Tips and tricks of uniportal video-assisted thoracoscopic surgery complex segmentectomy

Introduction

In 2004, the first pulmonary resection operation performed by uniportal video-assisted thoracoscopic surgery (U-VATS) was reported (1). Since then, uniportal surgeons have continually pushed the boundaries of technical innovation (2), extending the indications of U-VATS to complex procedures such as segmentectomy (3) and cases involving inflammatory lymph nodes (4), bronchoplasty (5), and angioplasty (6).

Relative to conventional multiportal VATS (M-VATS), which utilizes 3–5 ports, U-VATS has been associated with numerous benefits, including reduced postoperative pain and complications, shorter operative times, and shorter hospital stays (7-11). More recently, large-scale clinical trials have demonstrated the efficacy of segmentectomy in early-stage peripheral small non-small cell lung cancer (NSCLC) (12,13). These findings underscore the potential of U-VATS segmentectomy as a highly advantageous surgical strategy for patients with early-stage lung cancer, given its emphasis on “minimally invasive approaches” and “lung preservation”.

However, performing this technique safely and effectively requires advanced skills and substantial experience (14-16). Detailed reports on specific techniques, particularly for complex segmentectomies, remain limited. We herein present our institution’s approach to performing complex segmentectomies using U-VATS, with a focus on preoperative preparation, surgical techniques, and intraoperative strategies. We present this article in accordance with the SUPER reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-25-8/rc).

Preoperative preparations and requirements

All procedures performed in this study were in accordance with the ethical standards of the Institutional Review Board of Seirei Mikatahara General Hospital (No. 24-16, 2024) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this study, the accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Technical standards for performing uniportal VATS segmentectomy

U-VATS is inherently more technically demanding than M-VATS because of the higher likelihood of instrument interference (17). As a single-port technique, U-VATS requires baseline proficiency in controlling surgeries at the level of open thoracotomy, or M-VATS. According to a report by the Uniportal VATS Interest Group of the European Society of Thoracic Surgeons, 84% of members indicated that more than 50 cases are required to achieve proficiency in lobectomy using U-VATS (14). In contrast, for U-VATS complex segmentectomy, some studies suggest that surgeons already skilled in U-VATS lobectomy or simple segmentectomy can perform the procedure without additional preparation, with no significant learning curve reported (18). Synthesizing these findings, it can be concluded that surgeons with substantial experience in U-VATS lobectomy and the requisite technical ability to maintain control during surgery are likely capable of safely and satisfactorily performing simple and complex segmentectomies with U-VATS.

Identifying the tumor location

In U-VATS, tumor palpation is often difficult, making preoperative marking essential for visualizing the tumor location. Various marking methods have been reported, including hookwires (19), pigments (20), and electromagnetic navigation bronchoscopy (21). A study on preoperative pigment marking for U-VATS reported a procedural success rate of 99.5%, with a 100% success rate in lesion resection without conversion to thoracotomy (22). Consistent with these findings, our institution employs computed tomography (CT)-guided pigment marking, and we did not encounter any fatal complications. As an example, Figure 1 illustrates CT-guided pigment marking for right S1 segmentectomy.

Figure 1 The precise location of pigment marking based on preoperative CT imaging. Marking was used to facilitate accurate the right S1 segmentectomy. (A) Preoperative CT scan. (B) 3D reconstructed image generated from CT data. (C) The intra-operative findings in this case. CT, computed tomography.

Securing the surgical margin

For solid-dominant lesions, surgical margins should be at least 2 cm or greater than the tumor diameter (12). For ground-glass opacity dominant lesions, surgical margins of at least 5 mm are recommended (23,24). When necessary, combined resection of the adjacent subsegments should be considered to ensure adequate surgical margins.

Understanding the anatomy

Three-dimensional reconstruction of vessels and bronchi using imaging analysis software is highly recommended for segmentectomies (25,26). At our institution, Synapse Vincent (ver. 6.7, Fujifilm, Tokyo, Japan) was used to create three-dimensional (3D) reconstructed images in all cases. This application allows for a detailed understanding of vascular branching even when plain CT scans are used. On the basis of these reconstructed images, the segments to be resected and the vessels and bronchi to be dissected were carefully simulated before surgery.

Selection and use of surgical instruments

Various curved forceps are essential for U-VATS, including suction tubes, lung forceps, lymph node forceps, right-angle forceps, and snake forceps. Energy devices are indispensable in U-VATS, and their selection can be tailored according to the surgeon’s preference. The first author utilizes a 1-mm hook-shaped electrocautery device, AdTec^® mini (B.BRAUN AESCULAP, Melsungen, Germany) in their right hand, and a curved cotton device, CS Two-Way Handle^TM (Unimedic, Osaka, Japan) (27), in their left hand for vascular and bronchial dissection.

Identification of the intersegmental plane

In U-VATS, the identification of the intersegmental plane is often challenging due to limited visualization and instrument constraints. Indocyanine green (ICG) has proven to be an effective tool for this purpose (28). A study has shown that the injection of ICG using a syringe pump significantly improves the contrast between the circulation and ischemic areas compared to bolus injection (29), a method adopted at our institution. The delineated intersegmental plane was thoroughly marked with a pigment for stapling between the intersegmental planes (Figure 2).

Figure 2 This figure illustrates the process of delineating the intersegmental planes using indocyanine green fluorescence. Advance marking of the anticipated staple line facilitates accurate and efficient intersegmental stapling (the other mark was made by preoperative CT-guided marking). (A) Delineation of the intersegmental planes using indocyanine green. (B) After intersegmental marking. CT, computed tomography.

Stabilization of the intersegmental plane

This is the most critical step in U-VATS segmentectomy. In cases in which the tumor is not visible on the pleural surface, preoperative marking is essential to guide the appropriate stapling line. Owing to the limited maneuverability of instruments in U-VATS, intersegmental stapling requires careful techniques, including ligation, retraction, and control of all peripheral stumps of the dissected intersegmental veins and bronchi (Figure 3).

Figure 3 The figure demonstrates the ligation of the peripheral stumps of the vessels and bronchi, which assist in the safe and precise insertion of the stapler during segmentectomy. (A) Ligatures applied to the peripheral stumps. (B) Scene showing how the ligatures assist in proper stapler insertion.

Step-by-step description

Surgical video and description of the techniques

This section presents a surgical video of U-VATS right S1b + S3 segmentectomy and explains the techniques along with scene-specific tips (Video 1).

Case presentation

The patient was an elderly male in his 80s, with multiple comorbidities. A 2.8-cm solid nodule was identified in the right upper lobe and diagnosed as cStage IA3 adenocarcinoma of the lung. Considering the patient’s background, we opted for complex segmentectomy of the right upper lobe (S1b + S3).

Based on the 3D model of the pulmonary vasculature, the pulmonary arteries (PAs) for resection were A1b + 3 branching from the superior PA. The pulmonary veins (PVs) for resection included V1a + 3b, forming part of the apical vein, V2c, branching from the central vein, and V3a, branching near the pulmonary hilum.

The first author performed the procedure on the dorsal side of the patient for right-lung surgery. A 3.5 cm uniport was created in the fifth intercostal space.

Dissection of V2c and V3a, and interlobar separation

Extensive pleural adhesions were present and dissection was required. Special care was taken to avoid vascular injuries in the apical region (e.g., the subclavian and brachiocephalic veins).

The interlobar area was exposed to reveal the central vein and V2c was divided. Precise dissection of membranes using a hook-shaped electrocautery device is crucial. The central vein was mobilized proximally and V3a was divided.

Subsequently, the mediastinal pleura was incised near the pulmonary hilum, enabling the separation of the upper-middle lobar fissure. This provided a clear view of the hilum.

Dissection of V1a + 3b and A1b + 3

With an improved surgical field, V1a + 3b was divided. The superior PA was carefully dissected distally to identify A1b + 3 and recurrent PA (A1a + 2a in this case). After dividing A1b + 3, the distal stump of V1a + 3b was ligated. This step is effective for maintaining a clear surgical field for subsequent bronchial dissection.

Lymph node dissection (#12u) and bronchial division (B3, B1b)

The narrow working space in this area requires meticulous management. The bronchial sheath was carefully incised to expose bronchial walls. Lymph node #12u was first dissected to ensure better visualization of the segmental bronchi of the upper lobe. The anterior branching B3 was divided. In U-VATS, moving the lung during stapling was highly effective, and relying solely on the manipulation of the stapler often proved insufficient. The bronchus was further dissected distally and the B1ab spar was identified. Only B1b was divided.

Intersegmental stapling

First, lymph node #13 was dissected. The central vein was mobilized distally to expose the V2a + b, and the separating line between the intersegmental planes was clarified to preserve these veins. ICG was used to delineate intersegmental planes (S1a/S2b). The resection line was marked using pigment to ensure that both the chief surgeon and assistants had a shared understanding of the correct stapling line. A stapler was inserted while pulling the distal ligature. The scope position was adjusted as required to confirm the correct stapler direction before firing. After completing the intersegmental stapling procedure, the resected lung tissue was retrieved from the thoracic cavity.

Confirmation of residual lung expansion and sealing test

After complex segmentectomy, sufficient residual lung expansion was confirmed. A sealing test revealed no air leakage. Due to the potential risk of torsion of the remaining S1a + S2 segments, the lung and mediastinal fat were loosely ligated. Care was taken to avoid tight ligation, which could impair postoperative lung expansion. Finally, a chest drain was placed, the incision closed, and the procedure was completed.

Postoperative considerations and tasks

Postoperative recovery following U-VATS segmentectomy is significantly faster compared to other approaches (17). In the absence of air leakage, the chest drain can be removed at an early stage. Apart from this, there are no specific postoperative considerations or tasks unique to U-VATS segmentectomy.

In this case, the postoperative course was good and the patient was discharged on postoperative day 6 without any complications. The pathological diagnosis was 3.5 cm lung adenocarcinoma, pStage IB. A complete resection was performed.

Tips and pearls

Preoperative planning

Utilize 3D reconstruction software to analyze pulmonary anatomy and simulate the resection plan. Preoperative marking, such as CT-guided pigment marking, is essential for precise tumor localization.

Surgical technique

Use a 1-mm hook-shaped electrocautery device for precise dissection in confined spaces. Employ curved forceps and suction instruments to optimize visualization and maneuverability. Carefully dissect and control segmental vessels and bronchi to maintain a clear surgical field.

Intersegmental stapling

Utilize ICG injection to delineate intersegmental planes. Mark the planned resection line with pigment to ensure accurate stapling. Before stapling, ligate peripheral stumps of segmental vessels and bronchi and apply traction with sutures to stabilize intersegmental stapling.

Discussion

The application of U-VATS for complex segmentectomy represents a significant advancement in minimally invasive thoracic surgery. Compared to conventional M-VATS, U-VATS offers several advantages, including reduced postoperative pain, shorter hospital stays, and fewer complications (7-11). However, its widespread adoption remains limited in Japan due to the technical complexity and concerns of safety and surgical precision.

In our experience, successful execution of U-VATS complex segmentectomy requires a thorough preoperative plan, meticulous intraoperative technique, and proper utilization of advanced surgical tools. One of the primary challenges of U-VATS is instrument interference, which demands a high level of proficiency in handling curved and angled instruments. Surgeons transitioning from M-VATS to U-VATS should develop proficiency in maintaining optimal visualization and maneuverability within the restricted workspace (14,15,17).

Despite these challenges, recent studies indicate that U-VATS can achieve comparable oncological and surgical outcomes to those achieved with M-VATS or open thoracotomy (30). The continuous evolution of specialized U-VATS instruments and the refinement of techniques, such as peripheral vessel ligation and improved intersegmental stapling methods, have contributed to its increasing feasibility and safety. Our report demonstrates that even complex segmentectomy cases can be effectively managed with U-VATS, reinforcing its viability as an alternative to traditional approaches.

Further studies and long-term oncological outcomes will be necessary to establish U-VATS as a standard approach for complex segmentectomy. Nevertheless, with proper training and the adoption of strategic modifications, U-VATS has the potential to become an indispensable technique in the armamentarium of thoracic surgeons.

Conclusions

This article introduces the preparation, techniques, and tips for performing U-VATS complex segmentectomies. Although U-VATS has certain limitations, understanding its unique characteristics and applying appropriate strategies enables surgeons to achieve high-quality complex segmentectomy comparable to the quality achieved by M-VATS or open thoracotomy. We hope that this special issue will contribute to the global advancement and wider adoption of U-VATS.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Visualized Surgery for the series “Uniportal Video-Assisted Thoracoscopic Segmentectomy for Early-Stage Non-Small Cell Lung Cancer”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://jovs.amegroups.com/article/view/10.21037/jovs-25-8/rc

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-25-8/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-25-8/coif). The series “Uniportal Video-Assisted Thoracoscopic Segmentectomy for Early-Stage Non-Small Cell Lung Cancer” was commissioned by the editorial office without any funding or sponsorship. T.W. serves as an unpaid editorial board member of Journal of Visualized Surgery from August 2024 to July 2026 and served as the unpaid Guest Editor of the series. T.W. received lecture fees and fees for providing surgical videos from Ethicon, Inc., Medtronic, PLC., and B. Braun Aesculap and he also received a brochure preparation fee from B. Braun Aesculap. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work, ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the Institutional Review Board of Seirei Mikatahara General Hospital (No. 24-16, 2024) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this study, the accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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