A proposal for selecting appropriate intersegmental plane identification methods based on tumor characteristics in thoracoscopic segmentectomy

Introduction

Background

Segmentectomy has been widely performed following two clinical trials that reported segmentectomy to be non-inferior to lobectomy for lung cancer <2.0 cm (1,2). Nonetheless, this surgical procedure entails greater anatomic complexity than lobectomy, as more specific arteries, veins, and bronchi must be isolated and accurately identified intraoperatively. Although thoracoscopic segmentectomy is challenging, three-dimensional computed tomography (3D-CT) has greatly facilitated complex segmentectomies and subsegmentectomies by improving our intraoperative understanding of precise anatomy (3,4). Additionally, as segmentectomy involves more procedural steps than lobectomy, the outcomes are dependent on technical skill. Among these steps, intersegmental division is where segmentectomy differs most substantially from lobectomy. For accurate intersegmental division during segmentectomy, the intersegmental plane (ISP) must be clearly identified. While the intersegmental veins anatomically demarcate the ISP, the inflation-deflation method has traditionally been used (5,6). Recently, novel approaches have been introduced to identify the ISP, with near-infrared fluorescence (NIF) imaging combined with indocyanine green (ICG) injection being widely adopted in recent years (7-10). Thus, major ISP identification methods include intersegmental vein demarcation, the inflation-deflation method, and NIF imaging with ICG. These methods have distinct advantages and disadvantages during segmentectomy. Intersegmental vein demarcation provides an anatomically based reference but requires detailed anatomical knowledge for accurate interpretation. The inflation-deflation method can delineate the ISP precisely; however, it may interfere with the operative view and is challenging to perform in emphysematous lungs. NIF imaging with ICG is relatively straightforward to perform and presents a clear view of the ISP; however, the visualization time is short. Consequently, the choice of method differs among surgeons and institutions based on preference and clinical context.

Rationale

Among small-sized lung cancers, tumors with both a solid component and ground-glass opacities (GGOs) have been increasingly detected on thin-section CT. According to long-term analyses, surgical outcomes are favorable in patients with GGOs (11-13). The GGO ratio is an important factor for procedure selection and surgical outcome assessment (14,15). Although pure GGO and GGO-dominant lung cancers have extremely favorable outcomes, solid-dominant lung cancers are associated with lymph node metastases and local recurrence, even with small tumor sizes (16,17).

Although ISP identification during segmentectomy for small-sized lung cancers is primarily performed using the intravenous ICG approach per the European Society of Thoracic Surgeons recommendations (10), the oncological outcomes of segmentectomy have not been fully assessed for individual intersegmental identification methods; however, the success rates have been reviewed (18). Therefore, the suitability of using a standardized intravenous ICG approach for intersegmental division across all lung tumor types remains unclear.

Objective

To aid selection of the most appropriate intersegmental identification methods during segmentectomy, technical considerations regarding ISP identification are reviewed according to specific tumor characteristics. This article is presented in accordance with the SUPER reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-1-0005/rc).

Preoperative preparations and requirements

Patient selection

When a lung nodule is detected on thin-section CT, the location, size, and presence or absence of a GGO component are assessed. If a GGO component is present, the GGO ratio is calculated. After confirming whether surgical treatment will be tolerated based on electrocardiography, pulmonary function testing, blood biochemical analysis, and cardiac ultrasonography, segmentectomy may be indicated for suspected clinical stage IA lung cancer that meets the following criteria: (I) tumor size <2 cm and (II) GGO ratio >50%. After publication of the JCOG0802 trial, the GGO ratio was excluded from these criteria. Additionally, to preserve cardiopulmonary function, segmentectomy is indicated for patients with compromised cardiopulmonary function. Thus, segmentectomy is indicated in two settings: (I) intentional curative resection for small GGO-dominant lung cancer and (II) palliative resection in compromised patients for whom lobectomy is intolerable because of poor pulmonary function. In contrast, segmentectomy is contraindicated in cases of suspected clinical stage IA lung cancer when the tumor has a GGO ratio >80%, is located in the superficial parenchyma, and an adequate surgical margin can be achieved with wedge resection (13). When segmentectomy is deemed suitable for small lung nodules, thoracoscopy is preferred as a minimally invasive approach.

3D-CT reconstruction

On thin-section CT, tumor location is determined by segment, and the appropriate segmentectomy type is preliminarily selected. Multidetector CT is performed preoperatively according to the Digital Imaging and Communications in Medicine standard, and the data are stored on a computer. Workstations or client viewers (Vue PACS, Philips Japan, Inc., Tokyo, Japan; Synapse Vincent system, Fujifilm Corporation, Tokyo, Japan; and REVORAS, Ziosoft, Inc., Tokyo, Japan) are used for image analysis. 3D reconstruction images of pulmonary arterial, venous, and bronchial structures are generated by the operating surgeon. Both 3D-CT reconstruction images and horizontal thin-section CT images are used to identify intrasegmental arteries (arterial branches entering the affected segment) and intersegmental veins (venous branches surrounding the affected segment). The ISP is also displayed as a 3D image using REVORAS, and the surgical margin is evaluated preoperatively to determine whether the planned segmentectomy can achieve tumor removal with adequate margins. If an adequate surgical margin cannot be secured by the planned segmentectomy, the adjacent subsegment will be resected in combination. Ultimately, appropriate segmentectomy is determined during preoperative planning based on the pulmonary arteries, veins, and bronchi observed on 3D-CT reconstruction images.

Planning and selection of ISP identification methods

The method for identifying the ISP is planned preoperatively based on tumor location and characteristics. When tumor location is expected to be readily detectable, such as for tumors in superficial visceral pleura, the intravenous ICG method is prioritized as the first approach. Conversely, when tumor location is expected to be undetectable, such as for tumors in deep parenchyma or non-palpable, GGO-dominant tumors, a combined method incorporating intersegmental vein demarcation, inflation-deflation, and intravenous ICG injection is used to identify the ISP.

Ethical consideration

All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the Declaration of Helsinki and subsequent amendments. Written informed consent was obtained from the patients for publication of this study and the videos. A copy of the written consent is available for review by the editorial office of this journal. The clinical videos used in this study were sufficiently anonymized, and all patient identifiers were removed.

Step-by-step description

Thoracoscopic segmentectomy is performed in an operating theatre (cleanliness level II) at Okitama Public General Hospital, a tertiary facility in Japan. After the induction of general anesthesia and placement of a double-lumen endotracheal tube by an anesthesiologist, the patient is positioned in the decubitus position. The procedure is carried out by two thoracic surgeons (operator: the author; assistant: an experienced surgeon) and a clinical engineer (scopist) and is usually performed using a four-port approach. One 20-mm soft port is placed at the third or fourth position along the anterior axillary line, and three 5-mm rigid ports are placed at the fifth or sixth intercostal space along the anterior, middle, and posterior axillary lines. An endoscopic rod-lens telescope (5 mm; 30°) is used.

During thoracoscopic inspection of the entire thoracic cavity, it is confirmed whether the target tumor is detectable. A tumor is defined as detectable when its location can be identified either visually by pleural indentation or by palpation. In contrast, a tumor is considered undetectable when its location cannot be identified by either visual or tactile assessment.

First, hilar parenchyma is dissected along intersegmental veins using electrocautery or an energy device. Second, arterial branches are divided, and hilar lymph nodes are subsequently dissected and evaluated with frozen sections. Only the hilar lymph nodes are dissected, and mediastinal lymph node dissection is omitted when no hilar lymph node metastasis is confirmed on frozen sections. Third, the ISP identification method is selected during bronchial dissection. If using intravenous ICG, ICG (0.25 mg/kg; 2.5 mg/mL) is injected intravenously after division of the intrasegmental veins, and the ISP is visualized for approximately 5 minutes under the ICG mode of the thoracoscope. If using the inflation-deflation method, the bronchus is closed using a slipknot with a monofilament suture after bilateral lung inflation, and the bronchus is then divided using a stapler (19). In cases of detectable tumor locations, the intersegmental parenchyma is simply divided using staplers along the ISP demarcated by the intravenous ICG method. In cases where the tumor location is undetectable, the parenchyma is further dissected toward the periphery using electrocautery or an energy device along the ISP demarcated by the intravenous ICG method, inflation-deflation method, and intersegmental veins. The branches of the intrasegmental veins, which run within the affected segment, are divided, whereas the intersegmental veins, which run along the ISP of the remaining segments, are either divided or preserved according to the surgical margin. Intersegmental veins are divided in cases of solid nodules or marginal surgical margins, but are preserved in GGO-dominant lesions and in cases where an adequate surgical margin can be achieved. Staples are used to divide the peripheral intersegmental parenchyma when an adequate surgical margin from the target tumors can be secured. The flowchart of decision-making for the selection of the identification and division methods is shown in Figure 1. An adequate surgical margin, defined as >2 cm or equivalent to the tumor size, at the surgeon’s discretion, is determined by measuring the distance from the target tumor to the cut margin based on the macroscopic status of resected specimens. Segmentectomy combined with adjacent subsegmentectomy or additional wedge resection is performed if segmentectomy alone cannot provide an adequate surgical margin. Moreover, if the ISP cannot be clearly identified with the intravenous ICG or inflation-deflation methods, intersegmental veins are used for ISP identification because they provide the most reliable anatomical demarcation. Alternatively, the inflation-deflation method is applied by inflating the residual segment after dividing the target bronchus. If the residual segment is inflated, the intersegmental parenchyma may have to be divided outside of the ISP.

Figure 1 Selection of methods for identification and division of the ISP. GGO, ground-glass opacity; ICG, indocyanine green; ISP, intersegmental plane.

Postoperative considerations and tasks

Although postoperative care typically requires no special management, patients are managed in the intensive care unit or high-care unit on the operative day only. While monitoring heart rate, blood pressure, and percutaneous oxygen saturation, maintenance intravenous fluid infusion (1.5 mL/kg/h) is continued before oral fluid administration to ensure adequate urine output. One chest drain is placed in the thoracic cavity, and negative pressure (−5 cmH₂O) is maintained. The drain is usually removed on postoperative day one if no air leakage or bleeding is observed, regardless of pleural effusion volume. If air leakage is prolonged, drainage is continued under water-seal conditions to promote improvement, and pleurodesis is considered on postoperative day five. After discharge, follow-up CT is performed every 6 months.

Tips and pearls

Prior to the introduction of the intravenous ICG method, the ISP was identified using the inflation-deflation method and intersegmental veins. Intersegmental veins serve as anatomic demarcations of the ISP and are therefore used in emphysematous lungs where ISP identification by inflation-deflation is difficult. Additionally, this vein-first strategy is useful when the intersegmental parenchyma is first divided along the corresponding intersegmental veins (20), such as between the right S1 and S3, and the left S1+2 and S3 (Video 1). Since its introduction, the intravenous ICG method has been applied in all cases except those where the patients have an allergy to the ICG reagent. Although the intravenous ICG method is applied mainly in tumors with an intraoperatively detectable location (Video 2), a combination of all three methods can be used when the tumor location is undetectable owing to deep parenchymal localization and small, GGO-dominant nodules (Video 3).

More recently, another method was devised and applied to demarcate the ISP. This approach was developed based on experience with a patient who underwent a left upper S1+2-segmentectomy with a central vein type of the upper pulmonary vein, in which intersegmental division along the intersegmental vein (left V1+2a) between left S1+2 and S3 was difficult. In this case, the concave portion of the apical pleura was useful to identify the ISP (21). Based on these findings, the correlation between the intersegmental vein (left V1+2a) diverging from the upper pulmonary veins and the concave portion of the apical pleural structure was investigated. The results revealed an anatomical feature whereby the peripheral point of the intersegmental veins matches the concave portion of the apical pleural structure in all cases involving the central vein type of the left upper pulmonary vein. Furthermore, the three portions surrounding the concave portion of the apical pleural structure (anterior convex portion, concave portion, and apex convex portion) matched the peripheral points of the intersegmental veins (left V1+2a and right V1b) (22). This method represents a simple alternative to previous intersegmental identification methods, although its use is limited to apical or anterior segmentectomies (left S1+2, left S3, right S1, and right S3 segmentectomies) (Videos 4,5).

A total of 61 patients underwent thoracoscopic segmentectomy performed by the author since May 2022, when the intravenous ICG method was introduced at our institution. The median duration of surgery, intraoperative blood loss, drainage period, and postoperative stay were 206 minutes, 0 mL, 1 day, and 5 days, respectively. In segmentectomies in which the ISP was identified and intersegmental division was based on tumor characteristics, prolonged postoperative air leakage lasting more than 5 days occurred in 3 patients (4.9%). No local recurrences were observed during follow-up.

Discussion

Surgical highlights

Among the techniques used during sublobar resection, securing an adequate surgical margin is crucial to reduce cancer recurrence (23-25). In general, an adequate margin is considered >2 cm or at least equivalent to the tumor size in sublobar resection (26). Segmentectomy can achieve wider margins than wedge resection. Nonetheless, margins tend to be limited for tumors located deep within the parenchyma (23). To achieve adequate margins during segmentectomy, the intersegmental division line should be carefully planned.

Additionally, tumor characteristics should be considered when planning an appropriate segmentectomy. Oncological features of lung cancers with GGO components differ from those of solid lung cancers. Although the long-term outcomes of GGO-dominant lung cancers are favorable, solid lung cancers may exhibit lymph node metastasis or recurrence, even when the tumor size is small (16,17). In cases of solid nodules, extended segmentectomy may be preferred, using an approach in which the intersegmental parenchyma is divided outside sacrificed intersegmental veins to secure a more adequate surgical margin. Beyond surgical margin securement, selective lymphadenectomy may also be considered, even for tumor sizes <2 cm (17). Therefore, the technical strategy for segmentectomy must be based on the degree of malignancy.

Thus, when segmentectomy is performed for small tumors, appropriate ISP identification methods should be selected according to the tumor characteristics. Tumor characteristics can be broadly classified into two categories: intraoperative detectability (detectable versus undetectable) and presence of a GGO component.

For tumors detectable intraoperatively by visualization or palpation and those with GGO-dominant characteristics, the intravenous ICG method is considered appropriate and sufficient for approximate ISP delineation, as the margins can be secured by dividing the intersegmental line after confirming distance from the tumor. Wedge resection is also acceptable for GGO-dominant lung cancer when an adequate surgical margin can be secured (12,13); in such cases, precise anatomical dissection may not be required. Therefore, intersegmental division guided by more precise ISP identification may be unnecessary. Simple total intersegmental division using staplers can also be performed following the division of the inter- and intrasegmental veins. In intraoperatively detectable solid-dominant tumors with poor prognostic characteristics, extended resections—such as extended segmentectomy—may be preferable by dividing beyond the intersegmental veins. Although the ICG method is straightforward and broadly available, it has some drawbacks, including a short imaging time and unclear ISP visualization in the deep parenchyma. Connecting the peripheral pleural point of the ISP identified by ICG and the residual stump of the divided intersegmental vein with a straight line can demarcate the ISP, enabling division outside the identified ISP for a straightforward, curative resection. On this basis, structures surrounding the concave portion of the apical visceral pleura (apical convexity, anterior convexity, and other concave portions) may also serve as practical peripheral landmarks of the ISP when referenced to intersegmental veins (22). Although the use of this landmark is limited to anterior or apical segmentectomy, the findings of this alternative method provided the impetus for this study, as it is simple and easy to apply. Among the methods used to identify the ISP, the simplest method may be preferable in surgical practice. In cases in which the tumor is detectable intraoperatively, approximate identification of the ISP is sufficient, provided that an adequate surgical margin can be secured. Considering that the ISP can be identified with reference to apical pleural structures, the use of either intravenous ICG or demarcation using apical pleural structures is proposed for simple ISP identification in detectable tumors.

For intraoperatively undetectable tumors, ISP identification should be performed more carefully. ISP is preferably identified by combining intersegmental vein demarcation with the intravenous ICG and inflation-deflation methods. Intersegmental veins are the most common anatomic landmarks for ISP, and the distance from the target tumor to these veins can be measured using CT. With accurate assessment of the intersegmental veins, the segment containing the tumor can be resected by precise anatomic segmentectomy. Combining intersegmental vein-based and inflation-deflation methods could ensure an adequate surgical margin for thoracoscopic segmentectomy of undetectable tumors (27). The addition of the intravenous ICG method can further aid visual ISP identification. Furthermore, during intersegmental parenchymal division in segmentectomy, the management of intersegmental veins should be carefully considered according to the tumor location. When the tumor is located near the ISP or the surgical margin is marginal, division of the intersegmental veins may be appropriate, with parenchymal division performed along these veins using electrocautery or energy devices. In contrast, when the tumor is located far from the ISP, the intersegmental veins can be preserved in the residual segment. In such cases, the proximal intersegmental parenchyma can be divided along the intersegmental veins using electrocautery or energy devices, followed by division of the peripheral intersegmental parenchyma with staplers. These strategies for intersegmental identification and division may be vital in securing an adequate surgical margin in intraoperatively undetectable small-sized lung tumors.

Strengths and limitations

The intravenous ICG method is the simplest and most useful approach for ISP identification, as recommended by European Society of Thoracic Surgeons guidelines. A recent report suggests the superiority of intravenous ICG over inflation-deflation for securing an adequate surgical margin (28). Therefore, ICG injection should be considered in all cases where the patient has no allergy to ICG (10). However, the ICG method has some limitations. The suitability of NIF imaging with ICG for ISP identification is still debated. Moreover, reported ICG doses vary widely (5–25 mg/body or 0.05–0.5 mg/kg), with low-dose ICG injection still capable of visualizing the ISP (8,29,30). Additionally, methods such as pulmonary artery or vein blocking have recently been reported (31-34). Consequently, a standard ICG approach has not yet been established. Moreover, the ability of ICG to precisely identify the ISP remains unclear. For example, Yutaka et al. reported that the intersegmental line was not clearly defined in 8.0% of cases using intravenous ICG (35). Further research is required to clarify appropriate ICG dosing and usage and compare its suitability with other ISP identification methods.

Apical pleural structures can also serve as alternative landmarks to identify the ISP; however, this method is limited to bilateral upper segmentectomy. Previous reports have shown that a pulmonary ligament approach used basal pleural structures may be useful in lower segmentectomies, such as S9 or S10 segmentectomy (36). Therefore, demarcation of apical pleural structures may provide a useful alternative for identifying the ISP during segmentectomy.

Comparison with other surgical techniques and research

Various methods have been proposed for the preoperative marking of undetectable tumors in segmentectomy to ensure adequate surgical margins, including hook-wire placement, dye injection, and radiofrequency identification of the parenchyma adjacent to the target tumor (37-39). However, these methods require special devices, are expensive, and can cause substantial complications, such as cerebral air embolism (40); such complications should be avoided preoperatively. Although essential for resecting undetectable tumors with wedge resection, these techniques are supplementary options for segmentectomy. Rather than applying these methods, intersegmental veins can be used as a demarcation marker for the ISP; therefore, preoperative marking is not necessarily required for anatomical segmentectomy when the corresponding intersegmental veins are identified (27).

Implications and actions recommended

The outcomes of segmentectomy for small lung cancers are generally favorable for both thoracoscopic and robotic surgery. The traditional inflation-deflation method of ISP identification can limit working space during thoracoscopic or robotic surgery due to segment inflation. Therefore, further refinement of the intravenous ICG method may be preferable as a unified approach to ISP identification in undetectable tumors, both alone and in combination with intersegmental vein demarcation. Additionally, the intravenous ICG method and demarcation of apical pleural structures are recommended for approximate ISP identification in detectable tumors, which is considered sufficient for segmentectomy. However, as previous evaluations of oncological outcomes after segmentectomy have involved a combination of different ISP identification methods, future research is required to assess the oncological outcomes for each method individually.

The cost-effectiveness of thoracoscopic segmentectomy should also be considered. Although staplers are used for intersegmental division to reduce postoperative air leakage from the divided ISP, their use should be minimized in light of cost considerations. Furthermore, postoperative air leakage may prolong hospital stay. To reduce costs, air leakage, and postoperative hospital stay, staplers should be used appropriately. This can be achieved through adequate hilar dissection around the target segmental bronchus and by dividing the intersegmental parenchyma with minimal staples. Although optimizing stapler use might be challenging, efforts to reduce air leakage would improve cost-effectiveness. Therefore, accurate ISP identification and parenchymal division are crucial steps in segmentectomy.

Effective segmentectomy requires a well-balanced approach that tailors ISP identification and division methods to specific tumor characteristics. To achieve this balance, future research should evaluate the oncological outcomes for individual intersegmental identification and division methods.

Conclusions

In thoracoscopic segmentectomy, the selection of appropriate ISP identification methods should be based on the tumor characteristics. Specifically, either the intravenous ICG method or simple demarcation of apical pleural structures are considered suitable for approximate ISP identification in detectable tumors, whereas segmentectomy for undetectable tumors requires more precise identification using a combination of the ICG method, intersegmental vein visualization, and inflation-deflation.

Acknowledgments

I would like to thank Editage (www.editage.jp) for English language editing.

Footnote

Reporting Checklist: The author has completed the SUPER reporting checklist. Available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-1-0005/rc

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-1-0005/prf

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-1-0005/coif). H.K. serves as an unpaid editorial board member of Journal of Visualized Surgery from May 2025 to April 2027. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in 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 research committee and with the Declaration of Helsinki and subsequent amendments. Written informed consent was obtained from the patients for publication of this study and the videos. A copy of the written consent is available for review by the editorial office of this journal. The clinical videos used in this study were sufficiently anonymized, and all patient identifiers were removed.

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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