Analysis of the variation pattern in right upper pulmonary veins and establishment of simplified vein models for anatomical segmentectomy.
ABSTRACT: Thoracic surgeons must be erudite pulmonary vein variation when performing anatomical segmentectomy. We used three-dimensional CT (3DCT) to accumulate variations of the pulmonary veins of the right upper lobe (RUL) and created a simplified RUL vein model.We reviewed anatomical variations of the RUL pulmonary veins of 338 patients using 3DCT images, and classified them by position related with bronchus.Of the "anterior" and "central" RUL veins, all could be classified into 4 types: 2 Anterior with Central types (Iab and Ib), 1 Anterior type, and 1 Central type. The Anterior with Central type was observed in 273 patients (81 %), and was further classified into two types according to the origin of the anterior vein. In the Iab type, the anterior vein originated from V1a to V1b (54 %) whereas, in the Ib type, the anterior vein originated from only V1b (26 %). The Central type, which had no anterior vein, was evident in 23 cases (7 %). These three types could be further divided into three subcategories by reference to the branching pattern of the central vein. The Anterior type, which had no central vein, was evident in 42 cases (12 %), and this type could be further categorized into two types, depending on the branching pattern of the anterior vein.We created a simplified RUL vein model to facilitate anatomical segmentectomy. Our models should find wide application, especially when thoracic surgery requiring anatomical RUL segmentectomy is planned.
Project description:General thoracic surgeons must be familiar with anatomical variations in the pulmonary bronchi and vessels. We analyzed variations in the bronchovascular pattern of the right upper lung lobe using three-dimensional CT angiography and bronchography and then compared our results with those of previous reports.We reviewed anatomical variations in the right upper pulmonary bronchus and vessels of 263 patients using 3DCT angiography and bronchography images obtained using a 64-channel multidetector CT and workstation running volume-rendering reconstruction software.Variations in the pulmonary vein were classified into four types: the "anterior-plus-central vein type" was the most common, noted in 219 cases (83.2 %). The "anterior vein type" was evident in 23 cases (8.8 %), a significantly lower incidence than in previous reports (p < 0.001). Also, the branching patterns of the segmental arteries of the pulmonary artery differed partially from those noted in previous reports. Furthermore, we identified some new variations. The "B(1)- or B(2)-defective branch type" bronchus was noted in 19 cases (7.2 %), which was a higher prevalence than that in previous reports.We explored the bronchovascular pattern and the frequency of variations in the right upper lobe using a large number of 3DCT images. The incidences of variations differed, sometimes significantly, from those noted by previous reports. Moreover, we report some new branching variations. Our data can be used by thoracic surgeons to perform safe and precise lung resections.
Project description:Lung segmental resection is of two types: a simple type with resection of only one intersegmental plane, such as lingual or superior segmentectomy; and a complicated type with resection of two or more intersegmental planes, such as anterior segmentectomy. We present a method of identifying the intersegmental plane by physiological function. First, we cut the segmental pulmonary artery and vein. The entire lobe is then inflated with pure oxygen for 5 min. Immediately after oxygen inflation, the segmental bronchus is deflated and stapled. After a couple of minutes, the intersegmental plane is easily detected. In 117 patients who underwent segmentectomy, mean blood loss was 122 ± 193 ml and mean duration of drainage was 3.5 ± 4.8 days. Postoperative complications related to operative procedures occurred in 14 cases (12.0%). Our method of detecting intersegmental planes is convenient and useful for subsegmental resection, particularly for complicated-type cases.
Project description:Laparoscopic hepatectomy has rapidly evolved recently; however, laparoscopic anatomical hepatectomy has yet to become widely used, although anatomical hepatectomy is ideal, especially for curative treatment of hepatocellular carcinoma, and is widely accepted via open approach. This is because good-experienced skills, for example, exposing Glissonean pedicles and hepatic veins on the cutting plane, are required in order to perform anatomical hepatectomy via a pure laparoscopic approach. We obtained good results for various totally laparoscopic anatomical hepatectomies using the standardized techniques. We exposed the major hepatic veins from the root side by utilizing the unique view from the caudal side in the laparoscopic approach, and moved CUSA from the root side toward the peripheral side to avoid splitting the bifurcation of the hepatic vein. We performed totally laparoscopic anatomical hepatectomy for 47 patients from August, 2008, to December, 2012 (Table 1). In most types of anatomical hepatectomy, the mean blood loss was <500 ml. Conversion to open surgery was required in two patients. Postoperative complications were prolonged ascites in two, peroneal palsy in two, and biloma in one. Mortality was zero. The embedded video demonstrates totally laparoscopic right anterior sectorectomy. In conclusion, our standardized techniques make laparoscopic anatomical hepatectomy more feasible.
Project description:BACKGROUND Correctly diagnosing a staple-line mass after pulmonary resection for lung malignant tumor can be difficult. Differential diagnoses of recurrence, infectious mass, granuloma, and so on must be considered, despite their rarity. We report two cases of pulmonary staple-stump granuloma after segmentectomy for lung cancer. CASE REPORT Case 1 involved a 70-year-old man with small nodule in the left upper lobe identified on computed tomography (CT). Video-assisted thoracoscopic (VATS) left upper division segmentectomy was performed. Histopathological examination revealed squamous carcinoma. Follow-up CT 1 year postoperatively showed a shadow at the staple-stump, with growth evident later. CT-guided biopsy found no malignancy. However, complete left upper lobectomy was performed because of the gradually enlarging lesion. Histopathological examination revealed epithelioid granuloma. Case 2 involved a 60-year-old with suspected lung cancer in the right upper lobe. VATS right upper division segmentectomy (S2) was performed. CT at 30 months postoperatively showed a shadow at the staple line, with subsequent growth. VATS right upper lobectomy was performed. Intraoperative rapid diagnosis revealed epithelioid granuloma. These two cases were compared with five cases of staple-stump recurrence in our institution. All cases of recurrence grew concentrically or radially from the staple line with the mass surrounding the staple line. On the other hand, cases of granuloma extended along the long axis of the staple line, and 3-dimensional CT (3DCT) may help to understand the morphology. CONCLUSIONS Although preoperative differentiation of staple-line granuloma is difficult and pathological diagnosis is important, characteristic radiologic features and 3DCT may facilitate diagnosis.
Project description:The purpose of this study was to elaborate on the anastomoses between the paraumbilical and systemic veins, particularly the ensiform veins. The connections with the ensiform veins have received little attention in the anatomical and radiological literature, and remain incompletely described. Too small to be reliably traced in normal CT scans, the paraumbilical veins can dilate in response to increased blood flow from systemic veins in superior vena cava obstruction (SVCO), allowing a study of their arrangement and connections. Collateral paraumbilical veins were therefore analyzed retrospectively in 28 patients with SVCO using CT. We observed inferior and superior groups of collateral vessels in 23/28 (82%) and 17/28 (61%) patients, respectively. Inferior veins ascended towards the liver and drained into portal veins (19/28, 68%) or the umbilical vein (8/28, 29%); superior veins descended and drained into portal veins. The inferior veins (N = 27) could be traced to ensiform veins in almost all of the cases (26/27, 96%), and a little over half (14/27, 52%) were also traceable to subcutaneous and deep epigastric veins. They were opacified by ensiform (25/27, 93%), deep epigastric (4/27, 15%) and subcutaneous (4/27, 15%) veins. The superior veins (N = 17) were supplied by diaphragmatic (13/17, 76%) and ensiform veins (4/17, 24%); the diaphragmatic veins were branches of collateral internal thoracic, left pericardiacophrenic and anterior mediastinal veins. Collateral ensiform veins were observed in 22 patients and anastomosed with internal thoracic (19/22, 86%), superior epigastric (9/22, 41%), diaphragmatic (4/22, 18%), subcutaneous (3/22, 14%) and anterior mediastinal veins (1/22, 5%). These observations show that the paraumbilical veins communicate with ensiform, deep epigastric, subcutaneous and diaphragmatic veins, joining the liver to the properitoneal fat pad, anterior trunk, diaphragm and mediastinum. In SVCO, the most common sources of collateral flow to the paraumbilical veins are the ensiform and diaphragmatic branches of the internal thoracic veins.
Project description:The aim of the present study was to evaluate magnetic resonance venography (MRV) scanned by breath-hold volume interpolated body examination with spectral fat saturation (VIBE-fs), combined with Dixon fat-suppressed VIBE (VIBE-Dixon) by using a 1.5T MR scanner for detecting deep venous thrombosis (DVT) compared with duplex sonography. A total of 31 patients with DVT were identified using duplex sonography and were enrolled in the present study for MRV examination, from the inferior vena cava to the ankle level after injection of gadopentetate dimeglumine. Venous segment-to-segment comparison was assessed for DVT detection between MRV and duplex sonography. A total of two radiologists separately performed subjective image quality assessment using a 5-point scale. Cohen's ? coefficient, Wilcoxon rank sum test and intraclass correlation coefficient values were used for statistical analysis. Of the 303 evaluated vein segments, duplex sonography identified 119 (39.3%; 119/303) venous segments with thrombus, while MRV detected 170 (56.1%; 170/303) venous segments with thrombus. The diagnostic agreement rate of DVT between duplex sonography and MRV was poor in the deep femoral vein and anterior tibial veins, while it was excellent in the inferior vena cava (IVC), common iliac vein, external iliac vein, femoral vein, popliteal vein, posterior tibial veins and peroneal veins. In addition, poor reliability was detected in the deep femoral vein, anterior tibial veins and peroneal veins, but good to excellent reliability was observed in IVC, common iliac vein, external iliac vein, femoral vein, popliteal vein and posterior tibial veins. Furthermore, image quality scores of each venous segment between the two radiologists indicated no statistical difference. Therefore, MRV scanned using VIBE-fs for the suprainguinal and VIBE-Dixon for the infrainguinal region may be a useful method for detecting DVT compared with duplex sonography. The results of present study proved this MR protocol to be a beneficial alternative imaging modality for the detection of DVT when duplex sonography is inadequate or not able to be performed.
Project description:BackgroundCurrently, methods for identifying the intersegmental plane during anatomical segmentectomy can be classified into 2 categories: the bronchial method and the vascular method. One of the vascular methods, the arterial-ligation-alone method, has not yet been validated or objectively evaluated in a large case series. We thus aimed to confirm that the arterial-ligation-alone method could effectively and accurately identify the intersegmental plane.MethodsWe retrospectively reviewed the records of 104 patients who were scheduled for thoracoscopic anatomic segmentectomy. Preoperative three-dimensional (3D) reconstruction was performed on all the affected lungs to distinguish the targeted segmental arteries, veins and bronchi. The procedure was as follows: first, based on the 3D reconstruction of the lung, the targeted segmental arteries were distinguished and ligated. Second, bilateral pulmonary ventilation was performed with pure oxygen. When the affected lung had completely inflated, contralateral pulmonary ventilation was performed. After waiting for some time, the first intersegmental plane could be obtained, and the time was recorded as T1, with an electric coagulation hook being used for marking. Thirdly, when the targeted segmental veins and bronchi had been ligated, the second intersegmental plane could be obtained by the inflation-deflation method as before, with the waiting time being recorded as T2. The differences between the 2 intersegmental planes were evaluated by 2 experienced chief thoracic surgeons.ResultIn a total of 99 (95.2%) patients, the intersegmental planes were successfully and accurately identified by the arterial-ligation-alone method. Ultimately, 85 (81.7%) patients underwent thoracoscopic anatomic segmentectomy. The results for evaluating the differences between the 2 planes were as follows: completely consistent (94 cases, 94.9%), basically consistent (5 cases, 5.1%), and discrepant (0 cases, 0%). The mean T1 was 13.6±2.7 minutes (range, 8–25 minutes), and the mean T2 was 13.0±2.6 minutes (range, 8–23 minutes), with P=0.100 (95% CI). For 99 patients, the mean nodule size was 1.1±0.34 cm. In the 85 patients who underwent segmentectomy, the mean margin width was 2.84±0.51 cm, the mean operative duration was 165.6±18.3 minutes, the mean operative hemorrhage was 52.1±20.2 mL, and the mean duration of chest tube drainage was 3.9±1.3 days. Postoperative complications related to operative procedures occurred in 2 cases.ConclusionsThe arterial-ligation-only method can effectively, accurately and inexpensively identify the intersegmental plane, and is especially suitable for the patients whose veins or bronchi are difficult to anatomize. Whether the target bronchus is ligated has no effect on the intersegmental plane.
Project description:Ankle arthroscopy is a minimally invasive technique for ankle joint treatment. However, injury to the intermediate dorsal cutaneous nerve (IDCN) and the medial dorsal cutaneous nerve (MDCN) is a common complication during anterior portal placement. To prevent injuries, methods such as palpating the nerves topographically and marking the nerves by transilluminating the skin with an arthroscope have been proposed. Easier and more definitive methods of identifying the IDCN and MDCN should result in a reduction of complications. Recently, a vein imaging system was developed that projects images of subcutaneous vasculature directly onto the skin with the use of near-infrared (NIR) light. Because anatomic studies have shown that superficial veins accompany the IDCN and MDCN, protecting the subcutaneous veins could lower the risk of nerve injury. We introduce our technique for the creation of an ankle arthroscopic portal using an NIR imaging system, which displays the vein image on the skin, to prevent injury to the superficial veins and, consequently, reduce IDCN and MDCN injuries. This is the first technical report on the prevention of vein and nerve injuries using an NIR imaging system. Our technique for avoiding vein injury using a peripheral vein illumination device during anterior portal placement in ankle arthroscopy could lower the risk of complications.
Project description:This report describes successful port-access thoracoscopic anatomical left lateral and posterior basal (S9 + 10) lung segmentectomy performed for intralobar pulmonary sequestration (ILPS) in a 5-year-old girl with recurrent pneumonia. Computed tomography revealed a multilocular lung abscess and an anomalous artery arising from the left gastric artery supplying the affected segment. After diagnosing ILPS, we performed thoracoscopic anatomical S9 + 10 segmentectomy. We consider thoracoscopic lung segmentectomy to be an important therapeutic option for pediatric ILPS.
Project description:INTRODUCTION:The anatomical abnormalities in pulmonary veins can have a serious impact on pulmonary resections. PRESENTATION OF CASE:We report the case of a 70-year-old woman undergoing VATS right upper lobectomy for the treatment of non-small cell lung cancer. During subcarinal dissection, an anomalous vein draining from the superior segment of the right lower lobe into the left atrium and passing behind the bronchus intermedius was incidentally discovered. The patient had, in addition to the inferior pulmonary vein formed by the confluence of superior and common basal veins, a supernumerary vessel identified as: accessory right V6. Retrospective review of preoperative enhanced chest computed tomography confirmed the pulmonary vascular anomaly. DISCUSSION/CONCLUSION:A careful dissection during pulmonary resections can help to recognize variations of the pulmonary veins, avoiding unexpected intraoperative complications.