Lung Segmentation: The Combination of Lung Volume Analyzer VINCENT for Measuring Resection Margin and ICG Anatomical Segmentectomy

Abstract

Recent surgical topics in lung neoplasms are how to manage a non-palpable small nodule in the peripheral or intermediate portion and how to maintain adequate surgical margins during sublobar resection. To answer these questions, the establishment of precise tumor marking methods as well as anatomical sublobar resection with a measurable surgical margin is crucial.

We developed a novel approach for performing segmentectomy by using a near-infrared (NIR) thoracoscopy with transbronchial instillation of indocyanine green (ICG). This is aided by combining computer technology of making virtual sublobar resections and establishing a precise anatomical sublobar resection with an adequate surgical margin. This method can also serve both as tumor localization and anatomical partial lung resection for early stage lung cancers and metastatic lung tumors.

Before the operation, virtual segmentectomy is created by using a three-dimensional (3D)-CT volume analyzer Synapse VINCENT (Fujifilm Co., Tokyo, Japan), which makes surgical simulation of sublobar resection based on bronchial or vascular structures, and the appropriate area of segmentectomy is decided based on surgical margin. Under general anesthesia, 10 ml of tenfold diluted ICG is instilled into each associated bronchus. ICG is continuously retained in the segmentectomy area. Surgeons can confirm resection area at any time during operation and confirm vessels and bronchi to be divided.

The advantages of this method are as follows:

• 1. It is applicable to any type of sublobar resection.

• 2. It allows for the initial determination of the resection area during the operation.

• 3. It leads to transection of only those vessels and bronchi required for removal of the lung.

• 4. Fluorescence persists during the operation and the resection area can be checked at any time.