Usefulness of near-infrared angiography for identifying the intersegmental plane and vascular supply during video-assisted thoracoscopic segmentectomy

Abstract

Objectives: Segmentectomy by video-assisted thoracoscopic surgery (VATS) permits anatomical resection for diagnosis and treatment of small lung nodules but requires that intersegmental planes and segmental vessels be identified accurately. Near-infrared angiography with systemic injection of indocyanine green (ICG) can precisely identify the intersegmental plane. The purpose of this study was to confirm the usefulness of ICG angiography during VATS segmentectomy.

Methods: We retrospectively reviewed the records of 22 consecutive patients who underwent VATS segmentectomy performed with near-infrared angiography between November 2014 and October 2015. Segments were localized and anatomical vascular supply was identified on preoperative computed tomography scans. VATS segmentectomy was performed using an anterior approach with 2 ports and 1 non-spreading minithoracotomy, with ICG injected systemically after arterial ligation.

Results: VATS was feasible for all 22 segmentectomies, and in all patients, the intersegmental plane was identified accurately by ICG angiography. This angiography method was also useful in patients whose anatomical vascular segmentation was difficult to identify and, in a few patients, to assess the distribution of an artery before sectioning, to determine the vascular supply of the remaining lung and to distinguish between segmental and intersegmental veins. The postoperative course was uneventful for 18 patients and complicated for 2 patients who had prolonged air leak (10 and 15 days) with pneumonia, 1 patient with gastroparesis and 1 with colonic ileus. The drain was removed before the 3rd postoperative day in all but 2 patients, and the mean hospital stay was 5.4 ± 4.5 days. Anatomopathological examination indicated that 4 benign lesions and 18 primary lung cancers were completely removed, including 14 that were Stage IA, 2 Stage IIA and 2 Stage IIIA.

Conclusions: Indocyanine green angiography provides technical support for identifying the intersegmental plane and the vasculature during VATS segmentectomy. It contributes to the quality of diagnostic and therapeutic excisions of small nodules that are often not visible and not palpable during VATS.

Keywords: Indocyanine green; Lung neoplasm; Solitary pulmonary nodule; Video-assisted thoracic surgery (VATS).