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Thoracoscopic Segmentectomy
Thomas A. D’Amico MDGary Hock Endowed Professor
Chief Thoracic SurgeryChief Medical Officer, Duke Cancer Institute
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Disclosures
• Consultant for Scanlan
• No conflicts related to this presentation
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Indications for sublobar resection vs lobectomy for solid nodules
• Tumor size <2cm• Margins >2cm• Favorable segment-specific location• Significant patient co-morbidity• Previous resection(s)
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Pulmonary Segmentectomy: Thoracotomy Or Thoracoscopy
Atkins BZ, et al. Ann Thorac Surg 2007 84: 1107 - 1113
• 77 sub-lobar anatomic resections (2000-06)Thoracotomy (OS) 29 patients Thoracoscopy (TS) 48 patients
• No rib spreading• Complete hilar/mediastinal lymph node
dissection
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Thoracoscopic Segmentectomy
OS (n=29) TS (n=48)
Operative time 130 min 136 min
Estimated blood loss 280 ml 250 ml
Nodal stations sampled 3.9 ± 3 4.1 ± 3
Chest tube duration 3.7 days 3.5 days
Length of stay (p=0.03) 6.8 days 4.3 days
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• 193 segmentectomies, 47% by VATS • No significant differences in c-stage, p-stage,
total # LNs, or N2 stations sampled• VATS: ↓ LOS and pulmonary complications • 5-yr DFS favored VATS: 58% vs 47%; p = 0.013 • 5-yr OS favored VATS: 75% vs 62%; p = 0.017
Ghaly et al Ann Thorac Surg.2016;101:465-72;
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Bronchopulmonary Segments
Right Upper LobeS1 Apical S2 Posterior S3 Anterior
Right Middle LobeS4 LateralS5 Medial
Right Lower LobeS6 SuperiorS7 Medial basalS8 Anterior basalS9 Lateral basalS10 Posterior basal
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Right
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Duke Thoracic Oncology Program
Bronchopulmonary Segments
Left Upper LobeS1 Apical S2 Posterior S3 Anterior
LingulaS4 SuperiorS5 Inferior
Left Lower LobeS6 SuperiorS7 Medial basalS8 Anterior basalS9 Lateral basalS10 Posterior basal
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Duke Thoracic Oncology Program
Left
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Right upper Lobe
• S2 (Posterior segment)– Relatively easy– Likely to provide an advantage in lung function
• S3 (Anterior segment)– More difficult– Less likely to provide advantage
• S1 (Apical segment)– Most difficult
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Left upper lobe
• S1-3 (Lingular-sparing)– Common, easy, may be analogous to RUL
• S4-5 (Lingulectomy)– Common, easy, not analogous to RML
(bronchial drainage) – 2 cm margin rule should be kept
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Lower lobe
• S6 (Superior segmentectomy)– Very easy, but margins should be scrutinized
• S7+8+9+10 (Basilar segmentectomy) – Very easy, but what is the value?
• S7 or S8 or S7+8– Relatively easy
• S9 or S10 or S9+10– Most difficult, probably most useful wth GGOs
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J Thorac Dis 2016;8(Suppl 9):S710-S715
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A10
A9
A7
A8
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10th Annual Masters in Minimally Invasive Thoracic Surgery
September 21-23, 2017Waldorf AstoriaOrlando, Florida
endo.surgery.duke.edu/courses