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Page 8 of 11 Kato et al. Mini-invasive Surg 2021;5:5 I http://dx.doi.org/10.20517/2574-1225.2020.98

Figure 7. A three-dimensional model of the pulmonary vessels and bronchus was made using a three-dimensional printer. The pink color
represents the targeted tumor, the white color represents the bronchi, the red color represents the pulmonary arteries, and the blue color
represents the pulmonary veins.

location. The surgical margins were sufficiently secured, and there were no recurrences.

[48]
Recently, we introduced a wireless marking method for the treatment of indeterminate lung nodules .
Three patients underwent wedge resection after marking. In all cases, the tumors were completely resected,
and one patient was diagnosed with AIS. Although the number of cases is still small, we believe that these
methods are useful for tumor identification in wedge resection.

From July 2004 to August 2020, thoracoscopic segmentectomy and subsegmentectomy for lung cancer
were performed using 3D-CT simulation in 366 patients. Segmentectomy was done in 247 cases,
subsegmentectomy in 69 cases, and segmentectomy combined with adjacent subsegmentectomy in 50
cases. We applied 3D-CT simulation and the slip-knot technique for these anatomical sublobar resections.
First, the parenchyma was dissected using an energy device from the hilar site to the peripheral site along
the intersegmental veins. Following the division of the segmental artery and vein, the segmental bronchus
[44]
was dissected, and an inflation-deflation line was created . The inflation-deflation line can be gradually
identified as the intersegmental line. The bronchus was then divided with a stapler or ligated with a silk
thread based on the bronchial diameter. The parenchyma was then dissected along the intersegmental veins
and the inflation-deflation lines using either an electrocautery or an energy device, and the venous branches
running into the affected segment were divided. Finally, the peripheral parenchyma was divided using
a stapler. With these techniques, our thoracoscopic segmentectomy and subsegmentectomy procedures
secured sufficient surgical margins and were thoroughly improved. The outcomes of thoracoscopic
segmentectomy and subsegmentectomy were excellent, and there were no recurrences in intentional cases
on the basis of our criteria of sublobar resections, although a small number of compromised cases were
known to have recurrences. Thus, we performed thoracoscopic sublobar resections for small-sized lung
cancers using these methods, and the outcomes were satisfactory in terms of curative operation. Although
we have mainly indicated sublobar resection in GGO-dominant tumors, this procedure might also be
indicated in small-sized solid tumors less than 2.0 cm in diameter because previous studies have reported
favorable outcomes [10-15] .

In recent years, we have referred to a 3D model of the pulmonary vessels and bronchus before and during
surgery [Figure 7A and B]. The model is useful for understanding the precise anatomy of each patient. We
prepared this model mainly for anatomical sublobar resections in patients with whom tumor localization is
expected to be difficult. Moreover, reports on the single-port approach have been increasing. We also began
various types of segmentectomies using this approach and investigated its safety and feasibility.