incision was made at the 4th intercostal space of the anterior axillary line for the upper lobe segmentectomy and at the 5th intercostal space of the anterior axillary line for the lower lobe segmentectomy. The incision was about 2.5 to 4 cm in length, and a large incision protector was used routinely. All the instruments, including a thoracoscopic camera, entered the thoracic cavity through this single incision. The surgery was performed by the same surgeon and an assistant. The surgeon stood at the ventral side of the patient, and the assistant was at the dorsal position. A 5-mm or 10-mm thoracoscopic (HOPLIN II Forward Oblique Telescope 30°, Karl Storz, Tuttlingen, Germany) camera was usually placed at the posterior part of the incision. It was sometimes put at the anterior part, especially during separation of thoracic adhesions or a 7th group lymphadenectomy. The surgical instruments for pulmonary segmentectomy were the same as those used in uniportal VATS pulmonary lobectomy. The instruments were longer than 30 cm, double-jointed and curved, which permitted 3 or 4 instruments to pass through the single incision together without interference. Usually, sponge forceps, an aspirator and electrocautery (or an ultrasound scalpel) were used. It was rare to place 4 or more instruments together. Some of the instruments were self-invented by staff at Shanghai Pulmonary Hospital. Because there is still a lack of fixed steps for segmentectomy, different methods were adopted according to the different segments and the completeness of the lung fissure. The arteries and veins of the targeted lung segment were cut off by endostaplers (Endo GIA 30-mm Articulating Vascular Reload, Covidien, Dublin, Ireland), ligation, a titanium clip (WECK Hem-o-lok, Telelex, Morrisville, NC, USA) or an ultrasonic scalpel according to the diameter of the vessel. Next, the targeted bronchus was dissociated and cut off using the endoscopic stapler and an olecranon stapler when necessary. Then the lung was dilated by low pressure ventilation of the side of the operation to identify the segment boundary. When the boundary was unclear, it was judged according to the venous trend. Finally, the boundary was cut off by the Endo GIA. The veins could be used to help locate the boundary when it was not obvious after ventilation. For patients with primary lung cancer, the lymph node beside the bronchus was routinely tested by rapid pathological examination during the operation. The patients with local lymph node metastasis received the pulmonary lobectomy. The patients diagnosed as having invasive lung cancer were treated by systemic mediastinal lymphadenectomy. The patients diagnosed as having a minimally invasive adenocarcinoma (MIA) or an adenocarcinoma in situ (AIS) received mediastinal lymph nodal sampling. The mediastinal lymph node was removed by an ultrasonic scalpel combined with an aspirator. After the operation, a #28 chest tube was placed through the incision and a deep venipuncture tube was placed at the posterior costophrenic angle for drainage. All the operations were performed by the same surgeon (L.D.). Statistical analyses All data analyses were performed on SPSS 17.0 software (IBM Corp, Chicago, IL, USA). The measurement data are presented as mean ± standard deviation. The Student t-test was adopted to compare the distributions of continuous variables and the Fisher’s exact test was used to compare the frequencies of categorical measures between patient groups who were operated on in 2015 and 2016. Relationships between operation time and number of surgical experiences were assessed using a Spearman’s rank correlation test. Two-tailed values of P-value <0.05 were considered statistically significant. RESULTS The patients’ demographic information is summarized in Table 1. There were 49 men and 107 women with an average age of 53.4 ± 12.7 (16–82) years. Uniportal VATS pulmonary segmentectomy was successfully completed in 151 (96.8%) patients. Three patients received pulmonary segmentectomy combined with auxiliary incision due to thoracic adhesions. One patient was designated to have a left upper apical segmentectomy but received a left upper lobe wedge resection after cutting off the apical segmental artery due to the calcification of the lymph node beside the apical bronchus. One patient was scheduled to have a left upper lobe anterior segmentectomy but received a left upper trisegmentectomy due to an accidental cut of the posterior segmental vein. One patient was designated to have resection of the left dorsal segment but received a left lower lobectomy due to a nodule that was not discovered after segmentectomy. Table 1: Patient characteristics Characteristics Segmentectomy (n = 156) Age (years) 53.4 ± 12.7 (16–82) Gender, n (%)  Male 49 (31.4)  Female 107 (68.6) Smoking status 37 (23.7) Comorbidities (%), n (%)  COPD 48 (30.8)  Hypertension 61 (39.1)  Diabetes mellitus 67 (42.9)  Coronary artery disease 21 (13.5)  Cerebrovascular disease 13 (8.33)  Chronic renal failure 4 (2.56)  Prior cancer history 26 (4.33)  Arrhythmia 14 (8.97) Pulmonary function  FEV1 (%) 73.6 ± 31.4 (38–142)  VC 82.7 ± 28.5 (44–146) Tumour size (cm) 1.2 ± 0.4 (0.7–2.5) Reason for segmentectomy  Compromised 3  Intentional 153 Characteristics Segmentectomy (n = 156) Age (years) 53.4 ± 12.7 (16–82) Gender, n (%)  Male 49 (31.4)  Female 107 (68.6) Smoking status 37 (23.7) Comorbidities (%), n (%)  COPD 48 (30.8)  Hypertension 61 (39.1)  Diabetes mellitus 67 (42.9)  Coronary artery disease 21 (13.5)  Cerebrovascular disease 13 (8.33)  Chronic renal failure 4 (2.56)  Prior cancer history 26 (4.33)  Arrhythmia 14 (8.97) Pulmonary function  FEV1 (%) 73.6 ± 31.4 (38–142)  VC 82.7 ± 28.5 (44–146) Tumour size (cm) 1.2 ± 0.4 (0.7–2.5) Reason for segmentectomy  Compromised 3  Intentional 153 COPD: chronic obstructive pulmonary disease; FEV1: forced expiratory volume in 1 s; VC: vital capacity. Table 1: Patient characteristics Characteristics Segmentectomy (n = 156) Age (years) 53.4 ± 12.7 (16–82) Gender, n (%)  Male 49 (31.4)  Female 107 (68.6) Smoking status 37 (23.7) Comorbidities (%), n (%)  COPD 48 (30.8)  Hypertension 61 (39.1)  Diabetes mellitus 67 (42.9)  Coronary artery disease 21 (13.5)  Cerebrovascular disease 13 (8.33)  Chronic renal failure 4 (2.56)  Prior cancer history 26 (4.33)  Arrhythmia 14 (8.97) Pulmonary function  FEV1 (%) 73.6 ± 31.4 (38–142)  VC 82.7 ± 28.5 (44–146) Tumour size (cm) 1.2 ± 0.4 (0.7–2.5) Reason for segmentectomy  Compromised 3  Intentional 153 Characteristics Segmentectomy (n = 156) Age (years) 53.4 ± 12.7 (16–82) Gender, n (%)  Male 49 (31.4)  Female 107 (68.6) Smoking status 37 (23.7) Comorbidities (%), n (%)  COPD 48 (30.8)  Hypertension 61 (39.1)  Diabetes mellitus 67 (42.9)  Coronary artery disease 21 (13.5)  Cerebrovascular disease 13 (8.33)  Chronic renal failure 4 (2.56)  Prior cancer history 26 (4.33)  Arrhythmia 14 (8.97) Pulmonary function  FEV1 (%) 73.6 ± 31.4 (38–142)  VC 82.7 ± 28.5 (44–146) Tumour size (cm) 1.2 ± 0.4 (0.7–2.5) Reason for segmentectomy  Compromised 3  Intentional 153 COPD: chronic obstructive pulmonary disease; FEV1: forced expiratory volume in 1 s; VC: vital capacity. The types of resected lung segments are shown in Table 2. Almost all lung segmentectomies were performed using uniportal VATS. Most cases were right apical and apical posterior segments and left trisegments. Only 1 patient each received a right middle interior segmentectomy, a left upper apical anterior segmentectomy or a right lower posteriolateral segmentectomy, respectively. No left lower posterolateral or right middle lateral segmentectomy was performed. Table 2: Surgical segment distribution Total Right side  S1 26  S1 + S2 14  S2 16  S3 6  S1 + S3 3  S5 1  S6 13  S8 4  S7 + S8 + S9 + S10 3  S9 + S10 1  S1 + S2 + S6 1 Left side  S1 + S2 + S3 26  S4 + S5 8  S1 5  S3 5  S2 3  S1 + S3 1  S1 + S2 7  S6 5  S7 + S8 + S9 + S10 1  S7 + S8 3  S2 + S6 1  S3 + S4 + S5 1  S2 + S4 + S5 2 Total Right side  S1 26  S1 + S2 14  S2 16  S3 6  S1 + S3 3  S5 1  S6 13  S8 4  S7 + S8 + S9 + S10 3  S9 + S10 1  S1 + S2 + S6 1 Left side  S1 + S2 + S3 26  S4 + S5 8  S1 5  S3 5  S2 3  S1 + S3 1  S1 + S2 7  S6 5  S7 + S8 + S9 + S10 1  S7 + S8 3  S2 + S6 1  S3 + S4 + S5 1  S2 + S4 + S5 2 Table 2: Surgical segment distribution Total Right side  S1 26  S1 + S2 14  S2 16  S3 6  S1 + S3 3  S5 1  S6 13  S8 4  S7 + S8 + S9 + S10 3  S9 + S10 1  S1 + S2 + S6 1 Left side  S1 + S2 + S3 26  S4 + S5 8  S1 5  S3 5  S2 3  S1 + S3 1  S1 + S2 7  S6 5  S7 + S8 + S9 + S10 1  S7 + S8 3  S2 + S6 1  S3 + S4 + S5 1  S2 + S4 + S5 2 Total Right side  S1 26  S1 + S2 14  S2 16  S3 6  S1 + S3 3  S5 1  S6 13  S8 4  S7 + S8 + S9 + S10 3  S9 + S10 1  S1 + S2 + S6 1 Left side  S1 + S2 + S3 26  S4 + S5 8  S1 5  S3 5  S2 3  S1 + S3 1  S1 + S2 7  S6 5  S7 + S8 + S9 + S10 1  S7 + S8 3  S2 + S6 1  S3 + S4 + S5 1  S2 + S4 + S5 2 The perioperative data are listed in Table 3. The average operation time was 123 ± 45 (40–240) min, and the average bleeding volume was 60 ± 14 (10–300) ml. A total of 26.9% subjects had preoperative hookwire localization, and the postoperative length of stay was 4.2 ± 1.6 (2–14) days. No intraoperative vessel injury or anatomical variants caused significant changes in the surgical plan, like transit thoracotomy or multiport VATS. No death occurred during the perioperative period. Postoperative complications occurred in 13 (8.3%) cases (Table 4), including postoperative haemoptysis in 5 cases, pulmonary infection in 3 cases, postoperative leakage extension in 2 cases and others in 3 cases, respectively. All complications were cured after symptomatic and aetiological treatment. The venipuncture tube and the chest tube were removed simultaneously after the operation. One patient had postoperative subcutaneous emphysema after a right upper apical segmentectomy due to poor placement of the chest tube. He was cured after replacement of the chest drainage tube through the 2nd intercostal space on the midclavicular line. One patient had a postoperative haemorrhage because a staple ruptured and was reoperated on by suturing the lung using a Prolene thread. Table 3: Perioperative outcomes after segmentectomy Variables Current series Han et al. (n = 30) Schuchert et al. (n = 785) Okada et al. (n = 52) Preoperative localization, n (%) 42 (26.9) 14 (66.7) NR NR Operative time (min) 123 ± 45 (40–240) 159 ± 56 (30–236) 134 (30–367) 155 (85–225) Estimated blood loss (ml) 60 ± 14 (10–300) NR 100 (25–750) 60 (10–210) Complications, n (%) 13 (8.3) 4 (13.3) 274 (34.9) 7 (13.5) Deaths 0 1 (3.3) 1.1 0 Conversion to open surgery, n (%) 3 (1.9) 30 (6.4) NR Conversion to lobectomy, n (%) 1 (0.6) 1 (3.3) 4 (0.5) NR Drain indwelling time (days) 4.6 ± 1.6 3 (2–13) Hospitalization after operation (days) 4.2 ± 1.6 (2–14) NR 6 (2–52) NR Variables Current series Han et al. (n = 30) Schuchert et al. (n = 785) Okada et al. (n = 52) Preoperative localization, n (%) 42 (26.9) 14 (66.7) NR NR Operative time (min) 123 ± 45 (40–240) 159 ± 56 (30–236) 134 (30–367) 155 (85–225) Estimated blood loss (ml) 60 ± 14 (10–300) NR 100 (25–750) 60 (10–210) Complications, n (%) 13 (8.3) 4 (13.3) 274 (34.9) 7 (13.5) Deaths 0 1 (3.3) 1.1 0 Conversion to open surgery, n (%) 3 (1.9) 30 (6.4) NR Conversion to lobectomy, n (%) 1 (0.6) 1 (3.3) 4 (0.5) NR Drain indwelling time (days) 4.6 ± 1.6 3 (2–13) Hospitalization after operation (days) 4.2 ± 1.6 (2–14) NR 6 (2–52) NR NR: not reported. Table 3: Perioperative outcomes after segmentectomy Variables Current series Han et al. (n = 30) Schuchert et al. (n = 785) Okada et al. (n = 52) Preoperative localization, n (%) 42 (26.9) 14 (66.7) NR NR Operative time (min) 123 ± 45 (40–240) 159 ± 56 (30–236) 134 (30–367) 155 (85–225) Estimated blood loss (ml) 60 ± 14 (10–300) NR 100 (25–750) 60 (10–210) Complications, n (%) 13 (8.3) 4 (13.3) 274 (34.9) 7 (13.5) Deaths 0 1 (3.3) 1.1 0 Conversion to open surgery, n (%) 3 (1.9) 30 (6.4) NR Conversion to lobectomy, n (%) 1 (0.6) 1 (3.3) 4 (0.5) NR Drain indwelling time (days) 4.6 ± 1.6 3 (2–13) Hospitalization after operation (days) 4.2 ± 1.6 (2–14) NR 6 (2–52) NR Variables Current series Han et al. (n = 30) Schuchert et al. (n = 785) Okada et al. (n = 52) Preoperative localization, n (%) 42 (26.9) 14 (66.7) NR NR Operative time (min) 123 ± 45 (40–240) 159 ± 56 (30–236) 134 (30–367) 155 (85–225) Estimated blood loss (ml) 60 ± 14 (10–300) NR 100 (25–750) 60 (10–210) Complications, n (%) 13 (8.3) 4 (13.3) 274 (34.9) 7 (13.5) Deaths 0 1 (3.3) 1.1 0 Conversion to open surgery, n (%) 3 (1.9) 30 (6.4) NR Conversion to lobectomy, n (%) 1 (0.6) 1 (3.3) 4 (0.5) NR Drain indwelling time (days) 4.6 ± 1.6 3 (2–13) Hospitalization after operation (days) 4.2 ± 1.6 (2–14) NR 6 (2–52) NR NR: not reported. Table 4: Postoperative complications Complications 13 (8.3%) Haemoptysis 5 Pneumonia 3 Prolonged air leak (>5 days) 2 Subcutaneous emphysema 1 Atrial fibrillation 1 Bleeding after surgery 1 Complications 13 (8.3%) Haemoptysis 5 Pneumonia 3 Prolonged air leak (>5 days) 2 Subcutaneous emphysema 1 Atrial fibrillation 1 Bleeding after surgery 1 Table 4: Postoperative complications Complications 13 (8.3%) Haemoptysis 5 Pneumonia 3 Prolonged air leak (>5 days) 2 Subcutaneous emphysema 1 Atrial fibrillation 1 Bleeding after surgery 1 Complications 13 (8.3%) Haemoptysis 5 Pneumonia 3 Prolonged air leak (>5 days) 2 Subcutaneous emphysema 1 Atrial fibrillation 1 Bleeding after surgery 1 Statistical analyses of data collected between 2015 and 2016 showed that the operation time, hookwire localization rate, blood loss and complication rate were significantly different. Operation time, blood loss and complication rate were obviously lower in 2016 compared with 2015. In contrast, the preoperative hookwire localization rate was markedly higher in 2016 compared with 2015 (Table 5). There was a significant correlation between the operation time and the cumulative sum of the number of VATS segmentectomies performed by the surgeon (r = −0.593, P < 0.001, Fig. 1). All the hookwires were placed at the location within 2 cm from the lesion. The use of hookwires reduced the necessity of a bi- or trisegmentectomy to achieve an adequate margin. Table 5: Comparisons between uniportal thoracoscopic segmentectomies performed in 2015 and 2016 2015 (52) 2016 (104) P-value Tumour size (cm) 1.1 ± 0.7 (0.7–2.5) 1.2 ± 0.5 (0.7–2.5) 0.31 Preoperative hookwire localization, n (%) 6 (11.5) 36 (34.6) 0.002 Double segmentectomy, n (%) 7 (13.4) 17 (16.3) 0.82 Operative time (min), mean ± SD 146 ± 56 113 ± 32 <0.001 Blood loss (ml), mean ± SD 63 ± 17 54 ± 13 <0.001 Conversion to open surgery 1 2 1.0 Hospitalization after operation (days), mean ± SD 4.1 ± 1.7 4.2 ± 1.8 0.74 Complications (%) 7 (13.5) 6 (5.8) 0.013 2015 (52) 2016 (104) P-value Tumour size (cm) 1.1 ± 0.7 (0.7–2.5) 1.2 ± 0.5 (0.7–2.5) 0.31 Preoperative hookwire localization, n (%) 6 (11.5) 36 (34.6) 0.002 Double segmentectomy, n (%) 7 (13.4) 17 (16.3) 0.82 Operative time (min), mean ± SD 146 ± 56 113 ± 32 <0.001 Blood loss (ml), mean ± SD 63 ± 17 54 ± 13 <0.001 Conversion to open surgery 1 2 1.0 Hospitalization after operation (days), mean ± SD 4.1 ± 1.7 4.2 ± 1.8 0.74 Complications (%) 7 (13.5) 6 (5.8) 0.013 SD: standard deviation. Table 5: Comparisons between uniportal thoracoscopic segmentectomies performed in 2015 and 2016 2015 (52) 2016 (104) P-value Tumour size (cm) 1.1 ± 0.7 (0.7–2.5) 1.2 ± 0.5 (0.7–2.5) 0.31 Preoperative hookwire localization, n (%) 6 (11.5) 36 (34.6) 0.002 Double segmentectomy, n (%) 7 (13.4) 17 (16.3) 0.82 Operative time (min), mean ± SD 146 ± 56 113 ± 32 <0.001 Blood loss (ml), mean ± SD 63 ± 17 54 ± 13 <0.001 Conversion to open surgery 1 2 1.0 Hospitalization after operation (days), mean ± SD 4.1 ± 1.7 4.2 ± 1.8 0.74 Complications (%) 7 (13.5) 6 (5.8) 0.013 2015 (52) 2016 (104) P-value Tumour size (cm) 1.1 ± 0.7 (0.7–2.5) 1.2 ± 0.5 (0.7–2.5) 0.31 Preoperative hookwire localization, n (%) 6 (11.5) 36 (34.6) 0.002 Double segmentectomy, n (%) 7 (13.4) 17 (16.3) 0.82 Operative time (min), mean ± SD 146 ± 56 113 ± 32 <0.001 Blood loss (ml), mean ± SD 63 ± 17 54 ± 13 <0.001 Conversion to open surgery 1 2 1.0 Hospitalization after operation (days), mean ± SD 4.1 ± 1.7 4.2 ± 1.8 0.74 Complications (%) 7 (13.5) 6 (5.8) 0.013 SD: standard deviation. Figure 1: View largeDownload slide Assessment of correlation between the number of operations performed and the operating times. Figure 1: View largeDownload slide Assessment of correlation between the number of operations performed and the operating times. The postoperative pathological results are shown in Table 6. There were 26 cases of benign lesions (including 17 cases of atypical hyperplasia) and 130 cases of non-small-cell lung cancer (including 100 cases of AIS and MIA and 30 cases of invasive adenocarcinoma, mucinous adenocarcinoma and carcinoid). For histological staging, 27 cases were Stage Ia whereas 3 cases were Stage Ib. The 3 patients who had Stage Ib received a left upper trisegmentectomy because of the second-phase lobectomy on the right side. Two patients, limited by age and poor pulmonary function, received a lingular segmentectomy or a left lower dorsal segmentectomy. Table 6: Pathological diagnosis Total Benign disease 26  Atypical adenomatous hyperplasia 15 Inflammatory consolidation 5 Hamartoma 3  Tuberculosis 2  Pulmonary cryptococcosis 1 Malignant disease 130  Adenocarcinoma in situ 61  Microinvasive adenocarcinoma 39  Infiltrating adenocarcinoma 27 Mucinous adenocarcinoma 2 Carcinoid 1 Stage  Ia 27  Ib 3 Total Benign disease 26  Atypical adenomatous hyperplasia 15 Inflammatory consolidation 5 Hamartoma 3  Tuberculosis 2  Pulmonary cryptococcosis 1 Malignant disease 130  Adenocarcinoma in situ 61  Microinvasive adenocarcinoma 39  Infiltrating adenocarcinoma 27 Mucinous adenocarcinoma 2 Carcinoid 1 Stage  Ia 27  Ib 3 Table 6: Pathological diagnosis Total Benign disease 26  Atypical adenomatous hyperplasia 15 Inflammatory consolidation 5 Hamartoma 3  Tuberculosis 2  Pulmonary cryptococcosis 1 Malignant disease 130  Adenocarcinoma in situ 61  Microinvasive adenocarcinoma 39  Infiltrating adenocarcinoma 27 Mucinous adenocarcinoma 2 Carcinoid 1 Stage  Ia 27  Ib 3 Total Benign disease 26  Atypical adenomatous hyperplasia 15 Inflammatory consolidation 5 Hamartoma 3  Tuberculosis 2  Pulmonary cryptococcosis 1 Malignant disease 130  Adenocarcinoma in situ 61  Microinvasive adenocarcinoma 39  Infiltrating adenocarcinoma 27 Mucinous adenocarcinoma 2 Carcinoid 1 Stage  Ia 27  Ib 3 A total of 72 patients diagnosed as AIS or MIA received mediastinal lymph nodal sampling with a mean lymph node number of 6 ± 2. All 30 cases of invasive adenocarcinoma, mucinous adenocarcinoma and carcinoid had a systematic mediastinal lymphadenectomy. All of the resected lymph nodes were negative, which was confirmed by pathological examination. DISCUSSION Kirby and Rice [7] first reported VATS for pulmonary lobectomy in 1993. Since then, VATS has been widely adopted in the treatment of lung diseases. Its safety, minimal invasiveness and therapeutic effectiveness have been fully proved in clinical situations. Also in 1993, Roviaro et al. [8] reported pulmonary segmentectomy by VATS for the first time. The prospective randomized controlled study of peripheral T1N0M0 non-small-cell lung cancer performed by the US Lung Cancer Study Group in 1995 showed a higher local recurrence rate and a worse long-term survival rate with sublobectomy compared to lobectomy. Thus, pulmonary lobectomy has been regarded as the standard surgical procedure for lung cancer. Pulmonary segmentectomy was used only in compromise surgical situations in which the pulmonary lobectomy was restricted by the lung function [9]. The VATS pulmonary segmentectomy has become one of the most minimally invasive procedures for early lung cancer. Compared to pulmonary lobectomy, pulmonary segmentectomy can retain more lung function [10]. Compared with wedge resection, it can ensure adequate distance of the lesion from the margin, thereby reducing tumour recurrence and improving long-term survival [11]. As with the VATS pulmonary lobectomy, the VATS pulmonary segmentectomy also has progressed from 4, 3 and 2-port to uniport. In addition to fewer injuries to the intercostal nerves and reduced postoperative pain [2], the largest advantage of the uniport operation is that it provides the same angle of view as a thoracotomy [12]. Because a segmentectomy involves more local operative activity, the uniport operation has the obvious advantage of displaying the superior mediastinum and the local area. In contrast, the biggest difficulty with uniportal VATS is the change of the angle and the path during the process of cutting off the vessels, the bronchus and the lung segments. Moreover, having all the instruments pass through a single incision increases the difficulty of the procedure [13]. However, these issues can be overcome by the selection of the incision position, sufficient dissection and the application of a rotating or a wisdom stapler (Johnson & Johnson, New Brunswick, NJ, USA). Where the incision is made is of great significance for uniportal VATS pulmonary segmentectomy. In past years, we usually selected the 4th intercostal space on the anterior axillary line, which provides the best exposure and dissection. However, it provides a poor angle for treating the segmental bronchus and intersegmental fissure with the stapler, especially bilateral anterior segmentectomies. Thus, we more recently selected the 4th intercostal space on the anterior axillary line only for bilateral apical segmentectomies. For the other segmental resections, we made the incision at the 5th intercostal space on the anterior axillary line because it simplified the treatment of the segmental bronchus and intersegmental fissure. In addition, interlobar fissure is necessary to achieve dissection in the resection of some segments. In our opinion, the interlobar fissure should be opened for the lower lobe segments, lingular segment, posterior segment and right upper anterior segment. The ‘tunnel method’ should be adopted for patients with interlobar fissure aplasia. In this study, almost all the pulmonary segmentectomies were performed using uniportal VATS. In our opinion, the uniport method is better than the 2-port or 3-port method when treating the right apical segment, left trisegment and bilateral dorsal segment, especially in exposing the anterior apical segmental artery and apical bronchus. Furthermore, it provides a better visual angle to reveal the relationship between the stapler and the intersegmental fissure. In a 3- or 2-port operation, some surgeons place the camera near the main operating hole for better exposure when dissecting the right upper artery or the anterior apical branch of the left lung artery. Various methods can be adopted in the localization of nodules during pulmonary segmentectomy. The preoperative localization ratio can be as high as 66.7% in Han’s et al. [6] uniportal VATS. In this study, the preoperative localization rate was 26.9%, which was performed with a CT-guided hookwire. The preoperative localization ratio in 2016 (34.6%) was higher than that in 2015 (11.5%), which may be due to the fact that we mainly performed lobectomies in 2015 in patients with nodules near the intersegmental fissure, in whom segmentectomy would be difficult and who had unguaranteed marginal distances. However, in 2016, for similar cases, if AIS or MIA was suspected before the operation, we would use hookwire localization-assisted expanded segmentectomy or bilateral segmentectomy, which effectively removed the nodules and avoided an unnecessary pulmonary lobectomy. Some scholars consider that the increased difficulty of performing uniportal VATS may prolong the operation time. The average operation time in our series was 123 min, which was similar to the times reported by others [6, 14, 15]. In the initial stage, the operation time for uniportal VATS was indeed prolonged due to the unfamiliarity of the dissection and surgical procedures. However, as the number of surgical cases increased and our in-depth understanding of bronchial anatomy improved, the operation time in 2016 was significantly shorter than that in 2015. Most lung resections could be completed within 1 h and some within a half hour. In our opinion, regardless of whether we use the uniportal or the porous method, the key to pulmonary segmentectomy lies in the accurate knowledge of the anatomy and the appropriate treatment of the segmental bronchus. In recent years, the complication rate of VATS pulmonary segmentectomy was reported to be 11.5–34.9% [6, 14–18]. It was 8.3% in our series, which was similar to the complication reported by other researchers. Moreover, with the improvement of technology, our complication rate was obviously lower in 2016 compared with 2015. Postoperative haemoptysis was the most common complication (3 cases, 5.9%). Compared with pulmonary lobectomy, the treatment of intersegmental fissure using pulmonary segmentectomy increases the chance of wounding the lung and bleeding. Most of the postoperative haemoptysis can be cured by conservative treatment, i.e. termination of the anticoagulant drug and without the use of haemostatic agents. To reduce the incidence of haemoptysis, we sewed the lung fissure after stapler treatment in high-risk cases. It is possible that the segmental vein and bronchus may be treated improperly when continued haemoptysis occurs. Considerable difficulties may be encountered in the pulmonary segmentectomy due to the tight adhesions between the hilar lymph node, the artery and the segmental bronchus, which make dissection impossible. Under these conditions, it is difficult to complete the pulmonary segmentectomy. We suggest that pulmonary lobectomy can be performed instead in young patients with strong pulmonary function. On the contrary, we advise wedge resection for patients with poor pulmonary function who could not withstand a lobectomy. In this study, 1 patient was scheduled to have a left upper apical segmentectomy but received instead a left upper lobe wedge resection after the apical segmental artery was cut off due to the calcification of a lymph node beside the bronchus. The ratio of AIS to MIA is high (54 cases, 72.0%), which is related to the selection process. Although most researches believed that a Stage Ia lung cancer with a diameter <2 cm can be treated with segmental excision [18–20], there is controversy about treating early peripheral lung cancer with a VATS pulmonary segmentectomy. A recent study indicated that the long-term survival of patients who had a pulmonary lobectomy was significantly better than that of patients who had a pulmonary segmentectomy and a wedge resection for Stage Ia lung cancer of a diameter larger or smaller than 1 cm [21], suggesting that caution should be used when recommending a pulmonary segmentectomy to treat Stage Ia lung cancer. For young patients with solid nodules, suspected invasive lung cancer and good lung function, pulmonary lobectomy is preferred to reduce the risk of recurrence. Pulmonary segmentectomy is selected only for elderly patients with poor lung function, ground glass opacities, suspected AIS or MIA, and in whom wedge resection cannot be performed or the marginal distance of wedge resection is smaller than 2 cm. At present, it is proposed that pulmonary segmentectomy should be cautiously selected when treating young patients with Stage Ia invasive lung cancer with a diameter smaller than 2 cm. To summarize, uniportal VATS pulmonary segmentectomy is safe and feasible in its clinical applications. Compared with the 2- or 3-port method, we encountered some technical difficulties in the early period of uniportal VATS that can be overcome by a period of practice. Funding This work was supported by the National Natural Science Foundation of China [81500060]. Conflict of interest: none declared. REFERENCES 1 Gonzalez D , Paradela M , Garcia J , Dela Torre M. Single-port video-assisted thoracoscopic lobectomy . Interact CardioVasc Thorac Surg 2011 ; 12 : 514 – 15 . Google Scholar CrossRef Search ADS PubMed 2 Jutley RS , Khalil MW , Rocco G. Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia . Eur J Cardiothorac Surg 2005 ; 28 : 43 – 6 . Google Scholar CrossRef Search ADS PubMed 3 Koike T , Yamato Y , Yoshiya K , Shimoyama T , Suzuki R. Intentional limited pulmonary resection for peripheral T1 N0 M0 small-sized lung cancer . J Thorac Cardiovasc Surg 2003 ; 125 : 924 – 8 . Google Scholar CrossRef Search ADS PubMed 4 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 . J Thorac Cardiovasc Surg 2006 ; 132 : 769 – 75 . Google Scholar CrossRef Search ADS PubMed 5 Wang BY , Tu CC , Liu CY , Shih CS , Liu CC. Single-incision thoracoscopic lobectomy and segmentectomy with radical lymph node dissection . Ann Thorac Surg 2013 ; 96 : 977 – 82 . Google Scholar CrossRef Search ADS PubMed 6 Han KN , Kim HK , Lee HJ , Choi YH. Single-port video-assisted thoracoscopic pulmonary segmentectomy: a report on 30 cases . Eur J Cardiothorac Surg 2016 ; 49(Suppl 1) : i42 – 7 . Google Scholar PubMed 7 Kirby TJ , Rice TW. Video-assisted pulmonary lobectomy . Semin Thorac Cardiovasc Surg 1993 ; 5 : 316 – 20 . Google Scholar PubMed 8 Roviaro GC , Rebuffat C , Varoli F , Vergani C , Maciocco M , Grignani F et al. Videoendoscopic thoracic surgery . Int Surg 1993 ; 78 : 4 – 9 . Google Scholar PubMed 9 Ginsberg RJ , Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group . Ann Thorac Surg 1995 ; 60 : 615 – 22 . Google Scholar CrossRef Search ADS PubMed 10 Keenan RJ , Landreneau RJ , Maley RH Jr , Singh D , Macherey R , Bartley S et al. Segmental resection spares pulmonary function in patients with stage I lung cancer . Ann Thorac Surg 2004 ; 78 : 228 – 33 . Google Scholar CrossRef Search ADS PubMed 11 Okada M , Nishio W , Sakamoto T , Uchino K , Yuki T , Nakagawa A et al. Effect of tumor size on prognosis in patients with non-small cell lung cancer: the role of segmentectomy as a type of lesser resection . J Thorac Cardiovasc Surg 2005 ; 129 : 87 – 93 . Google Scholar CrossRef Search ADS PubMed 12 Rocco G , Martin-Ucar A , Passera E. Uniportal VATS wedge pulmonary resections . Ann Thorac Surg 2004 ; 77 : 726 – 8 . Google Scholar CrossRef Search ADS PubMed 13 Gonzalez-Rivas D , Paradela M , Fernandez R , Delgado M , Fieira E , Mendez L et al. Uniportal video-assisted thoracoscopic lobectomy: two years of experience . Ann Thorac Surg 2013 ; 95 : 426 – 32 . Google Scholar CrossRef Search ADS PubMed 14 Okada M , Mimura T , Ikegaki J , Katoh H , Itoh H , Tsubota N. A novel video-assisted anatomic segmentectomy technique: selective segmental inflation via bronchofiberoptic jet followed by cautery cutting . J Thorac Cardiovasc Surg 2007 ; 133 : 753 – 8 . Google Scholar CrossRef Search ADS PubMed 15 Schuchert MJ , Abbas G , Awais O , Pennathur A , Nason KS , Wilson DO et al. Anatomic segmentectomy for the solitary pulmonary nodule and early-stage lung cancer . Ann Thorac Surg 2012 ; 93 : 1780 – 5 . Google Scholar CrossRef Search ADS PubMed 16 Kilic A , Schuchert MJ , Pettiford BL , Pennathur A , Landreneau JR , Landreneau JP et al. Anatomic segmentectomy for stage I non-small cell lung cancer in the elderly . Ann Thorac Surg 2009 ; 87 : 1662 – 6 . Google Scholar CrossRef Search ADS PubMed 17 Leshnower BG , Miller DL , Fernandez FG , Pickens A , Force SD. Video-assisted thoracoscopic surgery segmentectomy: a safe and effective procedure . Ann Thorac Surg 2010 ; 89 : 1571 – 6 . Google Scholar CrossRef Search ADS PubMed 18 Donahue JM , Morse CR , Wigle DA , Allen MS , Nichols FC , Shen KR et al. Oncologic efficacy of anatomic segmentectomy in stage IA lung cancer patients with T1a tumors . Ann Thorac Surg 2012 ; 93 : 381 – 7 . Google Scholar CrossRef Search ADS PubMed 19 Nomori H , Mori T , Ikeda K , Yoshimoto K , Iyama K , Suzuki M. Segmentectomy for selected cT1N0M0 non-small cell lung cancer: a prospective study at a single institute . J Thorac Cardiovasc Surg 2012 ; 144 : 87 – 93 . Google Scholar CrossRef Search ADS PubMed 20 Carr SR , Schuchert MJ , Pennathur A , Wilson DO , Siegfried JM , Luketich JD et al. Impact of tumor size on outcomes after anatomic lung resection for stage 1A non-small cell lung cancer based on the current staging system . J Thorac Cardiovasc Surg 2012 ; 143 : 390 – 7 . Google Scholar CrossRef Search ADS PubMed 21 Dai C , Shen J , Ren Y , Zhong S , Zheng H , He J et al. Choice of surgical procedure for patients with non-small-cell lung cancer </= 1 cm or > 1 to 2 cm among lobectomy, segmentectomy, and wedge resection: a population-based study . J Clin Oncol 2016 ; 34 : 3175 – 82 . Google Scholar CrossRef Search ADS PubMed © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. 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One hundred and fifty-six cases of anatomical pulmonary segmentectomy by uniportal video-assisted thoracic surgery: a 2-year learning experience

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
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1010-7940
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1873-734X
DOI
10.1093/ejcts/ezy142
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Abstract

Abstract OBJECTIVES Our goal was to explore the outcome of the study and the feasibility for patients of the technique of anatomical pulmonary segmentectomy by uniportal video-assisted thoracic surgery (VATS). METHODS A total of 156 consecutive patients with lung lesions who received anatomical pulmonary segmentectomy by VATS between 2015 and 2016 in our hospital were enrolled. All the subjects had high-resolution, thin-section chest computed tomography (CT) examinations with 3-dimensional reconstruction, a pulmonary function test, abdominal ultrasonography, electrocardiogram and cardiac ultrasonography. The lung lesion was localized before the operation using CT reconstruction or a hookwire to plan the operative method. RESULTS Uniportal VATS pulmonary segmentectomy was successfully completed in 151 (96.8%) patients. Most cases involved the right apical and apical posterior segments and the left trisegment. Only 1 patient had a right middle interior segmentectomy, left upper apical anterior segmentectomy or a right lower posteriolateral segmentectomy, respectively. There were 26 cases of benign lesions (including 17 cases of atypical hyperplasia) and 130 cases of non-small-cell lung cancer. Operation time (146 ± 56 vs 113 ± 32 min), blood loss (63 ± 17 vs 54 ± 13 ml) and complication rates (13.5% vs 5.8%) were obviously lower in 2016 compared with 2015 (P < 0.01). In contrast, the preoperative hookwire localization rate was markedly higher in 2016 compared with 2015. CONCLUSIONS Uniportal VATS anatomical pulmonary segmentectomy is safe and feasible in clinical applications. Compared with the 2- or 3-port method, there were some technical difficulties in the early phase of the learning curve for uniportal VATS that were overcome through a period of practice. Anatomical pulmonary segmentectomy , Uniportal video-assisted thoracic surgery , Lung cancer INTRODUCTION The use of uniportal video-assisted thoracic surgery (VATS) has continued to expand to involve almost all lung cancer resections since the Spanish scholar Gonzalez [1] first performed it in a pulmonary lobectomy in 2011. Compared to traditional multiport VATS, a single incision is enough for uniportal VATS, which minimizes injury to the chest intercostal nerve and has the obvious advantage of reducing postoperative pain [2]. Scholars in Japan and other countries found no significant difference in the efficacy of pulmonary segmentectomy compared to that of pulmonary lobectomy for Stage Ia peripheral lung cancer with a diameter <2 cm, giving rise to the use of pulmonary segmentectomy with VATS [3, 4]. At present, the multiport surgical method (2-, 3- or 4-port method) is mainly used worldwide in the treatment of early stage lung cancer through VATS pulmonary segmentectomy. A limited number of hospitals and doctors perform uniportal VATS pulmonary segmentectomy [5, 6]. The authors changed from the 3-port method to the 2-port method in VATS pulmonary segmentectomy in 2013. Then, in March 2015, we began to perform uniportal VATS pulmonary lobectomy and segmentectomy. This study explored the learning curve and feasibility of the technique by comparing the 52 cases of pulmonary segmentectomy performed in 2015 with the 104 cases performed in 2016. MATERIALS AND METHODS Patients A total of 156 consecutive patients undergoing VATS anatomical segmentectomy at Shanghai Pulmonary Hospital from March 2015 to December 2016 were retrospectively enrolled. All of them had a uniportal segmentectomy initially. Data from eligible patients were obtained from electronic medical records and office clinical records. All the subjects had a high-resolution, thin-section chest computed tomography (CT) examination with 3-dimensional reconstruction, pulmonary function test, abdominal ultrasonography, electrocardiogram and cardiac ultrasonography. The patients who were suspected of having lung cancer were further tested by brain magnetic resonance imaging and emission CT or positron emission tomography-CT to exclude distant metastases. The lung lesion was localized before the operation by CT reconstruction or a hookwire to design the operative method. This study was approved by the ethics committee of Shanghai Pulmonary Hospital. Indication criteria Uniportal VATS pulmonary segmentectomy was used for the following types of cases: (i) benign lung diseases in which wedge resection could be performed and which had ground glass opacities; (ii) T1N0M0 peripheral lung cancer with tumour diameter ≤2 cm; (iii) patients with peripheral lung cancer whose lung function could not tolerate the lobectomy; (iv) ground glass opacities lesions that could not guarantee that the margin would be more than 2 cm by wedge resection; (v) multiple nodules and bilateral surgery. Operative technique The patient was placed on his or her side with double-lumen endotracheal intubation and combined intravenous-inhalation anaesthesia. The incision was made at the 4th intercostal space of the anterior axillary line for the upper lobe segmentectomy and at the 5th intercostal space of the anterior axillary line for the lower lobe segmentectomy. The incision was about 2.5 to 4 cm in length, and a large incision protector was used routinely. All the instruments, including a thoracoscopic camera, entered the thoracic cavity through this single incision. The surgery was performed by the same surgeon and an assistant. The surgeon stood at the ventral side of the patient, and the assistant was at the dorsal position. A 5-mm or 10-mm thoracoscopic (HOPLIN II Forward Oblique Telescope 30°, Karl Storz, Tuttlingen, Germany) camera was usually placed at the posterior part of the incision. It was sometimes put at the anterior part, especially during separation of thoracic adhesions or a 7th group lymphadenectomy. The surgical instruments for pulmonary segmentectomy were the same as those used in uniportal VATS pulmonary lobectomy. The instruments were longer than 30 cm, double-jointed and curved, which permitted 3 or 4 instruments to pass through the single incision together without interference. Usually, sponge forceps, an aspirator and electrocautery (or an ultrasound scalpel) were used. It was rare to place 4 or more instruments together. Some of the instruments were self-invented by staff at Shanghai Pulmonary Hospital. Because there is still a lack of fixed steps for segmentectomy, different methods were adopted according to the different segments and the completeness of the lung fissure. The arteries and veins of the targeted lung segment were cut off by endostaplers (Endo GIA 30-mm Articulating Vascular Reload, Covidien, Dublin, Ireland), ligation, a titanium clip (WECK Hem-o-lok, Telelex, Morrisville, NC, USA) or an ultrasonic scalpel according to the diameter of the vessel. Next, the targeted bronchus was dissociated and cut off using the endoscopic stapler and an olecranon stapler when necessary. Then the lung was dilated by low pressure ventilation of the side of the operation to identify the segment boundary. When the boundary was unclear, it was judged according to the venous trend. Finally, the boundary was cut off by the Endo GIA. The veins could be used to help locate the boundary when it was not obvious after ventilation. For patients with primary lung cancer, the lymph node beside the bronchus was routinely tested by rapid pathological examination during the operation. The patients with local lymph node metastasis received the pulmonary lobectomy. The patients diagnosed as having invasive lung cancer were treated by systemic mediastinal lymphadenectomy. The patients diagnosed as having a minimally invasive adenocarcinoma (MIA) or an adenocarcinoma in situ (AIS) received mediastinal lymph nodal sampling. The mediastinal lymph node was removed by an ultrasonic scalpel combined with an aspirator. After the operation, a #28 chest tube was placed through the incision and a deep venipuncture tube was placed at the posterior costophrenic angle for drainage. All the operations were performed by the same surgeon (L.D.). Statistical analyses All data analyses were performed on SPSS 17.0 software (IBM Corp, Chicago, IL, USA). The measurement data are presented as mean ± standard deviation. The Student t-test was adopted to compare the distributions of continuous variables and the Fisher’s exact test was used to compare the frequencies of categorical measures between patient groups who were operated on in 2015 and 2016. Relationships between operation time and number of surgical experiences were assessed using a Spearman’s rank correlation test. Two-tailed values of P-value <0.05 were considered statistically significant. RESULTS The patients’ demographic information is summarized in Table 1. There were 49 men and 107 women with an average age of 53.4 ± 12.7 (16–82) years. Uniportal VATS pulmonary segmentectomy was successfully completed in 151 (96.8%) patients. Three patients received pulmonary segmentectomy combined with auxiliary incision due to thoracic adhesions. One patient was designated to have a left upper apical segmentectomy but received a left upper lobe wedge resection after cutting off the apical segmental artery due to the calcification of the lymph node beside the apical bronchus. One patient was scheduled to have a left upper lobe anterior segmentectomy but received a left upper trisegmentectomy due to an accidental cut of the posterior segmental vein. One patient was designated to have resection of the left dorsal segment but received a left lower lobectomy due to a nodule that was not discovered after segmentectomy. Table 1: Patient characteristics Characteristics Segmentectomy (n = 156) Age (years) 53.4 ± 12.7 (16–82) Gender, n (%)  Male 49 (31.4)  Female 107 (68.6) Smoking status 37 (23.7) Comorbidities (%), n (%)  COPD 48 (30.8)  Hypertension 61 (39.1)  Diabetes mellitus 67 (42.9)  Coronary artery disease 21 (13.5)  Cerebrovascular disease 13 (8.33)  Chronic renal failure 4 (2.56)  Prior cancer history 26 (4.33)  Arrhythmia 14 (8.97) Pulmonary function  FEV1 (%) 73.6 ± 31.4 (38–142)  VC 82.7 ± 28.5 (44–146) Tumour size (cm) 1.2 ± 0.4 (0.7–2.5) Reason for segmentectomy  Compromised 3  Intentional 153 Characteristics Segmentectomy (n = 156) Age (years) 53.4 ± 12.7 (16–82) Gender, n (%)  Male 49 (31.4)  Female 107 (68.6) Smoking status 37 (23.7) Comorbidities (%), n (%)  COPD 48 (30.8)  Hypertension 61 (39.1)  Diabetes mellitus 67 (42.9)  Coronary artery disease 21 (13.5)  Cerebrovascular disease 13 (8.33)  Chronic renal failure 4 (2.56)  Prior cancer history 26 (4.33)  Arrhythmia 14 (8.97) Pulmonary function  FEV1 (%) 73.6 ± 31.4 (38–142)  VC 82.7 ± 28.5 (44–146) Tumour size (cm) 1.2 ± 0.4 (0.7–2.5) Reason for segmentectomy  Compromised 3  Intentional 153 COPD: chronic obstructive pulmonary disease; FEV1: forced expiratory volume in 1 s; VC: vital capacity. Table 1: Patient characteristics Characteristics Segmentectomy (n = 156) Age (years) 53.4 ± 12.7 (16–82) Gender, n (%)  Male 49 (31.4)  Female 107 (68.6) Smoking status 37 (23.7) Comorbidities (%), n (%)  COPD 48 (30.8)  Hypertension 61 (39.1)  Diabetes mellitus 67 (42.9)  Coronary artery disease 21 (13.5)  Cerebrovascular disease 13 (8.33)  Chronic renal failure 4 (2.56)  Prior cancer history 26 (4.33)  Arrhythmia 14 (8.97) Pulmonary function  FEV1 (%) 73.6 ± 31.4 (38–142)  VC 82.7 ± 28.5 (44–146) Tumour size (cm) 1.2 ± 0.4 (0.7–2.5) Reason for segmentectomy  Compromised 3  Intentional 153 Characteristics Segmentectomy (n = 156) Age (years) 53.4 ± 12.7 (16–82) Gender, n (%)  Male 49 (31.4)  Female 107 (68.6) Smoking status 37 (23.7) Comorbidities (%), n (%)  COPD 48 (30.8)  Hypertension 61 (39.1)  Diabetes mellitus 67 (42.9)  Coronary artery disease 21 (13.5)  Cerebrovascular disease 13 (8.33)  Chronic renal failure 4 (2.56)  Prior cancer history 26 (4.33)  Arrhythmia 14 (8.97) Pulmonary function  FEV1 (%) 73.6 ± 31.4 (38–142)  VC 82.7 ± 28.5 (44–146) Tumour size (cm) 1.2 ± 0.4 (0.7–2.5) Reason for segmentectomy  Compromised 3  Intentional 153 COPD: chronic obstructive pulmonary disease; FEV1: forced expiratory volume in 1 s; VC: vital capacity. The types of resected lung segments are shown in Table 2. Almost all lung segmentectomies were performed using uniportal VATS. Most cases were right apical and apical posterior segments and left trisegments. Only 1 patient each received a right middle interior segmentectomy, a left upper apical anterior segmentectomy or a right lower posteriolateral segmentectomy, respectively. No left lower posterolateral or right middle lateral segmentectomy was performed. Table 2: Surgical segment distribution Total Right side  S1 26  S1 + S2 14  S2 16  S3 6  S1 + S3 3  S5 1  S6 13  S8 4  S7 + S8 + S9 + S10 3  S9 + S10 1  S1 + S2 + S6 1 Left side  S1 + S2 + S3 26  S4 + S5 8  S1 5  S3 5  S2 3  S1 + S3 1  S1 + S2 7  S6 5  S7 + S8 + S9 + S10 1  S7 + S8 3  S2 + S6 1  S3 + S4 + S5 1  S2 + S4 + S5 2 Total Right side  S1 26  S1 + S2 14  S2 16  S3 6  S1 + S3 3  S5 1  S6 13  S8 4  S7 + S8 + S9 + S10 3  S9 + S10 1  S1 + S2 + S6 1 Left side  S1 + S2 + S3 26  S4 + S5 8  S1 5  S3 5  S2 3  S1 + S3 1  S1 + S2 7  S6 5  S7 + S8 + S9 + S10 1  S7 + S8 3  S2 + S6 1  S3 + S4 + S5 1  S2 + S4 + S5 2 Table 2: Surgical segment distribution Total Right side  S1 26  S1 + S2 14  S2 16  S3 6  S1 + S3 3  S5 1  S6 13  S8 4  S7 + S8 + S9 + S10 3  S9 + S10 1  S1 + S2 + S6 1 Left side  S1 + S2 + S3 26  S4 + S5 8  S1 5  S3 5  S2 3  S1 + S3 1  S1 + S2 7  S6 5  S7 + S8 + S9 + S10 1  S7 + S8 3  S2 + S6 1  S3 + S4 + S5 1  S2 + S4 + S5 2 Total Right side  S1 26  S1 + S2 14  S2 16  S3 6  S1 + S3 3  S5 1  S6 13  S8 4  S7 + S8 + S9 + S10 3  S9 + S10 1  S1 + S2 + S6 1 Left side  S1 + S2 + S3 26  S4 + S5 8  S1 5  S3 5  S2 3  S1 + S3 1  S1 + S2 7  S6 5  S7 + S8 + S9 + S10 1  S7 + S8 3  S2 + S6 1  S3 + S4 + S5 1  S2 + S4 + S5 2 The perioperative data are listed in Table 3. The average operation time was 123 ± 45 (40–240) min, and the average bleeding volume was 60 ± 14 (10–300) ml. A total of 26.9% subjects had preoperative hookwire localization, and the postoperative length of stay was 4.2 ± 1.6 (2–14) days. No intraoperative vessel injury or anatomical variants caused significant changes in the surgical plan, like transit thoracotomy or multiport VATS. No death occurred during the perioperative period. Postoperative complications occurred in 13 (8.3%) cases (Table 4), including postoperative haemoptysis in 5 cases, pulmonary infection in 3 cases, postoperative leakage extension in 2 cases and others in 3 cases, respectively. All complications were cured after symptomatic and aetiological treatment. The venipuncture tube and the chest tube were removed simultaneously after the operation. One patient had postoperative subcutaneous emphysema after a right upper apical segmentectomy due to poor placement of the chest tube. He was cured after replacement of the chest drainage tube through the 2nd intercostal space on the midclavicular line. One patient had a postoperative haemorrhage because a staple ruptured and was reoperated on by suturing the lung using a Prolene thread. Table 3: Perioperative outcomes after segmentectomy Variables Current series Han et al. (n = 30) Schuchert et al. (n = 785) Okada et al. (n = 52) Preoperative localization, n (%) 42 (26.9) 14 (66.7) NR NR Operative time (min) 123 ± 45 (40–240) 159 ± 56 (30–236) 134 (30–367) 155 (85–225) Estimated blood loss (ml) 60 ± 14 (10–300) NR 100 (25–750) 60 (10–210) Complications, n (%) 13 (8.3) 4 (13.3) 274 (34.9) 7 (13.5) Deaths 0 1 (3.3) 1.1 0 Conversion to open surgery, n (%) 3 (1.9) 30 (6.4) NR Conversion to lobectomy, n (%) 1 (0.6) 1 (3.3) 4 (0.5) NR Drain indwelling time (days) 4.6 ± 1.6 3 (2–13) Hospitalization after operation (days) 4.2 ± 1.6 (2–14) NR 6 (2–52) NR Variables Current series Han et al. (n = 30) Schuchert et al. (n = 785) Okada et al. (n = 52) Preoperative localization, n (%) 42 (26.9) 14 (66.7) NR NR Operative time (min) 123 ± 45 (40–240) 159 ± 56 (30–236) 134 (30–367) 155 (85–225) Estimated blood loss (ml) 60 ± 14 (10–300) NR 100 (25–750) 60 (10–210) Complications, n (%) 13 (8.3) 4 (13.3) 274 (34.9) 7 (13.5) Deaths 0 1 (3.3) 1.1 0 Conversion to open surgery, n (%) 3 (1.9) 30 (6.4) NR Conversion to lobectomy, n (%) 1 (0.6) 1 (3.3) 4 (0.5) NR Drain indwelling time (days) 4.6 ± 1.6 3 (2–13) Hospitalization after operation (days) 4.2 ± 1.6 (2–14) NR 6 (2–52) NR NR: not reported. Table 3: Perioperative outcomes after segmentectomy Variables Current series Han et al. (n = 30) Schuchert et al. (n = 785) Okada et al. (n = 52) Preoperative localization, n (%) 42 (26.9) 14 (66.7) NR NR Operative time (min) 123 ± 45 (40–240) 159 ± 56 (30–236) 134 (30–367) 155 (85–225) Estimated blood loss (ml) 60 ± 14 (10–300) NR 100 (25–750) 60 (10–210) Complications, n (%) 13 (8.3) 4 (13.3) 274 (34.9) 7 (13.5) Deaths 0 1 (3.3) 1.1 0 Conversion to open surgery, n (%) 3 (1.9) 30 (6.4) NR Conversion to lobectomy, n (%) 1 (0.6) 1 (3.3) 4 (0.5) NR Drain indwelling time (days) 4.6 ± 1.6 3 (2–13) Hospitalization after operation (days) 4.2 ± 1.6 (2–14) NR 6 (2–52) NR Variables Current series Han et al. (n = 30) Schuchert et al. (n = 785) Okada et al. (n = 52) Preoperative localization, n (%) 42 (26.9) 14 (66.7) NR NR Operative time (min) 123 ± 45 (40–240) 159 ± 56 (30–236) 134 (30–367) 155 (85–225) Estimated blood loss (ml) 60 ± 14 (10–300) NR 100 (25–750) 60 (10–210) Complications, n (%) 13 (8.3) 4 (13.3) 274 (34.9) 7 (13.5) Deaths 0 1 (3.3) 1.1 0 Conversion to open surgery, n (%) 3 (1.9) 30 (6.4) NR Conversion to lobectomy, n (%) 1 (0.6) 1 (3.3) 4 (0.5) NR Drain indwelling time (days) 4.6 ± 1.6 3 (2–13) Hospitalization after operation (days) 4.2 ± 1.6 (2–14) NR 6 (2–52) NR NR: not reported. Table 4: Postoperative complications Complications 13 (8.3%) Haemoptysis 5 Pneumonia 3 Prolonged air leak (>5 days) 2 Subcutaneous emphysema 1 Atrial fibrillation 1 Bleeding after surgery 1 Complications 13 (8.3%) Haemoptysis 5 Pneumonia 3 Prolonged air leak (>5 days) 2 Subcutaneous emphysema 1 Atrial fibrillation 1 Bleeding after surgery 1 Table 4: Postoperative complications Complications 13 (8.3%) Haemoptysis 5 Pneumonia 3 Prolonged air leak (>5 days) 2 Subcutaneous emphysema 1 Atrial fibrillation 1 Bleeding after surgery 1 Complications 13 (8.3%) Haemoptysis 5 Pneumonia 3 Prolonged air leak (>5 days) 2 Subcutaneous emphysema 1 Atrial fibrillation 1 Bleeding after surgery 1 Statistical analyses of data collected between 2015 and 2016 showed that the operation time, hookwire localization rate, blood loss and complication rate were significantly different. Operation time, blood loss and complication rate were obviously lower in 2016 compared with 2015. In contrast, the preoperative hookwire localization rate was markedly higher in 2016 compared with 2015 (Table 5). There was a significant correlation between the operation time and the cumulative sum of the number of VATS segmentectomies performed by the surgeon (r = −0.593, P < 0.001, Fig. 1). All the hookwires were placed at the location within 2 cm from the lesion. The use of hookwires reduced the necessity of a bi- or trisegmentectomy to achieve an adequate margin. Table 5: Comparisons between uniportal thoracoscopic segmentectomies performed in 2015 and 2016 2015 (52) 2016 (104) P-value Tumour size (cm) 1.1 ± 0.7 (0.7–2.5) 1.2 ± 0.5 (0.7–2.5) 0.31 Preoperative hookwire localization, n (%) 6 (11.5) 36 (34.6) 0.002 Double segmentectomy, n (%) 7 (13.4) 17 (16.3) 0.82 Operative time (min), mean ± SD 146 ± 56 113 ± 32 <0.001 Blood loss (ml), mean ± SD 63 ± 17 54 ± 13 <0.001 Conversion to open surgery 1 2 1.0 Hospitalization after operation (days), mean ± SD 4.1 ± 1.7 4.2 ± 1.8 0.74 Complications (%) 7 (13.5) 6 (5.8) 0.013 2015 (52) 2016 (104) P-value Tumour size (cm) 1.1 ± 0.7 (0.7–2.5) 1.2 ± 0.5 (0.7–2.5) 0.31 Preoperative hookwire localization, n (%) 6 (11.5) 36 (34.6) 0.002 Double segmentectomy, n (%) 7 (13.4) 17 (16.3) 0.82 Operative time (min), mean ± SD 146 ± 56 113 ± 32 <0.001 Blood loss (ml), mean ± SD 63 ± 17 54 ± 13 <0.001 Conversion to open surgery 1 2 1.0 Hospitalization after operation (days), mean ± SD 4.1 ± 1.7 4.2 ± 1.8 0.74 Complications (%) 7 (13.5) 6 (5.8) 0.013 SD: standard deviation. Table 5: Comparisons between uniportal thoracoscopic segmentectomies performed in 2015 and 2016 2015 (52) 2016 (104) P-value Tumour size (cm) 1.1 ± 0.7 (0.7–2.5) 1.2 ± 0.5 (0.7–2.5) 0.31 Preoperative hookwire localization, n (%) 6 (11.5) 36 (34.6) 0.002 Double segmentectomy, n (%) 7 (13.4) 17 (16.3) 0.82 Operative time (min), mean ± SD 146 ± 56 113 ± 32 <0.001 Blood loss (ml), mean ± SD 63 ± 17 54 ± 13 <0.001 Conversion to open surgery 1 2 1.0 Hospitalization after operation (days), mean ± SD 4.1 ± 1.7 4.2 ± 1.8 0.74 Complications (%) 7 (13.5) 6 (5.8) 0.013 2015 (52) 2016 (104) P-value Tumour size (cm) 1.1 ± 0.7 (0.7–2.5) 1.2 ± 0.5 (0.7–2.5) 0.31 Preoperative hookwire localization, n (%) 6 (11.5) 36 (34.6) 0.002 Double segmentectomy, n (%) 7 (13.4) 17 (16.3) 0.82 Operative time (min), mean ± SD 146 ± 56 113 ± 32 <0.001 Blood loss (ml), mean ± SD 63 ± 17 54 ± 13 <0.001 Conversion to open surgery 1 2 1.0 Hospitalization after operation (days), mean ± SD 4.1 ± 1.7 4.2 ± 1.8 0.74 Complications (%) 7 (13.5) 6 (5.8) 0.013 SD: standard deviation. Figure 1: View largeDownload slide Assessment of correlation between the number of operations performed and the operating times. Figure 1: View largeDownload slide Assessment of correlation between the number of operations performed and the operating times. The postoperative pathological results are shown in Table 6. There were 26 cases of benign lesions (including 17 cases of atypical hyperplasia) and 130 cases of non-small-cell lung cancer (including 100 cases of AIS and MIA and 30 cases of invasive adenocarcinoma, mucinous adenocarcinoma and carcinoid). For histological staging, 27 cases were Stage Ia whereas 3 cases were Stage Ib. The 3 patients who had Stage Ib received a left upper trisegmentectomy because of the second-phase lobectomy on the right side. Two patients, limited by age and poor pulmonary function, received a lingular segmentectomy or a left lower dorsal segmentectomy. Table 6: Pathological diagnosis Total Benign disease 26  Atypical adenomatous hyperplasia 15 Inflammatory consolidation 5 Hamartoma 3  Tuberculosis 2  Pulmonary cryptococcosis 1 Malignant disease 130  Adenocarcinoma in situ 61  Microinvasive adenocarcinoma 39  Infiltrating adenocarcinoma 27 Mucinous adenocarcinoma 2 Carcinoid 1 Stage  Ia 27  Ib 3 Total Benign disease 26  Atypical adenomatous hyperplasia 15 Inflammatory consolidation 5 Hamartoma 3  Tuberculosis 2  Pulmonary cryptococcosis 1 Malignant disease 130  Adenocarcinoma in situ 61  Microinvasive adenocarcinoma 39  Infiltrating adenocarcinoma 27 Mucinous adenocarcinoma 2 Carcinoid 1 Stage  Ia 27  Ib 3 Table 6: Pathological diagnosis Total Benign disease 26  Atypical adenomatous hyperplasia 15 Inflammatory consolidation 5 Hamartoma 3  Tuberculosis 2  Pulmonary cryptococcosis 1 Malignant disease 130  Adenocarcinoma in situ 61  Microinvasive adenocarcinoma 39  Infiltrating adenocarcinoma 27 Mucinous adenocarcinoma 2 Carcinoid 1 Stage  Ia 27  Ib 3 Total Benign disease 26  Atypical adenomatous hyperplasia 15 Inflammatory consolidation 5 Hamartoma 3  Tuberculosis 2  Pulmonary cryptococcosis 1 Malignant disease 130  Adenocarcinoma in situ 61  Microinvasive adenocarcinoma 39  Infiltrating adenocarcinoma 27 Mucinous adenocarcinoma 2 Carcinoid 1 Stage  Ia 27  Ib 3 A total of 72 patients diagnosed as AIS or MIA received mediastinal lymph nodal sampling with a mean lymph node number of 6 ± 2. All 30 cases of invasive adenocarcinoma, mucinous adenocarcinoma and carcinoid had a systematic mediastinal lymphadenectomy. All of the resected lymph nodes were negative, which was confirmed by pathological examination. DISCUSSION Kirby and Rice [7] first reported VATS for pulmonary lobectomy in 1993. Since then, VATS has been widely adopted in the treatment of lung diseases. Its safety, minimal invasiveness and therapeutic effectiveness have been fully proved in clinical situations. Also in 1993, Roviaro et al. [8] reported pulmonary segmentectomy by VATS for the first time. The prospective randomized controlled study of peripheral T1N0M0 non-small-cell lung cancer performed by the US Lung Cancer Study Group in 1995 showed a higher local recurrence rate and a worse long-term survival rate with sublobectomy compared to lobectomy. Thus, pulmonary lobectomy has been regarded as the standard surgical procedure for lung cancer. Pulmonary segmentectomy was used only in compromise surgical situations in which the pulmonary lobectomy was restricted by the lung function [9]. The VATS pulmonary segmentectomy has become one of the most minimally invasive procedures for early lung cancer. Compared to pulmonary lobectomy, pulmonary segmentectomy can retain more lung function [10]. Compared with wedge resection, it can ensure adequate distance of the lesion from the margin, thereby reducing tumour recurrence and improving long-term survival [11]. As with the VATS pulmonary lobectomy, the VATS pulmonary segmentectomy also has progressed from 4, 3 and 2-port to uniport. In addition to fewer injuries to the intercostal nerves and reduced postoperative pain [2], the largest advantage of the uniport operation is that it provides the same angle of view as a thoracotomy [12]. Because a segmentectomy involves more local operative activity, the uniport operation has the obvious advantage of displaying the superior mediastinum and the local area. In contrast, the biggest difficulty with uniportal VATS is the change of the angle and the path during the process of cutting off the vessels, the bronchus and the lung segments. Moreover, having all the instruments pass through a single incision increases the difficulty of the procedure [13]. However, these issues can be overcome by the selection of the incision position, sufficient dissection and the application of a rotating or a wisdom stapler (Johnson & Johnson, New Brunswick, NJ, USA). Where the incision is made is of great significance for uniportal VATS pulmonary segmentectomy. In past years, we usually selected the 4th intercostal space on the anterior axillary line, which provides the best exposure and dissection. However, it provides a poor angle for treating the segmental bronchus and intersegmental fissure with the stapler, especially bilateral anterior segmentectomies. Thus, we more recently selected the 4th intercostal space on the anterior axillary line only for bilateral apical segmentectomies. For the other segmental resections, we made the incision at the 5th intercostal space on the anterior axillary line because it simplified the treatment of the segmental bronchus and intersegmental fissure. In addition, interlobar fissure is necessary to achieve dissection in the resection of some segments. In our opinion, the interlobar fissure should be opened for the lower lobe segments, lingular segment, posterior segment and right upper anterior segment. The ‘tunnel method’ should be adopted for patients with interlobar fissure aplasia. In this study, almost all the pulmonary segmentectomies were performed using uniportal VATS. In our opinion, the uniport method is better than the 2-port or 3-port method when treating the right apical segment, left trisegment and bilateral dorsal segment, especially in exposing the anterior apical segmental artery and apical bronchus. Furthermore, it provides a better visual angle to reveal the relationship between the stapler and the intersegmental fissure. In a 3- or 2-port operation, some surgeons place the camera near the main operating hole for better exposure when dissecting the right upper artery or the anterior apical branch of the left lung artery. Various methods can be adopted in the localization of nodules during pulmonary segmentectomy. The preoperative localization ratio can be as high as 66.7% in Han’s et al. [6] uniportal VATS. In this study, the preoperative localization rate was 26.9%, which was performed with a CT-guided hookwire. The preoperative localization ratio in 2016 (34.6%) was higher than that in 2015 (11.5%), which may be due to the fact that we mainly performed lobectomies in 2015 in patients with nodules near the intersegmental fissure, in whom segmentectomy would be difficult and who had unguaranteed marginal distances. However, in 2016, for similar cases, if AIS or MIA was suspected before the operation, we would use hookwire localization-assisted expanded segmentectomy or bilateral segmentectomy, which effectively removed the nodules and avoided an unnecessary pulmonary lobectomy. Some scholars consider that the increased difficulty of performing uniportal VATS may prolong the operation time. The average operation time in our series was 123 min, which was similar to the times reported by others [6, 14, 15]. In the initial stage, the operation time for uniportal VATS was indeed prolonged due to the unfamiliarity of the dissection and surgical procedures. However, as the number of surgical cases increased and our in-depth understanding of bronchial anatomy improved, the operation time in 2016 was significantly shorter than that in 2015. Most lung resections could be completed within 1 h and some within a half hour. In our opinion, regardless of whether we use the uniportal or the porous method, the key to pulmonary segmentectomy lies in the accurate knowledge of the anatomy and the appropriate treatment of the segmental bronchus. In recent years, the complication rate of VATS pulmonary segmentectomy was reported to be 11.5–34.9% [6, 14–18]. It was 8.3% in our series, which was similar to the complication reported by other researchers. Moreover, with the improvement of technology, our complication rate was obviously lower in 2016 compared with 2015. Postoperative haemoptysis was the most common complication (3 cases, 5.9%). Compared with pulmonary lobectomy, the treatment of intersegmental fissure using pulmonary segmentectomy increases the chance of wounding the lung and bleeding. Most of the postoperative haemoptysis can be cured by conservative treatment, i.e. termination of the anticoagulant drug and without the use of haemostatic agents. To reduce the incidence of haemoptysis, we sewed the lung fissure after stapler treatment in high-risk cases. It is possible that the segmental vein and bronchus may be treated improperly when continued haemoptysis occurs. Considerable difficulties may be encountered in the pulmonary segmentectomy due to the tight adhesions between the hilar lymph node, the artery and the segmental bronchus, which make dissection impossible. Under these conditions, it is difficult to complete the pulmonary segmentectomy. We suggest that pulmonary lobectomy can be performed instead in young patients with strong pulmonary function. On the contrary, we advise wedge resection for patients with poor pulmonary function who could not withstand a lobectomy. In this study, 1 patient was scheduled to have a left upper apical segmentectomy but received instead a left upper lobe wedge resection after the apical segmental artery was cut off due to the calcification of a lymph node beside the bronchus. The ratio of AIS to MIA is high (54 cases, 72.0%), which is related to the selection process. Although most researches believed that a Stage Ia lung cancer with a diameter <2 cm can be treated with segmental excision [18–20], there is controversy about treating early peripheral lung cancer with a VATS pulmonary segmentectomy. A recent study indicated that the long-term survival of patients who had a pulmonary lobectomy was significantly better than that of patients who had a pulmonary segmentectomy and a wedge resection for Stage Ia lung cancer of a diameter larger or smaller than 1 cm [21], suggesting that caution should be used when recommending a pulmonary segmentectomy to treat Stage Ia lung cancer. For young patients with solid nodules, suspected invasive lung cancer and good lung function, pulmonary lobectomy is preferred to reduce the risk of recurrence. Pulmonary segmentectomy is selected only for elderly patients with poor lung function, ground glass opacities, suspected AIS or MIA, and in whom wedge resection cannot be performed or the marginal distance of wedge resection is smaller than 2 cm. At present, it is proposed that pulmonary segmentectomy should be cautiously selected when treating young patients with Stage Ia invasive lung cancer with a diameter smaller than 2 cm. 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European Journal of Cardio-Thoracic Surgery – Oxford University Press

Published: Apr 6, 2018

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