胸腔镜解剖性肺段切除术技术要点

由于肺段支气管、血管的解剖变异繁多，胸腔镜肺段切除术的技术较肺叶切除术更加精细复杂。术前三维CT支气管血管成像（three dimensional-computed tomography bronchography and angiography,3D-CTBA）可以显示肺段的解剖结构以及肺段支气管、血管的变异，明确肺部结节的肺段归属，有助于制定手术计划。术前结节定位在胸腔镜肺段切除术中起着重要作用。解剖性肺段切除术的技术包括：分别切断靶段动脉、支气管、段内静脉，保留段间静脉，采用膨胀萎陷法确定肺段间交界面，使用电刀和/或切割缝合器分离段间肺组织。恶性结节行肺段切除术时必须确保切缘宽度≥2 cm，或≥肿瘤直径，同时需要进行N1、N2站淋巴结采样及冰冻切片分析。胸腔镜解剖性肺段切除术的并发症发生率较低。肺段与肺叶的解剖关系为，若干个呈不规则锥形结构的肺段组成一个肺叶，段间静脉行走于肺段间。本中心探索出一种按照锥形结构原理自肺叶中分离出肺段的方法，并命名为“锥式肺段切除术”。“锥式肺段切除术”的技术涵盖了准确判断和处理靶段支气管和血管以及解剖性分离段间交界面，可以实现精准的肺段切除。

The Main Technical Points of Thoracoscopic Anatomical Lung Segment Resection

hToracoscopic segmentectomy is technically much more meticulous than lobectomy, due to the com-plicated anotomical variations of segmental bronchi and vessels. Preoperative three-dimensional computed tomography bron-chography and angiography, 3D-CTBA) could reveal the anatomical structures and variations of the segmental bronchi/vessels and locate the pulmonary nodules, which is helpful for surgery planning. Preoperative nodule localization is of vital importance for thoracoscopic segmentectomy. Techniques involved in this procedure include dissection of the targeted arteries, bronchus and intra-segmental veins, retention of the inter-segmental veins, identiifcation of the inter-segmental boarder with the inlfa-tion-delfation method and seperation of intra-segmental pulmonary tissues by electrotome and/or endoscopic staplers. hTe incision margin for malignant nodules should be at least 2 cm or the diameter of the tumor. Meanwhile, sampling of N1 and N2 station lymph nodes and intraoperative frozen section is also necessary. hTe complication rate of thoracoscopic segmentectomy is comparatively low. hTe anatomic relationship between pulmonary segments and lobes is that a lobe consists of several ir-regular cone-shaped segments with the inter-segmental veins lies between the segments. Our center has explored a method to separate pulmonary segments from the lobe on the basis of cone-shaped principle, and we named it“Cone-shaped Segmentec-tomy”. hTis technique could precisely decide and dissect the targeted bronchi and vessels, and anatomically separate the inter-segmental boarder, which ultimately achieve a completely anatomical segmentectomy.