Atlas of Thoracoscopic Anatomical Pulmonary Subsegmentectomy

By Liang Chen, Quan Zhu and Weibing Wu

Atlas of Thoracoscopic Anatomical Pulmonary Subsegmentectomy provides an in-depth and comprehensive overview and guidance on anatomical pulmonary subsegmentectomy, from both theoretical and technical perspectives. The book is divided in two parts: Part I is dedicated to theoretical background of surgery, including surgical subsegmental anatomy, CT three-dimensional reconstruction of pulmonary structures, surgical techniques, and perioperative patient management. Part II presents more than 40 kinds of subsegmentectomies of the left and right lungs, both upper and lower lobes.

As the rapid development of three-dimensional computed tomographic images has made it possible to provide more refined individualized anatomic details, and has consequently enabled advances in pulmonary subsegmentectomy, this book is a valuable resource to thoracic surgeons and physicians interested in thoracic surgery and mini-invasive surgical approaches in the thorax.

• Features complete coverage of all aspects of thoracoscopic anatomical pulmonary subsegmentectomy, from theory to practice
• Presents more than 40 kinds of subsegmentectomies of the left and right lungs, both upper and lower lobes
• Includes videos of 3D models and operations

• Language: English
• Publisher: Elsevier Science
• Release date: Aug 18, 2023
• ISBN: 9780323957878

Liang Chen

Dr Chen is Chief Surgeon, Professor and Doctoral Supervisor, Director of the Department of Thoracic Surgery of the First Affiliated Hospital with Nanjing Medical University (Jiangsu Province Hospital) and deputy director of Department of Thoracic Surgery of the First Clinical College of Nanjing Medical University. Current chairman of the Thoracic Surgery Branch of the Jiangsu Medical Association, chairman-designate of the Thoracic Surgery Branch of Jiangsu Medical Doctor Association, member of the Thoracoscopy Group of the Fourth Chinese Society of Thoracic and Cardiovascular Surgery. He is committed to the surgical treatment of early lung cancer, has completed more than 1,000 cases of thoracoscopic anatomical pulmonary segmentectomy and more than 400 cases of pulmonary subsegmentectomy. Dr Chen was the first to report thoracoscopic pulmonary sub-subsegmentectomy in the world. He was the first in China to propose the concept of "three-dimensional computed tomography bronchography and angiography (3D-CTBA)-guided precise thoracoscopic pulmonary segmentectomy" and devoted himself to promoting precise thoracoscopic pulmonary segmentectomy worldwide.

Book preview

9780323957878_FC

Atlas of Thoracoscopic Anatomical Pulmonary Subsegmentectomy

First Edition

Liang Chen

Chief Surgeon, Professor and Doctoral Supervisor, Director, Department of Thoracic Surgery, The First Affiliated Hospital with Nanjing Medical University, China

Quan Zhu

Chief Physician and Deputy Director of Thoracic Surgery, The First Affiliated Hospital with Nanjing Medical University, China

Weibing Wu

Chief Physician and Deputy Director of Surgery, The First Affiliated Hospital with Nanjing Medical University, China

Yifei Huang

Fellow, Department of Cardiothoracic Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia

publogo

Table of Contents

Cover

Title page

Copyright

Contributors

Acknowledgments

Part One: Theoretical background

Chapter One: History of pulmonary segmentectomy and subsegmentectomy

Abstract

References

Chapter Two: Subsegmental anatomy of the lungs

Abstract

1: Development of nomenclature for subsegmental anatomy

2: Nomenclature of pulmonary segments

3: Branching patterns of segmental bronchi, arteries and veins

References

Chapter Three: Formation of three-dimensional broncho-vascular images

Abstract

1: History of three-dimensional pulmonary broncho-vascular reconstruction

2: Method of thoracic 3D reconstruction

3: Chest image data acquisition for 3D reconstruction

References

Chapter Four: Theory and key techniques in cone-shaped pulmonary segmentectomy

Abstract

1: Theory of cone-shaped segmentectomy

2: Planning of segmentectomy guided by 3D-CTBA navigation

3: Precise demarcation of intersegmental interfaces

4: Anatomical dissection of intersegmental interfaces

5: Individualized pulmonary nodule resection based on three-dimensional nodule localization and subsegment as surgical unit

References

Chapter Five: Surgical process and management of patients

Abstract

1: Indications for segmentectomy and subsegmentectomy

2: Preoperative preparation of surgical equipment and instruments

3: Anesthesia, patient position, and incisions

4: Localization of nodules in surgery

5: Intraoperative considerations

References

Chapter Six: Common complications and management

Abstract

1: Intraoperative complications and management

2: Postoperative complications and management

References

Part Two: Subsegmentectomies

Chapter Seven: Subsegmentectomy in the right upper lobe

Abstract

1: Single subsegmentectomy

2: Combined subsegmentectomy

3: Subsubsegmentectomy

4: Triple subsegmentectomy

Chapter Eight: Subsegmentectomy in the left upper lobe

Abstract

1: Single subsegmentectomy

2: Double subsegmentectomy

3: Combined subsegmentectomy

4: Subsubsegmentectomy

5: Triple subsegmentectomy

Chapter Nine: Subsegmentectomy in the right lower lobe

Abstract

1: Single subsegmentectomy

2: Combined subsegmentectomy

3: Triple subsegmentectomy

Chapter Ten: Subsegmentectomy in the left lower lobe

Abstract

1: Single subsegmentectomy

2: Combined subsegmentectomy

Index

Copyright

Elsevier

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Notices

Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary.

Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility.

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Contributors

Liang Chen     Chief Surgeon, Professor, Director, Department of Thoracic Surgery, Jiangsu Province Hospital, The First Affiliated Hospital with Nanjing Medical University; Chairman, Thoracic Surgery Branch of the Jiangsu Medical Association, Nanjing, Jiangsu, China

Zhicheng He     Thoracic Surgery, Jiangsu Province Hospital, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China

Yifei Huang     Fellow, Department of Cardiothoracic Surgery, Royal North Shore Hospital, St Leonards, NSW, Australia

Haoran Lin     Thoracic Surgery, Jiangsu Province Hospital, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China

Xianglong Pan     Thoracic Surgery, Jiangsu Province Hospital, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China

Wenjun Tan     Centre of Excellence in Intelligent Computing for Medical Imaging, the Ministry of Education of China, Northeastern University, Shenyang, Liaoning, China

Lijun Tang     Department of Nuclear Medicine, Jiangsu Province Hospital, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China

Jun Wang     Thoracic Surgery, Jiangsu Province Hospital, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China

Wei Wen     Thoracic Surgery, Jiangsu Province Hospital, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China

Weibing Wu     Thoracic Surgeon, Deputy Director, Department of Surgery, Jiangsu Province Hospital, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China

Jing Xu     Thoracic Surgery, Jiangsu Province Hospital, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China

Wenzheng Xu     Thoracic Surgery, Jiangsu Province Hospital, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China

Xinfeng Xu     Thoracic Surgery, Jiangsu Province Hospital, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China

Fei Yao     Thoracic Surgery, The Affiliated Jiangning Hospital with Nanjing Medical University, Nanjing, Jiangsu, China

Jianan Zheng     Thoracic Surgery, Jiangsu Province Hospital, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China

Quan Zhu     Thoracic Surgeon, Deputy Director, Department of Thoracic Surgery, Jiangsu Province Hospital, The First Affiliated Hospital with Nanjing Medical University, Nanjing, Jiangsu, China

Acknowledgments

I would like to acknowledge Prof. Wenjun Tan and his colleagues (Centre of Excellence in Intelligent Computing for Medical Imaging, the Ministry of Education of China, Northeastern University, China) for their tremendous support in developing the three-dimensional computed tomography bronchography and angiography (3D-CTBA) software DeepInsight over a number of years. Most of the 3D reconstruction models of lungs in this book were built using DeepInsight.

I also would like to thank Fujifilm, Japan, for the use of their Synapse 3D software in building some of the 3D reconstruction models of the lungs in this book.

I have been very appreciative of the support from Dr. Gang Huang (Department of Thoracic Surgery, The Third Hospital of Hebei Medical University, China) and his colleagues, who helped us build some of the 3D reconstruction models of lungs in this book using Materialise Mimics (Materialise Interactive Medical Image Control System).

I would like to take this opportunity to thank our two colleagues, Profs. Jiong Ding and Lei Li (Department of Human Anatomy of Nanjing Medical University, China). They added the Latin nomenclature to the section Anatomical Nomenclature of Lung Segments in this book.

Special thanks go to Dr. Tao Tao for the translation of the second part of this book and for making this project possible.

It is a great honor to have Dr. Scott J. Swanson, one of the pioneers in minimally invasive thoracic surgery, to write the preface of this book.

Finally, I extend my gratitude to the scrub nurses and other staff on our team for their patience and dedication. They have made thoracoscopic pulmonary subsegmentectomy into almost a routine procedure.

The download addresses of DeepInsight software installation files, application agreement, installation instructions, and operation instructions can be found at:

(Chinese version)

https://pan.baidu.com/s/18GyXNiXEoBmRE7aoxc9uEA

Extraction code: lclc

For the latest developments and news on DeepInsight, please follow the WeChat public account: DeepInsight System

(English version)

https://drive.google.com/drive/Deepinsight

Extraction code: lclc

For the latest developments and news on DeepInsight, please follow https://www.facebook.com/DeepInsightSystem

Liang Chen

Part One

Theoretical background

Chapter One: History of pulmonary segmentectomy and subsegmentectomy

Liang Chen; Wei Wen

Abstract

The evolution of our understanding of pulmonary anatomy and physiology, improvements in early diagnosis of lung cancer, advancements in medical imaging, and the use of thoracoscopic technique have all contributed to the transformation of lung surgery from pneumonectomy and lobectomy to segmentectomy and subsegmentectomy. These advances have brought about changes in surgical concepts, better results, and less suffering for patients. However, the advances will not stop here, as new aspects of lung surgery, robotic surgery, and mixed reality guided surgery, among others, are just around the corner.

Keywords

Lung surgery history; Lung surgery; Pulmonary anatomy; Subsegmentectomy; Segmentectomy

Necessity is the mother of invention. The emergence, development, and maturity of pulmonary segmentectomy and subsegmentectomy in our age have been closely related to the demand for surgical treatment of various lung diseases on the one hand, and the advances in clinical medicine, such as medical imaging and surgical techniques, and further understanding of pulmonary anatomy, on the other. From the end of the 19th century to the beginning of the 20th century, bronchiectasis, tuberculosis, and lung abscess became serious life-threatening diseases due to the lack of antibiotics. Resection of the entire affected lung, i.e., pneumonectomy, was the only treatment option. In 1895, Macewen reported a staged pneumonectomy for the first time.¹ Later, in 1922, Hinz described a method for ligating hilar structures.¹ Graham and Singer reported one-stage pneumonectomy in 1933.²

As a result of severe surgical trauma, immaturity of surgical techniques, excessive loss of healthy lung tissue, and lack of understanding of cardiopulmonary physiology, morbidity and mortality after pneumonectomy were extremely high in the past, and are still unacceptably high today, albeit with considerable improvement. Therefore how to completely remove diseased tissue while maximally preserving healthy, functional lung tissue became a top priority at the time. As a result, lobectomy and subsequently segmentectomy and subsegmentectomy were born, consistent with needs.

The evolving and subsequent advances of our knowledge of pulmonary segmental anatomy provided the necessary theoretical basis for segmentectomy. The history can be traced back to the 17th century, when the De Respirationis Organis et Usu of Willis (1676) presented diagrams of a embryological lobe with lines drawn around potential bronchopulmonary segments (Fig. 1.1).³ In 1685 Diemerbroeck produced a woodcut print of the human bronchial tree (Fig. 1.2), which displayed all now-recognized segmental bronchi.⁴ These two illustrations were the first to depict the structure of bronchial branches.

Fig. 1.1

Fig. 1.1 A structural diagram of the lobar bronchi presented by Willis in 1676.

Fig. 1.2

Fig. 1.2 The human bronchial tree woodcut made by Diemerbroeck in 1685.

In 1880, Aeby⁵ published Der Bronchialbaum der Säugethiere und des Mensch, which presented the comparative pulmonary anatomy of mammals and men. In the same year, Ewart⁶ also published his anatomical study of bronchi and blood vessels, with critical comparison to Professor Aeby’s views. These two anatomical monographs examined and described bronchial and pulmonary vascular branches in detail. Although the nomenclatures were different and the labeling of the segments was not present, it was recognized that the pulmonary lobes can be further divided into smaller anatomical units. Fifty years later (1932) the concept of bronchopulmonary segment was first proposed by Kramer and Glass.⁷ For the first time, they showed not only locations of the segments on the lung surface, but also concluded that all lung abscesses were clearly located in a segment. In 1934, Nelson⁸ divided each of the left and right lungs into four lobes, namely the upper, middle, dorsal, and lower lobes. He also described that bronchiectasis involves a cone-like area of lung (segment). In 1939, Churchill and Belsey⁹ showed that there are avascular planes between the four lobes (including the dorsal and basal segments of the lower lobe, the upper division and lingular segments of the left upper lobe). In that same year, Hardie-Neil, Gilmour, and Gwynne¹⁰ proposed to name tertiary bronchi as segmental bronchi.

In 1942, Brock, Hodgkiss, and Jones¹¹ demonstrated that the sizes of segments vary, and one segment can occupy the space of an adjacent segment. These pioneers and later Adams and Davenport,¹² Foster-Carter,¹³ and Appleton¹⁴ used different terminologies for segments at the time. Jackson and Huber later proposed (1943) to name anatomical units of the segments and subsegments by their position in a lobe, that is, the relationships between superior and inferior, posterior and anterior, and lateral and medial.¹⁵ This nomenclature was approved by the American Broncho-Esophagological Association and was used in the 25th edition of Gray’s Anatomy, the 10th edition of Morris’s Human Anatomy, and Grant’s Method of Anatomy,¹⁶ and it is still in use today. In 1945, Boyden¹⁷ adopted Jackson and Huber’s method to name segments, subsegments, and subsubsegments; meanwhile the corresponding bronchi, arteries, and accompanying veins were named using the same rules. He also pointed out that the distribution of peripheral (intersegmental) veins is principally in the intersegmental space. He proposed to use Arabic numerals positioned at the exponential position to identify an indexed lung segment, and alphabetical letters (a, b, and c) to identify its dichotomous subsegments, and, again, Arabic numerals following letters to identify subsubsegments. For example, the upper subsubsegment of the apical subsegment in the apical segment of the right upper lobe is identified as S¹a1.

At the same time, Boyden proposed a scientific anatomical definition of segment: the bronchopulmonary segment is defined as the zone of distribution of a major bronchus which may or may not be entered by arteries from adjacent segments and which is drained peripherally by veins occupying intersegmental planes. Subsequently, he published Segmental Anatomy of the Lung (1954).⁴ Yamashita published Roentgenologic Anatomy of the Lung in 1978.¹⁸ These two epoch-making monographs on the anatomy of pulmonary segments introduced and summarized the normal anatomy and variation of the segments and subsegments in great detail, and became the cornerstones of the history of segmentectomy.

In 2010, Gossot published Atlas of Endoscopic Major Pulmonary Resections.¹⁹ One year later, McKenna, Mahtabifard, and Swanson published Atlas of Minimally Invasive Thoracic Surgery (VATS).²⁰ In 2012, Nomori and Okada published Illustrated Textbook of Anatomical Pulmonary Segmentectomy.²¹ In 2015, Chen and Zhu published Atlas of Thoracoscopic Anatomical Pulmonary Segmentectomy in Chinese.²² These four monographs on anatomical segmentectomy have played a positive role in leading and promoting the development of modern segmentectomy.

The surgical history of segmentectomy can be traced back to the late 19th century. In their publication, Overholt et al. cited the prototype of segmentectomy by Dr. Bloch where he removed an apical part of the superior segment of a lower lobe by ligation and resection of lung tissue in 1881.²³ It wasn’t until almost half a century later (1939) that the anatomically meaningful segmentectomy emerged. Churchill of Massachusetts General Hospital in Boston and Belsey of Brompton Chest Hospital in London⁹ jointly reported their 125 cases (Churchill 44 cases, Belsey 81 cases) of segmentectomy for treatment of bronchiectasis. They termed segmental resection segmental pneumonectomy. The article also pointed out that bronchiectasis is usually confined to one or several segments of a lobe, and the pathology commonly existed in multiple lobes at the same time. The concept of removing diseased segments while preserving normal segments as much as possible was proposed. The authors recommended segments rather than lobes as independent surgical resection targets. Technically, they suggested that segmental bronchus and blood vessels should be treated separately. They described the deflation technique which was used to determine the intersegmental interfaces in operations. They also described the technique for treating intersegmental interface, i.e., to apply vascular clamps along the plane between the segments, to resect the diseased segment and to close the surgical edge of preserved lung using continuous suture.

In 1942, Adams and Davenport¹² described that the intersegmental planes are avascular and diverging planes. In the same year, Kent and Blades²⁴ referred to segmentectomy as partial pulmonary resection. In 1943, Blades²⁵ reported single and double segmentectomy of the basal segments, and single segmentectomy of the right upper lobe. They termed segmentectomy partial lobectomy. In 1946, Clagett and Detering²⁶ reported 17 cases of lingular segmentectomy of the left upper lobe. For the first time, they used blunt dissection along a rather avascular plane to separate interfaces between segments in the intersegmental plane, and a technique of traction dissection was proposed that is still in use today. They called segmentectomy segmental pulmonary resection. In 1947, Overholt and Langer²⁷ once again mentioned that bronchiectasis was mainly a disease of pulmonary segments, and emphasized that segmentectomy conformed to the two basic principles of surgery, i.e., to cure patients and preserve functional lung tissue as much as possible. In the article they described in detail the presentation of intersegmental plane and the method of blunt separation of the plane used in their medical center, which significantly reduced incidence of postoperative complications. Contrary to the modern theory of preserving intersegmental veins, the paper described division of intersegmental veins. In their paper, resections of the apical, posterior, or anterior segments of the right upper lobe and the posterior basal segment of the right lower lobe were reported. Segmentectomy was termed pulmonary segmental resection. In 1949, Ramsay²⁸ differentiated segmental veins from intersegmental veins (intersegmental veins were first termed). Segmental veins are small venous vessels, closely accompanying segmental bronchi and arteries. While the proximal ends of the intersegmental veins are located in the hilar, they are not accompanied by segmental pulmonary arteries or bronchi. The peripheral part of intersegmental veins run in the intersegmental planes. Ramsay proposed for the first time that the intersegmental veins can be used as markers for dissection of the intersegmental interfaces in all segmentectomy. He also suggested that the intersegmental vein should be preserved, and only the venous tributaries from the diseased segment should be divided (i.e., Boyden’s interramal vein described in 1954,⁴ or the intrasegmental vein first described by Oizumi et al.²⁹ in 2011). It was clearly depicted that the hilar pulmonary artery, bronchus, and vein lead to a cone-shaped alveolar tissue area. This provided a theoretical basis for our proposed cone-shaped segmentectomy. In the same year, Scannell³⁰ reported the first case of resection of a basal segment in the right lower lobe (S⁷). In 1950, Overholt, Woods, and Ramsay²³ discussed prevention and treatment of complications such as pulmonary torsion, air leak from the surface of resection, and bronchopleural fistula. All these early explorations and summations of segmentectomy laid the theoretical foundation of segmentectomy. They became ever-lasting classic works in lung surgery. The term segmentectomy first appeared in the French literature³¹ in 1952 and in the English literature in 1959.³²

Before the 1950s, segmentectomy was mainly used to treat benign lung diseases such as pulmonary abscess, tuberculosis, and bronchiectasis. With the advent and clinical application of antibiotics such as penicillin and streptomycin, the majority of infectious pulmonary diseases became curable with medication, and surgery was then used only in special circumstances. As a result, the surgery of segmentectomy gradually faded out. In the 1960s, Clagett, Thomford, and Woolner³³,³⁴ reported segmentectomy for treating metastatic lung lesions. In 1972, Bonfils-Roberts and Clagett³⁵ first proposed that segmentectomy can be selectively used for elderly patients with lung cancer having poor cardiopulmonary functional reserve. This practice was followed by Jensik,³⁶,³⁷ Read,³⁸ Warren,³⁹ et al. It was reported that the oncological effect of segmentectomy for early-stage lung cancer was comparable to that of lobectomy, suggesting that segmentectomy is an option for surgical treatment of lung cancer.

Between 1982 and 1988, the North American Lung Cancer Study Group (LCSG) conducted a prospective, randomized Phase III clinical trial (LCSG821) comparing limited resection (segmentectomy and wedge resection) and lobectomy. Ginsberg and Rubinstein⁴⁰ reported the results of the study in 1995. The local and systemic recurrence rates, and all-cause and lung cancer-specific mortality rates were significantly higher after limited resection compared to lobectomy. Since then, lobectomy became the gold standard for the treatment of early-stage non-small cell lung cancer (NSCLC), while anatomical segmentectomy became one of the choices for patients with poor cardiopulmonary function and unable to tolerate lobectomy.

However, in recent years, the conclusions of LCSG821 have been questioned and challenged. In the publication of Ginsberg, wedge resection accounted for one-third of the limited resection group, and the tumor diameters were up to 3 cm. Therefore patient selection and surgical technique used in the trial compromised accuracy in comparing oncological efficacies between lobectomy and segmentectomy. The retrospective studies of Okada,⁴¹ Nomori,⁴² Swanson,⁴³ Koike,⁴⁴ D’Amico,⁴⁵ Shapiro,⁴⁶ Schuchert,⁴⁷ McKenna,⁴⁸ and other scholars found that when segmentectomy was used for NSCLC with a diameter of ≤2 cm, the resulting oncological effect was significantly better than that of wedge resection. Compared with lobectomy, there was no significant difference after segmentectomy. The advantages of segmentectomy were fewer postoperative complications and lower mortality while completely removing tumor and preserving normal lung tissue to the maximal extent.

In the past 10 years, with the improvement of clinical diagnostic techniques used in the detection of peripheral lung nodules, such as low-dose spiral CT screening, high-resolution CT, PET-CT, and electromagnetic navigation bronchoscopy (ENB), the diagnostic accuracy of early NSCLC has been greatly improved. A large number of studies have found that cell subtype and tumor size of adenocarcinoma are closely related to prognosis after surgery. In 2015, the World Health Organization (WHO) released the latest histological classification of lung tumors.⁴⁹ In 2017, the eighth edition (AJCC/UICC) of the international lung cancer staging⁵⁰ divides T1 into T1a (≤1 cm), T1b (>1 cm, ≤2 cm), and T1c (>2 cm, ≤3 cm). At the same time, two multi-center, prospective, randomized phase III clinical trials (CALGB 140503 and JCOG0802/WJOG4607) comparing segmentectomy and lobectomy for the treatment of early-stage lung cancer are in progress. Patient enrollment in the trials had been completed at the time of this writing, and the JCOG0802/WJOG4607 study was published with favorable results for sublobar resection. We look forward to the publication of CALGB 140503 results.

Contemporary segmentectomy, especially thoracoscopic anatomical segmentectomy, has reached a stage of maturity. Its development is complementary to the development of modern imaging technology. The emergence and clinical application of three-dimensional CT vascular and bronchial reconstruction technology have led thoracoscopic anatomical segmentectomy into a new era of individualized, precise resection. In 2003, Watanabe et al.⁵¹ first reported the application of three-dimensional CT angiography in lung resections. In 2009, Yamada et al.⁵² first reported the application of multi-slice CT angiography in thoracoscopic segmentectomy. In 2015, Chan et al.⁵³ reported the technique of three-dimensional reconstruction before anatomical segmentectomy or lobectomy for the treatment of early stage NSCLC. In 2016, Wu and Chen et al.⁵⁴,⁵⁵ evaluated three-dimensional computed tomographic bronchography and angiography (3D-CTBA) in thoracoscopic segmentectomy, subsegmentectomy, and subsubsegmentectomy. The concept of intersubsegmental veins and intersubsubsegmental veins was proposed for the first time. In the course of continuous improvement of the surgical technique of segmentectomy, people are also exploring the removal of smaller anatomical units than the segment. In 1947, Overholt and Langer²⁷ first reported two cases of subsegmentectomy (RS³b, LS⁶a segmentectomy). In 1990, Itoi et al.⁵⁶ first reported in detail a case of a subsegmental resection of S³b of the anterior segment of the right upper lobe. In 2010, Nakamoto et al.⁵⁷ reported thoracotomy for super-selective segmentectomy under the guidance of three-dimensional CT vascular reconstruction. The article included five cases of subsegmentectomy (called daughter segmentectomy, DS, in Japan). Subsequently (2016), Wu and Chen et al.⁵⁴ reported two cases of thoracoscopic subsubsegmentectomy under the guidance of three-dimensional imaging.

In the last century, we have witnessed the evolution of segmentectomy, the development of anatomy, and the advancement of science and technology. At present, the preoperative planning and intraoperative precise surgical techniques under the guidance of 3D-CTBA have enabled thoracic surgeons to complete individualized operations centered on pulmonary nodules, that is, the resection of subunits of pulmonary segments, including subsegmentectomy, combined subsegmentectomy, subsubsegmentectomy, and combined subsubsegmentectomy, etc. The history of lung surgery will certainly not stop here and innovation is the driving force of scientific and technological development. It is the wishes of the authors that this surgical atlas will provide a stepping stone and platform for interested thoracic surgeons to further develop and exchange experience in subsegmentectomy and subsubsegmentectomy that will eventually benefit our patients.

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Chapter Two: Subsegmental anatomy of the lungs

Jun Wang; Liang Chen; Fei Yao

Abstract

The development of pulmonary anatomical nomenclature and the current commonly used international nomenclature for segmental anatomy are presented in this chapter. In the first section, the history of pulmonary anatomy and the evolution of pulmonary nomenclature are laid out along a timeline of the studies and clinical applications of anatomy by anatomists, radiologists, respiratory physicians, and thoracic surgeons. In the second section, the international nomenclature of pulmonary segmental and subsegmental anatomy, i.e., bronchi, arteries, and veins, is presented according to the current rules of international nomenclature. Due to the importance of pulmonary veins in segmentectomy and subsegmentectomy, some of the pulmonary vein nomenclature is modified based on the regular pattern that the tributaries of pulmonary veins distribute between pulmonary segments and subsegments. The evidence of the changes is given in detail in the notes following the suggested changes, with the aim of facilitating reader understanding of the fundamentals of surgery.

Keywords

History of segmentectomy; Pulmonary nomenclature; Pulmonary anatomy; Pulmonary segment; Pulmonary subsegment

1: Development of nomenclature for subsegmental anatomy

Exploration of the unknown is a never-ending activity of humans. As knowledge accumulates, our concern and curiosity about our own body also expand. In the course of the study of human anatomy, there were characteristic stages of research into pulmonary anatomy. The study of pulmonary anatomical structures and important advances in the basic concepts of pulmonary anatomy have essentially been launched around the study of the bronchial tree. As stated by Huber, the ultimate study of the lungs is actually a complete analysis of the entire bronchial tree that enters the lungs. Indeed, the development of nomenclature for bronchopulmonary segments reflects not only the history of pulmonary anatomy but also the progress of lung surgery.

1.1: Beginning of segmental study

The beginning of pulmonary anatomical study can be traced to the invention of the microscope in the early 17th century. Malpighi Marcello, professor of medicine at Bologna, Italy, observed the capillary network around the alveoli of the frog under microscope in 1661. He also found that the trachea ended in dilated vesicles rather than in the porous parenchyma in the lungs, as previously believed. These findings initiated modern studies of pulmonary anatomy.¹ In the same era in Holland, Diemerbroeck lsbrandi De,² professor of Medicine and Anatomy at the University of Utrecht, published a comprehensive woodcut of the bronchial tree (Fig. 1.2), which already showed the segmental bronchi that would later appear in all modern anatomical publications. He described the trachea bifurcating at the level of the 4th thoracic vertebra. The first branch enters one side of the lungs, then subdivides sequentially into small branches scattered between the roots of pulmonary arteries and veins, and continues with vesicles of the lungs. These small muscular terminal branches were called BRONCHIA. However, study of pulmonary anatomy paused there, until the arrival of the golden age of comparative anatomy and embryology in the late 19th century.

Nomenclature of the pulmonary segments essentially started with research by Christoph Theodor Aeby. He studied comparative anatomy in his student period following Professor Rutimeyer at Basel, Switzerland. Aeby’s interest in this aspect began in 1878 when he studied metal-injected lungs in an intact cadaver. He noticed that the left bronchus had less steepness compared to the right counterpart. Further, the left upper lobe had a different morphology compared to the right upper lobe. Thus he started comparative anatomy to study his observations. It should be pointed out that in the history of studying anatomy, the earliest recordings or predicates of anatomy were written in Latin. There was no nomenclature in Latin. From a systematic point of view, special anatomical vocabulary was used in anatomy, as in other scientific fields at the time. However, unlike other aspects of science, the differences between anatomical terminology and anatomical nomenclature are strictly distinct. Terminology is understood as a system of terms used in each scientific field. Nomenclature, covering the terms created within the scope of terminology, is a standardized system of exact terms arranged according to certain principles, which must be approved by specialty scientific committees and be widely accepted by the specialty’s scientific communities.³

The first monograph devoted to the study of patterns of bronchial branching was published by Aeby in 1880. It was based on pulmonary dissection and cast models of the lungs of 14 different mammal species. Studies of human lung used a metal casting method exclusively.⁴ In his book, Aeby described the bronchi below the bilateral pulmonary artery trunk as hyparterial bronchi with four pairs of ventral and dorsal branches (Fig. 2.1.1) and labeled them as v1 to v4 and d1 to d4. The right upper lobe bronchus, positioned superior to the pulmonary artery, was marked separately as the eparterial bronchus. The first right ventral bronchus led to the right middle lobe, while the first left ventral bronchus led to the left upper lobe. Aeby labeled the right lower lobe bronchus distributed near the surface of the heart as c (the B⁷ in modern nomenclature), and this branch did not exist in the left lower lobe. He stressed that this c bronchus was an accessory branch on the opposite side below the first ventral hyparterial bronchus. In many other mammal species this c bronchus led to an independent infra-cardiac lobe. This method of bronchial classification and labeling based on ventral and dorsal sides is relatively simple. However, there are significant individual variations in bronchial distribution and the volume of lungs related to them. This results in inconveniences in understanding of the bronchial tree using this anatomical labeling system.

Fig. 2.1.1

Fig. 2.1.1 Diagram of bronchial branching published by Aeby in 1880. (From Aeby C. Der Bronchialbaum der Säugethiere und des Menchen. Leipzig; 1880.)

At the beginning, Aeby’s study of pulmonary anatomy failed to attract the attention of clinicians. But 12 years later, his former colleague Hasse published four anatomical images of adult lungs and four of newborn lungs.⁵ These images depicted bronchial trees within the framework of the lungs from anterior, lateral, and posterior aspects. He also applied terminology after modifications from that previously used by Aeby. For example, the lateral basal segmental bronchus (B⁹) was initially called the external terminal bronchus, and the posterior basal segmental bronchus (B¹⁰) was initially termed the internal bronchus. Hasse also made significant progress in his study of the right upper lobe. He confirmed the presence of three segmental bronchi and named them (the anterior, apical, and posterior segmental bronchi), terminology still used today. Hasse used the same terminology for the right upper lobe to describe the left counterpart. He termed the left upper lobe bronchial stem as the first branch of the left hyparterial bronchus.

Felix Walther published images of lungs, drawn by Hasse, in the second edition of Sauerbruch’s Chirurgie der Brustogane in 1920.⁶ It used Hasse’s terminology for the upper lobe but at the same time named the branches of the right middle lobe bronchus the lateral and anterior rami (segmental bronchi). All the terminology of the hyparterial bronchus coined by Aeby was adopted to construct the sketch of the bronchus, as shown in Fig. 2.1.2. By this time, the illustration of the human bronchial tree as shown by Hasse constituted the earliest lung map for clinical practice.

Fig. 2.1.2

Fig. 2.1.2 Sketch of bronchial distribution by Felix. (From Boyden EA. Segmental Anatomy of the Lung. New York: McGraw Hill; 1954.)

It was William Ewart, a physician and pathologist from the Brompton Hospital in London, who first pointed out the inadequacies of Aeby’s system for pulmonary anatomy. His critique was that it is farfetched to apply animal models of lungs to humans, because the pattern of human bronchial tree branching is more complicated than in animals. He pointed out that the differences between human and other animals are the results of evolution.⁷ Thirty years later, American anatomist George S. Huntington further clarified this view. He pointed out that there is no single pattern of bronchial structures among animal species. The morphological differences of lungs are the results of adaptation to the shape of thoracic structures, requirements of breathing, and pattern of body locomotion.⁸

Ewart first pointed out that the lungs present in coniform appearance, with the bilateral lung being half of a cone, and on this basis the lungs must be divided into smaller regions than the lobes in order to attain simplicity in description. He proposed to add other regions such as pectoral, cardiac, mid-dorsal, and retro-cardiac, etc., to the existing apical, basal, and upper and lower axillary regions. These regions of his description coincide with many primary bronchial distributions. The nine bronchial distributions are as follows (the corresponding terminology of pulmonary segments of Jackson CL and Huber JF are presented in brackets):

1.The apical distribution [apical segment]

2.The axillary distribution [posterior segment]

3.The pectoral distribution [anterior segment]

4.The cardiac distribution [lateral and medial segments]

5.The posterior-horizontal distribution [superior segment]

6.The retro-cardiac distribution [medial basal segment]

7.The anterior-basic distribution [anterior basal segment]

8.The axillary-basic distribution [lateral basal segment]

9.The posterior-basic distribution [posterior basal segment]

The standards used by Ewart for dividing regions of lungs have tremendous significance. These divisions were in fact the prototype of modern pulmonary segmental distribution. Ewart found that the distribution of arteries and bronchi in each region was highly consistent, while pulmonary veins were characterized by their distribution around lobules, and these peri-lobular veins supported a framework and bound adjacent districts of the lung. However, it is clear that he had not yet found a good way to name these anatomical structures uniformly. The numerical labels of the nine distributions in Ewart’s work did not match the modern segmental branches. For example, the numbers 1 and 2 represent third-level branches of the right bronchial stem. In comparison, number 4 corresponds to first-level branches and other numbers are second-level branches. In his work, Ewart selectively studied pulmonary areas supplied by relatively large bronchi near the origin of the hilus. Recognizing limitations of the subjective nature of the selective area for studying, he suggested postponing the definition of anatomical demarcation of the districts of the lungs until after studying the fine divisions of the bronchial tree. The terminology used by Ewart was based partly on local anatomical relations and partly on spatial orientations. He even labeled some small bronchial branches. He also compared some details of pulmonary arteries and veins. However, the illustrations had many overlapping structures, which made them difficult to understand. However, the monograph by Ewart is monumental in the study of the anatomy of lungs. It is a precise as well as original work, ahead of its time.

1.2: Advances of segmental study

In 1932, the research of Rudolph Kramer, a bronchoscopist, and Ameil Glass, a surgical resident of Mount Sinai Hospital, New York, opened a new chapter in the study of pulmonary anatomy. At that time, surgeons were eager to find an accurate method to localize pulmonary abscesses on the body surface, as well as the point of entry into the chest to drain pulmonary abscesses. It was due to this clinical demand that Glass proposed to identify such a localization unit which is smaller and more accurate than pulmonary lobes.⁹ Glass was not aware of the previous work of Ewart due to geographical distance and lack of means of communication. He called such a localization unit a bronchopulmonary segment and pointed out that it not only represents anatomical but also pathological unit. Apart from the current widely accepted term bronchopulmonary segment, Glass also demonstrated surface distribution of these bronchopulmonary segments by perfusing the major branches of each lobar bronchus with dyes of different color. Using this method, he labeled 11 bronchopulmonary segments. Aside from two subsegments of the pectoral district and two of the middle that were thought to be segments, other segments agree with the district proposed by Ewart in principle. The fundamental significance is that the research of Kramer and Glass applied basic anatomical study to clinical application. Glass also applied the same names to both the segment and its bronchus, and thereby simplified the terminology. However, there are some confusing situations, in that one name was used to label different segments, such as for the apical and axillary distribution areas in Glass’s labeling system. It was also misleading to single out