Comparison of different approaches in complete thoracoscopic segmentectomy of lung lower lobe

Background: Safe and oncologically acceptable segmentectomy outcomes were reported for earlystage lung cancer. The high-resolution computed tomography allowed us to find detailed structures inside the lungs, such as the pulmonary ligaments (PLs). Hence, we have presented the relatively anatomically challenging thoracoscopic segmentectomy, for the resection of the lateral basal segment, the posterior basal segment, and both segments through the PL as a PL approach. This study aimed to retrospectively examine the lung lower lobe segmentectomy, excluding the superior and basal segments (from S7 to S10), using the PL approach as an option to treat the lower lobe tumors of the lung. We then compared the efficacy of the PL approach in terms of safety with the interlobar fissure (IF) approach. The characteristics of the patients, intra- and postoperative complications, and surgical outcomes were analyzed. Methods: Of the 510 patients who underwent segmentectomy for malignant lung tumors from February 2009 to December 2020, 85 were included in this study. Among them, 41 underwent a complete lung lower lobe thoracoscopic segmentectomy, excluding S6 and basal segments (from S7 to S10), using the PL approach, and the remaining 44 used the IF approach. Results: The median age in 41 patients in the PL group was 64.0 years (range, 22-82), and that in 44 patients in the IF group was 66.5 years (range, 44-88), with significant differences in gender between these groups. Video-assisted thoracoscopic surgery and robot-assisted thoracoscopic surgery were performed on 37 and 4 patients in the PL group and 43 and 1 patient in the IF group, respectively. Postoperative complication frequency was not significantly different between these groups. The most common complications were the air leaks that persisted for over 7 days in 1 and 5 patients in the PL and IF groups, respectively. Conclusions: Complete thoracoscopic segmentectomy of the lower lobe, excluding S6 and basal segments, using the PL approach is a reasonable option for lung lower lobe tumors compared with the IF approach.