With the popularization of chest computed tomography (CT), the discovery of small pulmonary nodules is increasingly common, which also promotes the progress of segmentectomy [1, 2]. As reported in the previous cases, the anatomic structure of the pulmonary segment is sometimes variable [3-5]. The public’s attention is now shifting to how to achieve an accurate anatomic segmentectomy. The development and application of various 3D imaging softwares have given a strong technical support in terms of the successful resection . Preoperative reconstruction of the segment can clearly show the anatomic structure and judge whether there are variations, so as to make an accurate surgical plan. In this case, a 34-year-old female patient experienced a ground-glass nodule (GGN) at the right upper posterior segment (RS2). The preoperative three-dimensional CT bronchography and angiography (3D-CTBA) revealed multiple anatomic variations. Owing to the detailed planning of the operation, video-assisted thoracoscopic surgery (VATS) RS2 segmentectomy was performed successfully.
A 34-year-old female was admitted to us with a GGN in RS2, which was discovered by chest CT during a health checkup 1 year ago. A review of CT indicated that the subpleural GGN was slightly larger than before, with a diameter of 7 mm and a CT value of -400HU (Figure 1). She had no positive signs, no history of smoking, no history of malignant tumors, and no family history of lung cancer. Preoperative 3D-CTBA revealed multiple variations in the right upper lobe: (1) The apical subsegmental bronchi（B1a and B1b）originated from the posterior segmental bronchus (B2) and the anterior segmental bronchus (B3 ) , respectively. (2) The right upper pulmonary arteries shared a trunk without a posterior ascending artery (Asc.A2). (3) The right upper lobe had no central vein, with only 1 posterior intrasegmental vein (V2t); the other 2 veins pointed to intersegmental plane respectively without another posterior intrasegmental vein (V2b) (Figure 2). VATS anatomic RS2 segmentectomy and lymph node sampling were conducted accurately With the guidance of 3D-CTBA (Figure 3); all anatomic variations were successfully detected during the operation (Figure 4). Minimally invasive adenocarcinoma (MIA) was the fast-frozen pathology. The chest radiograph illustrated that the right lung was completely redilated, and on the second postoperative day, the incisal margin of the segment displayed no obvious exudation (Figure 5). The drainage tube was removed on the second postoperative day, and the patient was discharged on the third postoperative day. The postoperative pathology revealed MIA with negative surrounding lymph nodes.
Intravenous general anesthesia combined with double-lumen endotracheal intubation and contralateral one-lung ventilation were performed. The observation port was made in the seventh intercostal space of the posterior axillary line, and the operation port in the fourth intercostal space of the anterior axillary line. The surgical procedure was as follows: (1) Thoracoscopic exploration revealed a subpleural nodule at the RS2. (2) The parietal pleura was sectioned by harmonic, and then the Nos.11 lymph nodes were removed. (3) The V2t was dissociated and pulled by silk, and the Nos.12 and 13 lymph nodes around the bronchus were completely removed. (4) After ligating the V2t, the B2 was dissected out and transected with a thick tissular (blue cartridge) 45-mm long endostapler (EC45A, JJMC, USA). (5) According to the preoperative 3D-CTBA, the other 2 veins were judged as the intersegmental veins; hence, they were all preserved. (6) We reventilated the right lung with pure oxygen because the posterior segmental artery was very difficult to ligate; when the intersegmental plane was clear after 18 minutes, the segmental hilum was released sufficiently to expose the posterior segmental artery, and then the artery was ligated safely. (7) The intersegmental plane was divided along the inflation-deflation line using the endostaplers; thus, the posterior segment was removed successfully. A sterile glove was used to collect the specimen. Bleeding and air leakage were not observed after the pleural injection of inflation. No. 24 chest drainage tube was placed in the observation port. The incision was sutured after the right lung was completely dilated. The operative time was 75 minutes, and intraoperative blood loss was 50 mL.