Full thoracoscopic segmentectomies for lung cancer: rational of a multiportal fissure-based approach

Following the partial results of ongoing randomized trials, thoracoscopic anatomic sublobar resections (SLRs) may become the standard treatment of ground -glass opacities (GGO) and of some early- stage lung carcinomas. However, these procedures are challenging. The performance of closedchest pulmonary segmentectomies, especially for complex ones, requires a meticulous dissection of bronchovascular elements. A thorough preparation facilitates the procedure. In this article, we review the different technical and technological aspects of the multiportal approach with fissure -first dissection. Prerequisites are (I) precise preoperative study of the anatomical variations, based on 3D reconstructions or 3D printing, (II) preoperative evaluation of safety margins, based on a virtual margin, (III) for small nodules, localization of the target using either preoperative or intraoperative marking, (IV) fissure -based approach to allow extensive dissection of bronchovascular elements, (V) intraoperative analysis of resection margins and intersegmental lymph nodes in order to extend resection in case on invaded margin or lymph node, (VI) accurate delineation and division of the intersegmental plane. Technical and technological helpful means are discussed in this article.