Ann Thorac Cardiovasc Surg 2015; 21: 84–86
New Methods
Online March 15, 2014 doi: 10.5761/atcs.nm.13-00322
Simulation of the Fissureless Technique for Thoracoscopic Segmentectomy Using Rapid Prototyping Tadashi Akiba, MD, PhD, FACS, Takeo Nakada, MD, and Takuya Inagaki, MD, PhD
The fissureless lobectomy or anterior fissureless technique is a novel surgical technique, which avoids dissection of the lung parenchyma over the pulmonary artery during lobectomy by open thoracotomy approach or direct vision thoracoscopic surgery. This technique is indicated for fused lobes. We present two cases where thoracoscopic pulmonary segmentectomy was performed using the fissureless technique simulated by three-dimensional (3D) pulmonary models. The 3D model and rapid prototyping provided an accurate anatomical understanding of the operative field in both cases. We believe that the construction of these models is useful for thoracoscopic and other complicated surgeries of the chest. Keywords: rapid prototyping technique, fissureless technique, thoracoscopic surgery, pulmonary segmentectomy
Introduction
Materials and Methods
The fissureless lobectomy or anterior fissureless technique is a novel technique, in which dissection of the lung parenchyma over the pulmonary artery is avoided. This approach has been reportedly used for lobectomy by open thoracotomy or direct vision thoracoscopic surgery.1,2) In cases with fused lobes, division of the lung parenchyma using staples reduces the risk of air leaks.1) To the best of our knowledge, there have been no reports describing the utilization of this technique for a pulmonary segmentectomy. In addition, there are no reports of this technique being used in conjunction with threedimensional (3D) pulmonary models created using rapid prototyping. We describe thoracoscopic pulmonary segmentectomies using the fissureless technique with 3D pulmonary model simulation.
We present two cases where thoracoscopic pulmonary segmentectomy was performed in 2013 using the fissureless technique simulated by 3D pulmonary models. A four-port thoracoscopic segmentectomy was performed in the lateral decubitus position. The four skin incisions (1–2 cm long) were made on the mid- and anterior axillary lines. Based on volume analysis of Synapse Vincent (Fujifilm Medical Co., Ltd., Tokyo, Japan) data derived from contrast-enhanced computed tomography (CT) scans, we were able to fabricate a 3D mixed-color replica of the anatomy with a 3D model printer (Connex, Stratasys, Ltd., Tokyo, Japan).3,4) We used white resin for bronchi and transparent resin for vessels in the cases in this manuscript. We obtained the approval of institutional ethics committee before starting this research.
Department of Surgery, The Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan Received: November 13, 2013; Accepted: January 7, 2014 Corresponding author: Tadashi Akiba, MD, PhD, FACS. Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita, Kashiwa, Chiba 277-8567, Japan Email: [email protected] ©2015 The Editorial Committee of Annals of Thoracic and Cardiovascular Surgery. All rights reserved.
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Results Case 1 A 65-year-old female patient underwent a hysterectomy and bilateral salpingo-oophorectomy for uterine leiomyosarcoma in March 2010, and abdominal lymphadenectomy Ann Thorac Cardiovasc Surg Vol. 21, No. 1 (2015)
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Fissureless Technique for 3D Model VATS Segmentectomy
in April 2011. She was referred to our department for further examination of an abnormal lung shadow. Retrospective review of her chest CT revealed the tumor had grown from 0.4 cm to 2.7 cm in size during two years. The patient underwent thoracoscopic basal segmentectomy of the left lower lobe. At first, the left superior and inferior pulmonary veins were exposed. Because the upper and lower lobes were fused, the pulmonary artery was subsequently exposed at the anterior and posterior hilum (Fig. 1A and 1C). The periadventitial plane of the pulmonary artery was followed to undermine the major fissure. The stapler anvil was introduced in this plane, and the fused major fissure was divided using the stapler and ultrasonically activated scalpel protecting the superior segmental artery of the left lower lobe and the lingular artery (Fig. 1B and 1D). The basal pulmonary arteries, vein, and bronchus were consecutively divided. The intersegmental plane was visualized by creating an inflation and deflation line, and an intersegmental fissure was made using staplers. The pathological diagnosis was metastatic leiomyosarcoma. The patient’s postoperative course was uneventful, and she was discharged on postoperative day 6. Case 2 A 66-year-old female patient with an abnormal shadow of ground glass opacification was monitored for 3 years and 6 months. During this period, her tumor had grown from 6 mm to 10 mm in size. She underwent a thoracoscopic left anterior basal segmentectomy after a preoperative diagnosis of lung cancer. The upper and lower lobes were fused except for the posterior part. The left superior and inferior pulmonary veins were exposed, and the pulmonary artery was exposed in the anterior hilum (Fig. 2). The periadventitial plane of the pulmonary artery was followed from the anterior hilum to undermine the major fissure, and the fused major fissure was divided using staplers. The anterior basal pulmonary artery, bronchus, and vein were consecutively divided. The intersegmental plane was visualized by creating an inflation and deflation line, and an intersegmental plane was made using staplers. The pathological diagnosis was bronchioloalveolar carcinoma of the lung. The patient’s postoperative course was uneventful, and she was discharged on postoperative day 6.
Discussion For a lobectomy, the parenchyma over the pulmonary artery is typically divided by electrocautery or Ann Thorac Cardiovasc Surg Vol. 21, No. 1 (2015)
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Fig. 1 ( Case 1): (A) Anterior view of the three-dimensional pulmonary model (PM) showing the left inferior branch (A5) of the lingular artery and the anterior basal branch (A8) of the pulmonary artery lateral to the lingular bronchus (LB) and the anterior basal bronchus (B8) of the left lower lobe (LLL). Arrow: orifice or tract of the periadventitial plane of the pulmonary artery. (B) Lateral view of PM showing the pulmonary artery. A4, A5: the lingular arteries, A6: the superior pulmonary artery of LLL, A8, 9+10: the basal arteries of LLL. (C) Anterior view of the operative field showing A5 and A8 lateral to LB and B8. (D) Lateral view of the operative field showing A4, A5, A6, A8, and A9+10.
ultrasonically activated scalpel. However, this procedure may cause air leaks, which can prolong the durations of chest tube drainage and hospitalization. Temes, et al., in 1998, described a fissureless lobectomy with open thoracotomy, a technique in which the pulmonary artery is exposed using a stapler for the entire dissection of lung parenchyma over the pulmonary artery in order to minimize air leaks.2) They commented that this technique could be modified and adapted to segmentectomies or thoracoscopic lobectomies with incomplete fissures. GómezCaro, et al. reported that the fissureless technique for a right upper lobectomy with a posterolateral incision decreased the incidence of prolonged air leakage after lobectomy.1) They divided the pulmonary artery after dividing the corresponding bronchus. Ng, et al. reported that the anterior fissureless technique for a right upper lobectomy with a lateral thoracotomy or muscle sparing lateral thoracotomy reduced air leakage and the duration 85
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Akiba T, et al.
understanding of the anatomy of the lesion even in an unusual operative field. Using 3D models, we can image and sense the depth of the structures of pulmonary vessels and bronchi. On the other hand, from 3D images using multidetector CT, we can also understand the relations of structures, for instance, which is anterior side or posterior side. But it is usually difficult to sense the depth of these structures. Experienced general thoracic surgeon may be able to image the depth of these structures, but for unexperienced general thoracic surgeons, 3D models will assist to understand the depth of the structures than 3D images. We believe that construction of these models is worthwhile for thoracoscopic and other complicated surgeries of the chest.
Disclosure Statement Fig. 2 (Case 2): (A) Anterior view of pulmonary model (PM) showing A5 and A8 lateral to the lingular bronchus (LB) and B8. Arrow: orifice or tract of the periadventitial plane of the pulmonary artery. (B) Anterolateral view of PM showing the A8, B8, and branch of left lower lobe pulmonary vein (PV). (C) Anterior view of the operative field showing A8 lateral to B8. (D) Anterolateral view of the operative field showing A8, B8, and PV.
of hospital stay.5) In addition, Refai, et al. reported that this procedure reduced air leakage and hospital costs without increasing operative time.6) Nomori, et al. described operative procedures for various pulmonary lobectomies with fused fissures using video-assisted thoracoscopic surgery.7) They usually divided the lobar bronchus first, followed by the pulmonary arterial branches within the fissure, and eventually the fissure itself. Thus, the fissureless technique appears to be useful for both open thoracotomies and thoracoscopic surgeries, but there are no reports of pulmonary segmentectomies or complete thoracoscopic surgeries in conjunction with this method to the best of our knowledge. In order to adopt a new operative technique in an unusual operative field, simulation is desirable. Rapid prototyping techniques have been proven to be beneficial in various fields of surgery.8,9) These 3D models can be useful for pre- and intraoperative surgical procedure planning; nevertheless, only a few pulmonary models have been detailed in the literature in the field of general thoracic surgery.3,4) The 3D model and rapid prototyping technique used in the two cases described above provided us with an accurate 86
05_15_NM_Akiba_322.indd
None to declare.
References 1) Gómez-Caro A, Calvo MJ, Lanzas JT, et al. The approach of fused fissures with fissureless technique decreases the incidence of persistent air leak after lobectomy. Eur J Cardiothorac Surg 2007; 31: 203-8. 2) Temes RT, Willms CD, Endara SA, et al. Fissureless lobectomy. Ann Thorac Surg 1998; 65: 282-4. 3) Akiba T, Nakada T, Inagaki T. Three-dimensional pulmonary model using rapid-prototyping in patient with lung cancer requiring segmentectomy. Ann Thorac Cardiovasc Surg 2013 Nov 8. [Epub ahead of print] 4) Akiba T, Nakada T, Inagaki T. Three-dimensional printing model of anomalous bronchi before surgery. Ann Thorac Cardiovasc Surg 2013 Oct 3. [Epub ahead of print] 5) Ng T, Ryder BA, Machan JT, et al. Decreasing the incidence of prolonged air leak after right upper lobectomy with the anterior fissureless technique. J Thorac Cardiovasc Surg 2010; 139: 1007-11. 6) Refai M, Brunelli A, Salati M, et al. Efficacy of ante rior fissureless technique for right upper lobectomies: a case-matched analysis. Eur J Cardiothorac Surg 2011; 39: 1043-6. 7) Nomori H, Ohtsuka T, Horio H, et al. Thoracoscopic lobectomy for lung cancer with a largely fused fissure. Chest 2003; 123: 619-22. 8) Kim MS, Hansgen AR, Wink O, et al. Rapid prototyping: a new tool in understanding and treating structural heart disease. Circulation 2008; 117: 2388-94. 9) Esses SJ, Berman P, Bloom AI, et al. Clinical applications of physical 3D models derived from MDCT data and created by rapid prototyping. AJR Am J Roentgenol 2011; 196: W683-8. Ann Thorac Cardiovasc Surg Vol. 21, No. 1 (2015)
86
2015/02/06
13:51:47
New Methods
Online March 15, 2014 doi: 10.5761/atcs.nm.13-00322
Simulation of the Fissureless Technique for Thoracoscopic Segmentectomy Using Rapid Prototyping Tadashi Akiba, MD, PhD, FACS, Takeo Nakada, MD, and Takuya Inagaki, MD, PhD
The fissureless lobectomy or anterior fissureless technique is a novel surgical technique, which avoids dissection of the lung parenchyma over the pulmonary artery during lobectomy by open thoracotomy approach or direct vision thoracoscopic surgery. This technique is indicated for fused lobes. We present two cases where thoracoscopic pulmonary segmentectomy was performed using the fissureless technique simulated by three-dimensional (3D) pulmonary models. The 3D model and rapid prototyping provided an accurate anatomical understanding of the operative field in both cases. We believe that the construction of these models is useful for thoracoscopic and other complicated surgeries of the chest. Keywords: rapid prototyping technique, fissureless technique, thoracoscopic surgery, pulmonary segmentectomy
Introduction
Materials and Methods
The fissureless lobectomy or anterior fissureless technique is a novel technique, in which dissection of the lung parenchyma over the pulmonary artery is avoided. This approach has been reportedly used for lobectomy by open thoracotomy or direct vision thoracoscopic surgery.1,2) In cases with fused lobes, division of the lung parenchyma using staples reduces the risk of air leaks.1) To the best of our knowledge, there have been no reports describing the utilization of this technique for a pulmonary segmentectomy. In addition, there are no reports of this technique being used in conjunction with threedimensional (3D) pulmonary models created using rapid prototyping. We describe thoracoscopic pulmonary segmentectomies using the fissureless technique with 3D pulmonary model simulation.
We present two cases where thoracoscopic pulmonary segmentectomy was performed in 2013 using the fissureless technique simulated by 3D pulmonary models. A four-port thoracoscopic segmentectomy was performed in the lateral decubitus position. The four skin incisions (1–2 cm long) were made on the mid- and anterior axillary lines. Based on volume analysis of Synapse Vincent (Fujifilm Medical Co., Ltd., Tokyo, Japan) data derived from contrast-enhanced computed tomography (CT) scans, we were able to fabricate a 3D mixed-color replica of the anatomy with a 3D model printer (Connex, Stratasys, Ltd., Tokyo, Japan).3,4) We used white resin for bronchi and transparent resin for vessels in the cases in this manuscript. We obtained the approval of institutional ethics committee before starting this research.
Department of Surgery, The Jikei University Kashiwa Hospital, Kashiwa, Chiba, Japan Received: November 13, 2013; Accepted: January 7, 2014 Corresponding author: Tadashi Akiba, MD, PhD, FACS. Department of Surgery, The Jikei University Kashiwa Hospital, 163-1 Kashiwashita, Kashiwa, Chiba 277-8567, Japan Email: [email protected] ©2015 The Editorial Committee of Annals of Thoracic and Cardiovascular Surgery. All rights reserved.
84
05_15_NM_Akiba_322.indd
Results Case 1 A 65-year-old female patient underwent a hysterectomy and bilateral salpingo-oophorectomy for uterine leiomyosarcoma in March 2010, and abdominal lymphadenectomy Ann Thorac Cardiovasc Surg Vol. 21, No. 1 (2015)
84
2015/02/06
13:51:46
Fissureless Technique for 3D Model VATS Segmentectomy
in April 2011. She was referred to our department for further examination of an abnormal lung shadow. Retrospective review of her chest CT revealed the tumor had grown from 0.4 cm to 2.7 cm in size during two years. The patient underwent thoracoscopic basal segmentectomy of the left lower lobe. At first, the left superior and inferior pulmonary veins were exposed. Because the upper and lower lobes were fused, the pulmonary artery was subsequently exposed at the anterior and posterior hilum (Fig. 1A and 1C). The periadventitial plane of the pulmonary artery was followed to undermine the major fissure. The stapler anvil was introduced in this plane, and the fused major fissure was divided using the stapler and ultrasonically activated scalpel protecting the superior segmental artery of the left lower lobe and the lingular artery (Fig. 1B and 1D). The basal pulmonary arteries, vein, and bronchus were consecutively divided. The intersegmental plane was visualized by creating an inflation and deflation line, and an intersegmental fissure was made using staplers. The pathological diagnosis was metastatic leiomyosarcoma. The patient’s postoperative course was uneventful, and she was discharged on postoperative day 6. Case 2 A 66-year-old female patient with an abnormal shadow of ground glass opacification was monitored for 3 years and 6 months. During this period, her tumor had grown from 6 mm to 10 mm in size. She underwent a thoracoscopic left anterior basal segmentectomy after a preoperative diagnosis of lung cancer. The upper and lower lobes were fused except for the posterior part. The left superior and inferior pulmonary veins were exposed, and the pulmonary artery was exposed in the anterior hilum (Fig. 2). The periadventitial plane of the pulmonary artery was followed from the anterior hilum to undermine the major fissure, and the fused major fissure was divided using staplers. The anterior basal pulmonary artery, bronchus, and vein were consecutively divided. The intersegmental plane was visualized by creating an inflation and deflation line, and an intersegmental plane was made using staplers. The pathological diagnosis was bronchioloalveolar carcinoma of the lung. The patient’s postoperative course was uneventful, and she was discharged on postoperative day 6.
Discussion For a lobectomy, the parenchyma over the pulmonary artery is typically divided by electrocautery or Ann Thorac Cardiovasc Surg Vol. 21, No. 1 (2015)
05_15_NM_Akiba_322.indd
85
Fig. 1 ( Case 1): (A) Anterior view of the three-dimensional pulmonary model (PM) showing the left inferior branch (A5) of the lingular artery and the anterior basal branch (A8) of the pulmonary artery lateral to the lingular bronchus (LB) and the anterior basal bronchus (B8) of the left lower lobe (LLL). Arrow: orifice or tract of the periadventitial plane of the pulmonary artery. (B) Lateral view of PM showing the pulmonary artery. A4, A5: the lingular arteries, A6: the superior pulmonary artery of LLL, A8, 9+10: the basal arteries of LLL. (C) Anterior view of the operative field showing A5 and A8 lateral to LB and B8. (D) Lateral view of the operative field showing A4, A5, A6, A8, and A9+10.
ultrasonically activated scalpel. However, this procedure may cause air leaks, which can prolong the durations of chest tube drainage and hospitalization. Temes, et al., in 1998, described a fissureless lobectomy with open thoracotomy, a technique in which the pulmonary artery is exposed using a stapler for the entire dissection of lung parenchyma over the pulmonary artery in order to minimize air leaks.2) They commented that this technique could be modified and adapted to segmentectomies or thoracoscopic lobectomies with incomplete fissures. GómezCaro, et al. reported that the fissureless technique for a right upper lobectomy with a posterolateral incision decreased the incidence of prolonged air leakage after lobectomy.1) They divided the pulmonary artery after dividing the corresponding bronchus. Ng, et al. reported that the anterior fissureless technique for a right upper lobectomy with a lateral thoracotomy or muscle sparing lateral thoracotomy reduced air leakage and the duration 85
2015/02/06
13:51:46
Akiba T, et al.
understanding of the anatomy of the lesion even in an unusual operative field. Using 3D models, we can image and sense the depth of the structures of pulmonary vessels and bronchi. On the other hand, from 3D images using multidetector CT, we can also understand the relations of structures, for instance, which is anterior side or posterior side. But it is usually difficult to sense the depth of these structures. Experienced general thoracic surgeon may be able to image the depth of these structures, but for unexperienced general thoracic surgeons, 3D models will assist to understand the depth of the structures than 3D images. We believe that construction of these models is worthwhile for thoracoscopic and other complicated surgeries of the chest.
Disclosure Statement Fig. 2 (Case 2): (A) Anterior view of pulmonary model (PM) showing A5 and A8 lateral to the lingular bronchus (LB) and B8. Arrow: orifice or tract of the periadventitial plane of the pulmonary artery. (B) Anterolateral view of PM showing the A8, B8, and branch of left lower lobe pulmonary vein (PV). (C) Anterior view of the operative field showing A8 lateral to B8. (D) Anterolateral view of the operative field showing A8, B8, and PV.
of hospital stay.5) In addition, Refai, et al. reported that this procedure reduced air leakage and hospital costs without increasing operative time.6) Nomori, et al. described operative procedures for various pulmonary lobectomies with fused fissures using video-assisted thoracoscopic surgery.7) They usually divided the lobar bronchus first, followed by the pulmonary arterial branches within the fissure, and eventually the fissure itself. Thus, the fissureless technique appears to be useful for both open thoracotomies and thoracoscopic surgeries, but there are no reports of pulmonary segmentectomies or complete thoracoscopic surgeries in conjunction with this method to the best of our knowledge. In order to adopt a new operative technique in an unusual operative field, simulation is desirable. Rapid prototyping techniques have been proven to be beneficial in various fields of surgery.8,9) These 3D models can be useful for pre- and intraoperative surgical procedure planning; nevertheless, only a few pulmonary models have been detailed in the literature in the field of general thoracic surgery.3,4) The 3D model and rapid prototyping technique used in the two cases described above provided us with an accurate 86
05_15_NM_Akiba_322.indd
None to declare.
References 1) Gómez-Caro A, Calvo MJ, Lanzas JT, et al. The approach of fused fissures with fissureless technique decreases the incidence of persistent air leak after lobectomy. Eur J Cardiothorac Surg 2007; 31: 203-8. 2) Temes RT, Willms CD, Endara SA, et al. Fissureless lobectomy. Ann Thorac Surg 1998; 65: 282-4. 3) Akiba T, Nakada T, Inagaki T. Three-dimensional pulmonary model using rapid-prototyping in patient with lung cancer requiring segmentectomy. Ann Thorac Cardiovasc Surg 2013 Nov 8. [Epub ahead of print] 4) Akiba T, Nakada T, Inagaki T. Three-dimensional printing model of anomalous bronchi before surgery. Ann Thorac Cardiovasc Surg 2013 Oct 3. [Epub ahead of print] 5) Ng T, Ryder BA, Machan JT, et al. Decreasing the incidence of prolonged air leak after right upper lobectomy with the anterior fissureless technique. J Thorac Cardiovasc Surg 2010; 139: 1007-11. 6) Refai M, Brunelli A, Salati M, et al. Efficacy of ante rior fissureless technique for right upper lobectomies: a case-matched analysis. Eur J Cardiothorac Surg 2011; 39: 1043-6. 7) Nomori H, Ohtsuka T, Horio H, et al. Thoracoscopic lobectomy for lung cancer with a largely fused fissure. Chest 2003; 123: 619-22. 8) Kim MS, Hansgen AR, Wink O, et al. Rapid prototyping: a new tool in understanding and treating structural heart disease. Circulation 2008; 117: 2388-94. 9) Esses SJ, Berman P, Bloom AI, et al. Clinical applications of physical 3D models derived from MDCT data and created by rapid prototyping. AJR Am J Roentgenol 2011; 196: W683-8. Ann Thorac Cardiovasc Surg Vol. 21, No. 1 (2015)
86
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