Identification of the intersegmental plane by arterial ligation method during thoracoscopic segmentectomy

Abstract

Background: Thoracoscopic segmentectomy is a common surgical procedure in thoracic surgery today. However, identifying the intersegmental plane is difficult in the surgical process. Therefore, we evaluated the feasibility of the arterial ligation method for determining the intersegmental plane and compared the demarcation status with the intravenous indocyanine green (ICG).

Methods: We retrospectively reviewed the records of 35 patients with peripheral small lung nodules who underwent thoracoscopic segmentectomy between May and December 2020. First, the preoperative three-dimensional reconstruction was performed to distinguish the location of lung nodules and the anatomical structures of targeted segmental arteries, veins, and bronchi. Second, the targeted segmental arteries were ligated, and the intersegmental plane was determined by the inflation-deflation technique. The waiting time for the appearance of the inflation-deflation line was recorded. Thirdly, the intersegmental plane was identified again using the ICG fluorescence method. Finally, the consistency of the two intersegmental planes was evaluated.

Results: The intersegmental planes were successfully observed in all patients using the arterial ligation method. Thirty-four patients underwent segmentectomy as planned, and one patient finally underwent lobectomy due to insufficient surgical margin. The waiting time for the appearance of the intersegmental plane by arterial ligation method was 13.7 ± 3.2 min (6-19 min). The intersegmental planes determined by the arterial ligation method and the ICG fluorescence method were comparable, with a maximum distance of no more than 5 mm between the two planes. The mean operative duration was 119.1 ± 34.9 min, and the mean blood loss was 76.9 ± 70.3 ml. No evident air leakage was found during the operation. Only one patient experienced a prolonged air leak (≥ 5 days) during the postoperative recovery. No atelectasis occurred in all cases. The chest tube duration was 3.1 ± 0.9 days.

Conclusion: The arterial ligation method can efficiently and accurately identify the intersegmental plane, comparable to the ICG fluorescence method.

Keywords: Intersegmental plane; Segmentectomy; Thoracoscopy.

Fig. 1

Identifying the intersegmental plane during the right S2 segmentectomy. a The first intersegmental plane was identified by the arterial ligation method. The targeted segmental artery (A²) and bronchi (B²) were dissected and the artery was ligated. b The second intersegmental plane was identified by the ICG fluorescence method. The marking line on the visceral pleura was the first intersegmental plane, and the boundary of the green fluorescence was the second intersegmental plane