Segmentectomy Made SimpleSegmentectomy Made SimpleSegmentectomy Made SimpleSegmentectomy Made Simple

Matthew J. Schuchert and Rodney J. LandreneauMatthew J. Schuchert and Rodney J. Landreneau

Department of Cardiothoracic SurgeryDepartment of Cardiothoracic Surgery

University of Pittsburgh Medical CenterUniversity of Pittsburgh Medical Center

Matthew J. Schuchert and Rodney J. LandreneauMatthew J. Schuchert and Rodney J. Landreneau

Department of Cardiothoracic SurgeryDepartment of Cardiothoracic Surgery

University of Pittsburgh Medical CenterUniversity of Pittsburgh Medical Center

Financial DisclosuresFinancial Disclosures

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Why Consider Anatomic Segmentectomy?Why Consider Anatomic Segmentectomy?

• Accomplishes fundamental surgical tenets of R0 resection with

systematic nodal staging for NSCLC

• Equivalent survival for Stage 1A disease

• Decreased morbidity and mortality risk - esp. in the elderly

• Lung Preservation - esp. in marginal patients, prior surgery,

tumors of low malignant potential

• Decreased morbidity and mortality risk - esp. in the elderly

●●●● Individual bronchial and vascular isolation and division

Anatomic Segmentectomy and Lobectomy - Tenets

●●●● VATS vs. Open

Surgical ApproachSurgical Approach

●●●● Same fundamental principles as lobectomy

●●●● Extended segmentectomy with stapled parenchymal margin

●●●● Lymph node sampling (N1/N2)

●●●● R0 Resection

●●●● Adequate surgical margins

VATS SegmentectomyVATS Segmentectomy

VATS APPROACH

• Small Tumors: < 2 cm in diameter

• Confined to a discrete segmental boundary

• Peripheral location (outer 1/3)

• Pathologic Margin (Margin/Tumor ratio>1)

Favorable Criteria for Anatomic Segmentectomy

Patient SelectionPatient Selection

• Elderly (Age >80)

• Marginal pulmonary function (FEV1/DLCO < 60%)

• Ground glass opacities – Adenocarcinoma in situ

• Prior lung resection

• Solitary Pulmonary Nodule

• Metastases

Operation n

Right Upper Lobe

Apical 83

Anterior 43

Posterior 79

ApicoPosterior 18

Right Middle Lobe

Medial 10

Segments ResectedSegments Resected

Medial 10

Lateral 17

Right Lower Lobe

Superior 78

Basilar 76

Left Upper Lobe

Upper Division 183

Lingula 69

Left Lower Lobe

Superior 62

Basilar 67

Total 785

Incisional AccessIncisional Access

●●●● Retraction/Stapler: 7th Interspace, Posterior Axillary Line

●●●● Access Incision: Inframammary Crease, Anterior Axillary Line

●●●● Camera: 7th Interspace, Mid-Axillary Line

●●●● Stab Incision – Axillary hair line

General PrinciplesGeneral Principles

●●●● Vein - Artery - Bronchus

●●●● Exceptions: Superior and Posterior Segments

●●●● Hilar approach – avoid dissecting in fissure when possible

●●●● Individual bronchial and vascular isolation and division; develop and

complete fissures with stapled approach

●●●● Preserve integrity of remaining lung

●●●● Be mindful of aberrant anatomy

●●●● Stapled extended segmentectomy

Segmental PearlsSegmental Pearls

●●●● Vein - Artery - Bronchus

●●●● Right Upper Lobe Vein – anteroapical and interlobar branches

Right Upper Lobe

●●●● Smaller vascular branches can be divided with energy or clipped

●●●● Posterior artery may arise as a proximal trunk from the main PA, as

a side-branch of the anteroapical trunk or as a recurrent branch

arising from the superior segment artery

Segmental PearlsSegmental Pearls

●●●● Vein - Artery - Bronchus

●●●● Left Upper Lobe Vein – Upper Division and Lingular branches

Left Upper Lobe

●●●● Variable arterial anatomy – multiple posterior branches

●●●● Lingular artery may arise as a proximal trunk from the main PA, as a

side-branch of the first apicoposterior trunk or as a recurrent branch

arising from the basilar segment artery

Segmental PearlsSegmental Pearls

●●●● Vein - Bronchus - Artery

●●●● Right Middle Lobe Vein – typically arises from upper lobe vein

Right Middle Lobe

●●●● Frequently incomplete fissure

●●●● The middle lobe artery may arise as a common trunk or frequently

as paired segmental branches

Segmental PearlsSegmental Pearls

●●●● Lower Lobe Vein – small superior trunk runs posterior to bronchus

Lower Lobes

●●●● Anatomic relationships most constant

●●●● Vein - Artery - Bronchus

●●●● Arterial variations include accessory branches from the RML or

lingular arteries to the anterior basilar segment, accessory branches

to superior segment from the basilar artery and recurring branches to

the lingula and RUL posterior segment

Pure EnergyPure Energy

● Excellent hemostasis during the course of resection

● Low profile jaws facilitate instrument positioning

● Ease of use – Open and VATS

● Excellent hemostasis during the course of resection

● Minimal thermal spread (2-3 mm)

● Reduced operative costs

● Can assist in development of the fissures

Energy - Upper Division Energy - Upper Division

Pulmonary Vein

Energy - Upper Division Energy - Upper Division

Pulmonary Artery

Anatomic SegmentectomyAnatomic Segmentectomy

71 M

Long-time smoker

CT: 1.7 cm Lung Nodule

No enlarged lymph nodes

FNA: Adenocarcinoma

Basilar SegmentectomyBasilar Segmentectomy

Basilar

Vein

Superior

Segmental

VeinSuperior

Segmental

Vein

Divided

Basilar

Vein

Basilar SegmentectomyBasilar Segmentectomy

Basilar

Artery

Basilar SegmentectomyBasilar Segmentectomy

Basilar

Bronchus

Basilar SegmentectomyBasilar Segmentectomy

Basilar SegmentectomyBasilar Segmentectomy

Segmentectomy

(n=227)

Lobectomy

(n=336)P Value

Recurrence Locoregional

Distant

44 (19.4%)

11 (4.8%)

33 (14.5%)

49 (14.6%)

12 (3.6%)

37 (11.0%)

0.13

0.52

0.24

T1a NSCLC (≤ 2 cm)T1a NSCLC (≤ 2 cm)F

ree

do

m f

rom

Re

cu

rre

nc

e (

%)

Propensity-Matching (n=162)

Fre

ed

om

fro

m R

ec

urr

en

ce

(%

)

Time (Months)

Lobectomy

Segmentectomy

P=0.18

Fre

ed

om

fro

m D

ea

th (

%)

Time (Months)

Lobectomy

Segmentectomy

P=0.16

ACS 2011ACS 2011

Why Consider Anatomic Segmentectomy?

Sublobar ResectionSublobar Resection

• Decreased mortality risk in the elderly

• Lung Preservation - esp. in marginal patients

• Solitary Pulmonary Nodule - Diagnostic and Therapeutic

• Metastasectomy; GGOs• Metastasectomy; GGOs

• Accomplishes fundamental surgical tenets of R0 resection with

systematic nodal staging for NSCLC

• Taking more tissue does not enhance survival –

esp. small tumors

• Taking less tissue (e.g. SRS, RFA) does not accomplish R0

resection or systematic nodal staging

���� Anatomic Segmentectomy can be performed safely in the setting of the

indeterminate pulmonary nodule or clinical stage I NSCLC.

���� Anatomic segmentectomy is associated with equivalent recurrence-free

survival rates compared with lobectomy for clinical stage IA disease.

ConclusionsConclusionsConclusionsConclusions

���� Same anatomic dissection techniques as lobectomy

���� Careful attention to adequacy of margin and preservation of residual

bronchovascular unit

���� In the era of image-guided ablation modalities, segmental resection

for Stage I tumors affords complete resection with adequate margins,

regional nodal staging and provides tissue for pharmacogenomic

assessment.

Thank You