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Right S9 and S10 VATS Segmentectomy "Butterfly Approach”: From Surgical Flight Simulation to Day-Surgery

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posted on 2023-01-23, 16:44 authored by Karel Pfeuty

The patient is a young woman without comorbidities presenting with a single 15 mm colorectal metastasis located between S9 and S10, requiring a combined segmentectomy for sufficient margin. The patient was first integrated in a midday multidisciplinary outpatient clinic Enhanced Recovery After Surgery (ERAS) program, including ERAS nurse counselling, with a video simulation, physiotherapy education, nurse anesthesiologist pain management education, an anesthesiologist preoperative visit, and a preoperative thin slice CT scan for 3D simulation. She was also considered fit for inclusion in the surgeons’ specific day-surgery program.

Preoperative 3D Simulation

To begin, a surgical simulation was designed using Fujifilm Synapse 3D software. After completing anatomical variations analysis, the surgeons built a step-by-step resection process map (1) focusing on stem-branch technique and intersegmental plan delimitation, mimicking real-life segmentectomy, and anticipating an inferior butterfly fissureless approach. The principle of this simulation was to create a virtual resection process map most closely reflecting surgical reality as the first preoperative part of the surgery. The anatomy was quite classical, and the surgeons had to mentally prepare the inferior view. 

The model showed that the first step would be the pulmonary ligament approach beginning with V10C ligation, followed by ISP1 division inferiorly between S10 and S7. Then, after V6 dissection, surgeons would open ISP2 posteriorly between S10 and S6. The time would then come for the crucial tunnel dissection along V8, giving the ISP3, and separating again S10 from S7 more centrally. This stapling would dramatically improve the view on S10 bronchovascular structures, leading to the next stem-branch technique step: V9+10 ligation, then A10c, B9+10, and A9+10 stapling. 

A global view shows S9 and S10 stumps clearly encircled by V6 and V8, giving access to the deep point at the intersection of S6, S9, and S8. This is the key point surgeons would have to reach for the most anatomical delimitation of the deep part of intersegmental plan, guided by intersegmental vein dissection. The fluorescence step gives an accurate delimitation of the superficial part of intersegmental plan. Then surgeons would move on to ISP4 anteriorly between S9 and S8, following by ISP5 more centrally from bottom to top, bringing together S6 and S8 in the most important stapling. Then, ISP6 and ISP7 would be finished by separating S9 from S8 and S6 anteriorly. The final view shows intersegmental vein outlining deep intersegmental plan and the 3D aspect of intersegmental plan that would have been delimitated finally.

The Surgery

The second part of the video that accompanies this article (see above) demonstrates the “augmented” surgery. 

Surgeons used a standardized biportal subxiphoid approach with 4K vision, assisted by the 3D planning. The 3D resection process map model was found to be accurate, very close to reality, and highly helpful during surgery. As expected, the surgery was highly superposable to the step-by-step preoperative simulation.

The patient benefited from an ERAS opioid-free day-surgery with an uneventful follow-up and a complete resection of the metastasis with a 4 cm margin. Day-surgery for such complex segmentectomy is probably anecdotal, but standardized day one discharge experiences have also been successfully described recently for more than half of all segmentectomies (2), and that has also been the trend in the daily practice of this article’s authors(3). Interestingly, 3D illustration showed a very good preservation of the lower lobe volume one year after this lung-sparing surgery.


Preoperative simulatation, including both resection process map and clinical preparation, appears to be an innovative and promising approach. The surgeons were able to obtain a highly reliable 3D model, leading to a safe and accurate surgery and allowing ERAS day-surgery in this selected patient. In addition, this original butterfly approach seems to be an efficient anatomically inferior way to approach complex S9 and S10 segmentectomy, giving an accurate intersegmental plan delimitation by association of both ICG for superficial guidance and advanced venous dissection for in depth guidance.

The best approach to complex basilar segmentectomies is still debated (4, 5, 6, 7) and Yamagata’s Japanese team showed equivalent excellent results either through fissural or nonfissural approach (4). The major issue remains adequate lymph node dissection in cases of solid invasive NSCLC, which requires a fissural dissection.


1. Matsuura N, Igai H, Ohsawa F, Numajiri K, Kamiyoshihara M. Novel thoracoscopic segmentectomy combining preoperative three-dimensional im- age simulation and intravenous administration of indocyanine green. Interact CardioVasc Thorac Surg 2022; doi:10.1093/icvts/ivac064. 

2. Pfeuty K, Lenot B. Early postoperative day 0 chest tube removal using a digital drainage device protocol after thoracoscopic major pulmonary resection. Interact Cardiovasc Thorac Surg. 2020 Nov 1;31(5):657-663. doi: 10.1093/icvts/ivaa170. PMID: 33051652.

3. Geraci TC, Chang SH, Chen S, Ferrari-Light D, Cerfolio RJ. Discharging Patients by Postoperative Day One After Robotic Anatomic Pulmonary Resection. Ann Thorac Surg. 2022 Jul;114(1):234-240. doi: 10.1016/j.athoracsur.2021.06.088. Epub 2021 Aug 10. PMID: 34389302.

4. Takamori S, Oizumi H, Suzuki J, Watanabe H, Sato K, Saito S et al. Thoracoscopic anatomical individual basilar segmentectomy. Eur J Cardiothorac Surg 2022; https://doi.org/10.1093/ejcts/ezab509. 

5. Gossot D, Mariolo AV, Grigoroiu M, Bardet J, Boddaert G, Brian E, Seguin-Givelet A. Thoracoscopic complex basilar segmentectomies: an analysis of 63 procedures. J Thorac Dis. 2021 Jul;13(7):4378-4387. doi: 10.21037/jtd-20-3521. PMID: 34422364; PMCID: PMC8339731.

6. Sato M, Murayama T, Nakajima J. Thoracoscopic stapler-based "bidirectional" segmentectomy for posterior basal segment (S10) and its variants. J Thorac Dis. 2018 Apr;10(Suppl 10):S1179-S1186. doi: 10.21037/jtd.2018.01.31. PMID: 29785292; PMCID: PMC5949398.

7. Pu Q, Liu C, Guo C, Mei J, Liu L. Stem-Branch: A Novel Method for Tracking the Anatomy During Thoracoscopic S9-10 Segmentectomy. Ann Thorac Surg. 2019 Nov;108(5):e333-e335. doi: 10.1016/j.athoracsur.2019.05.046. Epub 2019 Jul 6. PMID: 31288018.


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