Abstract
Background
Segmentectomy has been shown to be feasible and to convey outcomes comparable to those of lobectomy in several studies. These can be divided into simple (SS) or complex (CS), depending on the number of intersegmental planes dissected during resection. This study aimed to evaluate the postoperative outcomes of uniportal video-assisted thoracic surgery (u-VATS) in CS and SS.
Methods
We conducted a retrospective study from January 2017 to January 2025, including all patients who underwent anatomical segmentectomy via u-VATS. CS and SS were propensity score-matched with a 1:1 ratio.
Results
A total of 402 consecutive u-VATS segmentectomies were conducted during the studied period. After matching, 302 patients were selected. These included 151 SS and 151 CS. Overall, the median age in our study was 70 (64–75) years, with a predominance of female patients (60%, n=181). When contrasting CS with SS, we observed a larger proportion of patients with prolonged air leak [n=35 (23%) vs. n=12 (8%) P<0.001, effect size (ES) =0.210], which was consistent with a longer duration of thoracic drainage in place [3 (2–5) vs. 2 (2–3) days, P<0.001, ES =0.218] and a longer hospitalization period for the CS group [4 (3–6) vs. 3 (2–5) days, P<0.001, ES =0.088].
Conclusions
While small differences may arise when comparing SS and CS, these do not appear to substantially impact the early postoperative course. Ultimately, the complexity of segmentectomies is often determined by the surgeon’s practical experience with each specific segment.
Keywords: Segmentectomy, lung cancer, non-small-cell lung cancer (NSCLC)
Highlight box.
Key findings
• While overall early postoperative outcomes are comparable between simple and complex uniportal video-assisted thoracoscopic anatomical segmentectomies, complex resections tend to be associated with a higher incidence of prolonged air leak and longer hospitalization.
What is known and what is new?
• Segmentectomy has been shown to be a feasible procedure that provides oncological outcomes comparable to lobectomy in recent studies, with the additional advantage of preserving lung parenchyma. As a result, it has gained acceptance as a standard treatment for selected patients with stage I non-small-cell lung cancer, particularly for tumours ≤2 cm. Segmentectomies are generally classified as either simple (SS) or complex (CS), depending on the number of intersegmental planes dissected during resection. Given that a small number of studies have evaluated the outcomes of CS versus SS, this study aimed to compare the early postoperative outcomes of patients undergoing simple vs. complex uniportal-video-assisted thoracic surgery anatomical resections.
What is the implication, and what should change now?
• Although minor differences were noted between SS and CS, these did not translate into meaningful variations in early postoperative outcomes. Surgeons should not be discouraged from performing CS due to concerns over higher morbidity or mortality, which are often attributed to the increased number of planes dissected. Ultimately, the complexity of segmentectomies is often determined by the surgeon’s practical experience with each specific segment.
Introduction
Surgical resection has been the mainstay treatment for early-stage non-small-cell lung cancer (NSCLC), and since 1995, lobectomies have been considered the gold standard procedure (1,2). This same study by the Lung Cancer Study Group described the benefits of lobectomies (2) and also found that sublobar resections were associated with an increased rate of local recurrence and decreased overall survival, limiting this procedure to high-risk patients. However, the increasing use of low-dose computed tomography (LDCT) in lung cancer screening programs has enabled the diagnosis of early-stage cancer and raised questions about the need for less invasive resections. As such, segmentectomies have been shown to be feasible and convey outcomes comparable to those of lobectomy in several recent studies, with the added benefit of preserving lung parenchyma (3-7). Given these results, segmentectomy has increasingly been used as the standard treatment for stage I NSCLC in some centres, particularly for tumours ≤2 cm in diameter.
Segmentectomy is classified as either simple (SS) or complex (CS) based on the number of intersegmental planes dissected during resection. SS involves the dissection of a single intersegmental plane, as seen in procedures like tri-segmentectomy (left S1+2+3), S6, or lingular segmentectomy. In contrast, CS requires the dissection of two or more intersegmental planes (Figure 1) (1,8). Although these procedures are well standardised, technical difficulties have been encountered, particularly with minimally invasive techniques such as video-assisted thoracic surgery (VATS) and uniportal-VATS (u-VATS) (9,10).
Figure 1.
Simple and complex anatomical resections through a u-VATS approach. (A) S6 segmentectomy; (B) S6 + S10 segmentectomy. LL, lower lobe; ML, middle lobe; UL, upper lobe; u-VATS, uniportal video-assisted thoracoscopic surgery.
A small number of studies have evaluated the outcomes of CS versus SS, some reporting an increased number of complications for CS, and even a smaller number of them have evaluated the outcomes of those treated through u-VATS (1,5,8,9,11-14). This study aimed to compare the early postoperative outcomes of patients undergoing simple vs. complex u-VATS anatomical resections. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1762/rc).
Methods
Patient selection
This was a retrospective study of a prospectively maintained database of patients undergoing u-VATS anatomical segmentectomy. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of University Hospitals Coventry and Warwickshire under the following number: GF0972. Individual consent for this retrospective analysis was waived.
From January 2017 to January 2025, all patients who underwent anatomical segmentectomy at University Hospitals Coventry & Warwickshire Trust were considered for inclusion. Data was collected from the theatre and surgical logbooks. Demographic and clinical data were recorded, as well as intraoperative and postoperative findings.
All of the patients underwent the following preoperative investigations: full blood counts, serum biochemistry, computed tomography (CT) scans of the chest, positron emission tomography-CT scans (PET-CT), pulmonary function tests, flexible bronchoscopy, and electrocardiogram.
Patients referred to University Hospitals Coventry and Warwickshire are offered upfront surgery based on the opinion of a multidisciplinary team and the patient’s choice for surgery. This follows the national lung cancer screening program for the United Kingdom. The decision on which segment to remove and if CS or SS best suits the patient was made after a careful review of the chest CT by the thoracic surgery team. In our institution, segmentectomies are performed independently by two senior surgeons. Inclusion criteria for u-VATS segmentectomy consideration in our thoracic unit followed the recommendations from the European Society of Thoracic Surgeons expert consensus (15).
Prolonged air leak (pAL) was defined as any detectable air leak lasting more than 5 days. PET-CT activity was defined as follows: maximum standardised uptake value (SUVmax) <5 was identified as “low intensity”, 5–9 as “moderate”, 10–15 as “intense” and >15 as “very intense” (16).
Major complications were defined as any need for re-intervention, drain reinsertion, severe cardiovascular events, unplanned readmission to the intensive care unit (ICU), or the need for postoperative invasive airway management. Postoperative mortality was defined as any mortality occurring while hospitalised or within the first 30 postoperative days.
Surgical procedure
A 3–4 cm incision was made, followed by dissection into the thoracic cavity and placement of a wound protector to allow for easier insertion of the instruments. A 10-mm, 30° camera was placed at the cephalic end of the incision. Before resection, the lesion was identified by palpation and marked with a stitch. In patients where the lesion could not be palpated, the CT was reviewed intraoperatively in three plane projections (sagittal, coronal, transverse). Target segmental pulmonary arteries and veins were dissected using vascular staplers.
After the target bronchi were identified, clamping was carried out, followed by inflation and deflation to delineate the intersegmental plane, which was clamped with hemostatic forceps. On some occasions, bronchial transillumination was used. Both the target bronchi and the intersegmental plane were divided with endostaplers. A parenchymal tumour margin of ≥1 cm was achieved in all resections (15). Lymph node dissection was carried out at the segmental, hilar, and mediastinal nodes, with the removal of at least six lymph nodes (15,17). Before closure, a chest tube was inserted on the caudal side of the incision.
Postoperative care
Once the surgical procedure was concluded, the chest drain was connected to an underwater seal system or electronic drainage system (Thopaz; Medela Healthcare, Baar, Switzerland). The suction pressure was set at −20 cm H2O. The criteria for chest drain removal included the absence of air leak and drainage of <200 mL within 24 h. Hospital discharge was considered once the drain had been removed, pain was effectively controlled, and a satisfactory chest X-ray was obtained on the day of discharge. In a small proportion of patients with pAL, if it was safe to do so, they were discharged with a flutter bag and brought back for review.
Statistical analysis
Data from our study were presented as frequencies and percentages (%) for categorical variables and median and interquartile range (IQR). Data distribution was ascertained by the Kolmogorov-Smirnov test. Missing data was addressed through imputation, only when the proportion of missing values did not exceed 10% for any variable. The imputation method was selected according to the type of variable. For continuous variables, missing values were imputed using either the median or the mean, depending on the distribution of the data. For categorical variables, values were replaced with the mode.
A propensity score matching (PSM) analysis was chosen to minimise the potential bias introduced by the retrospective nature of the study. The propensity score included the following variables: age, gender, forced expiratory volume in 1 second as percent of predicted (FEV1%), transfer factor of the lung for carbon monoxide as percent of predicted (TLCO%), preoperative tumour size, pack-years index, chronic obstructive pulmonary disease (COPD) status, previous oncological disease, and body mass index (BMI). We used a logistic regression model to account for the propensity score and matched the scores with a 1:1 ratio, without repetition, utilising callipers with a width of 0.1. In order to determine the balance of the matched data, standardised mean differences (SMD) of <0.1 were utilised to determine the adequacy of the match.
For our comparative analysis, data were contrasted with Mann-Whitney U, chi-squared test, Fisher’s exact test, and Kruskal-Wallis test. The effect size (ES) was determined through point-biserial and Cramer’s V. The endpoint of our study was to compare the early postoperative outcomes between SS and CS. Statistical analysis was conducted using SPSS version 25.0 (SPSS Inc., Chicago, IL, USA), and R software version 4.1 (TIBCO, Silicon Valley, CA, USA). A P value <0.05 was considered statistically significant, and an ES >0.250 to establish a strong association.
Results
From January 2017 to January 2025, 402 consecutive u-VATS segmentectomies were conducted, which included 185 (46%) SS and 217 (54%) CS. Although SS were initially more common, CS have become increasingly prevalent over the course of our study, eventually exceeding the number of SS cases. The overall mortality of our study was 0.2% (n=1).
Preoperative
After PSM, 302 patients were selected. These included 151 SS and 151 CS. Analysis of SMD confirmed an adequate balance of covariates between groups. The distribution of the PSM analysis is exemplified in Figure 2A. The differences in SMD before and after matching for the matched variables are illustrated in Figure 2B and shown in Table 1. Overall, the median age in our study was 70 (IQR, 64–75) years, with a predominance of female patients (60%, n=181). Ninety-five (32%) patients had a history of previous oncological disease, which included 6 (6%) with previous lung cancer. In 85% (n=257) of our patients, there was either a history or active smoking status with a median packs-years index of 34 (IQR, 25–36). In 24% (n=71) of patients, there was a prior diagnosis of COPD.
Figure 2.
Scatter and forest plots before and after matching. (A) Scatterplot depicting the distribution of propensity scores between the control (CS) and treated group (SS) before and after matching. (B) Forest plot portraying standardized mean differences before and after PSM. BMI, body mass index; COPD, chronic obstructive pulmonary disease; CS, complex segmentectomy; FEV1%, forced expiratory volume in 1 second as percent of predicted; PSM, propensity score matching; SS, simple segmentectomy; TLCO%, transfer factor of the lung for carbon monoxide as percent of predicted.
Table 1. Baseline characteristics before and after matching.
| Characteristics | Before matching (n=402) | After matching (n=302) | |||||
|---|---|---|---|---|---|---|---|
| CS (n=215) | SS (n=187) | SMD | CS (n=151) | SS (n=151) | SMD | ||
| Age, years | 68 (60–74) | 70 (62–74) | 0.159 | 70 (64–75) | 70 (65–75) | 0.011 | |
| Female | 116 (54) | 99 (53) | −0.023 | 91 (60) | 91 (60) | −0.013 | |
| Smoking history | 189 (88) | 155 (83) | 0.148 | 128 (85) | 128 (85) | −0.017 | |
| COPD | 56 (26) | 60 (32) | 0.324 | 35 (23) | 38 (25) | 0.042 | |
| Pack-years | 41 (25–60) | 40 (25–60) | −0.075 | 34 (25–38) | 34 (30–34) | 0.068 | |
| Cancer history | 71 (33) | 69 (37) | 0.066 | 50 (33) | 45 (30) | −0.072 | |
| FEV1% | 83 (68–99) | 88 (69–99) | 0.025 | 87 (79–100) | 87 (74–97) | −0.027 | |
| TLCO% | 81 (72–93) | 80 (72–92) | 0.018 | 84 (79–97) | 84 (79–93) | 0.057 | |
| Preoperative tumour size, mm | 15 (12–18) | 15 (14–20) | 0.221 | 15 (12–18) | 15 (14–18) | 0.022 | |
| BMI, kg/m2 | 26 (25–27) | 26 (24–29) | −0.168 | 26 (25–27) | 26 (25–29) | 0.093 | |
Data are presented as median (interquartile range) or n (%). BMI, body mass index; COPD, chronic obstructive pulmonary disease; CS, complex segmentectomy; FEV1%, forced expiratory volume in 1 second as percent of predicted; SMD, standardised mean difference; SS, simple segmentectomy; TLCO%, transfer factor of the lung for carbon monoxide as percent of predicted.
Intraoperatively
Altogether, the most commonly resected segments were S1 (26%, n=79), S6 (21%, n=62), and trisegmentectomy (16%, n=49). In the SS group, left-sided resections predominated (77%, n=116). In this same group, S6 was the most common resection (41%), followed by trisegmentectomy (32%), lingular segmentectomies (17%, n=25), and basal segmentectomy (10%, n=15). In CS, S1 resection was performed in 52%, followed by S2 (13%, n=19) and S1, S2 (11%, n=16), which were more frequently resected on the right side (69%, n=104). In both the SS and CS groups, resection was carried out more commonly in the upper lobes (64%, n=193). Table 2 shows the features of each group of segmentectomy.
Table 2. Resected segments for simple (n=151) and complex segmentectomies (n=151).
| Segmentectomy | N (%) |
|---|---|
| Simple segmentectomy | |
| S6 | 62 (41) |
| S4 + S5 | 25 (17) |
| S1 + S2 + S3 | 49 (32) |
| S7 + S8 + S9 + S10 | 15 (10) |
| Complex segmentectomy | |
| S1 | 79 (52) |
| S2 | 19 (13) |
| S1 + S2 | 16 (11) |
| S3 | 8 (5) |
| Other segments | 29 (16) |
Other segments: S7; S8; S7 + S8; S9 + S10; S1 + S3; S2 + S6; S6 + S10; S6 + S9 + S10; S1 + S2 + S6; S8 + S9 + S10; S2 + S6 + S9 + S10.
Tumours characteristics
The median size of the tumour was 16 (IQR, 15–18) mm with a median SUVmax of 4 (IQR, 2–7) mm. These were histologically characterised as follows: 72% (n=217) were primary lung cancer, 6% (n=18) were patients with metastatic tumours, and 22% (n=66) were benign masses. When comparing the preoperative SUVmax values between patients with primary lung cancer and those with benign conditions, we encountered a tendency for higher SUVmax values in the former (P=0.02).
In those with the diagnosis of primary lung cancer, adenocarcinoma represented 79% (n=171), followed by squamous-cell carcinoma in 13% (n=28), and typical carcinoid tumours in 5% (n=11). The remaining 3% comprised large-cell neuroendocrine and adenosquamous tumours. Among patients diagnosed with a benign tumour, 50% (n=33) presented with infectious conditions, including caseating granuloma, aspergilloma, and pneumonia. Chronic changes, such as scar tissue and fibrosis, were observed in 22% (n=15). Hamartomas and cysts accounted for 15% (n=10). Inflammatory changes were identified in 12% (n=8). Tumour characteristics are shown in Table 3.
Table 3. Tumours characteristics.
| Characteristics | Value† | SUVmax (IQR) |
|---|---|---|
| Size, mm | 16 (15–18) | 4 (3–6) |
| Histology | ||
| Primary lung cancer | 217 (72) | 4 (3–8)* |
| Metastasis | 18 (6) | 4 (4–6) |
| Benign | 66 (22) | 4 (2–4) |
†, data are presented as median (IQR) for continuous variables or n (%) for categorical variables. *, P=0.02 on Kruskal-Wallis Test comparing SUVmax in primary lung cancer vs. benign conditions. IQR, interquartile range; SUVmax, maximum standardised uptake value.
Operative outcomes
When contrasting CS with SS, we observed a larger proportion of patients with pAL [n=35 (23%) vs. n=12 (8%), P<0.001, ES =0.210], which was consistent with a longer duration of thoracic drainage in place [3 (IQR, 2–5) vs. 2 (IQR, 2–3) days, P<0.001, ES =0.218] and a longer hospitalization period for the CS group [4 (IQR, 3–6) vs. 3 (IQR, 2–5) days, P<0.001, ES =0.088]. Furthermore, the use of a flutter bag beyond discharge was more common in the CS group [n=14 (9%) vs. n=5 (3%), P=0.03, ES =0.123].
Interestingly, when evaluating the rate of major complications, these were more prevalent in the SS group [5% (n=8) vs. 1% (n=2); P=0.052, ES =0.111]. Additionally, the conversion rate from u-VATS to thoracotomy [1% (n=2) vs. 0.6% (n=1); P=0.31, ES =0.033] was higher in the SS group; however, this difference was not significant. Despite these differences, there was no overall increase in mortality (0.3% of our cohort; P>0.99, ES =0.056). These results are presented in Table 4.
Table 4. Postoperative outcomes of simple vs. complex segmentectomy after propensity score matching.
| Variables | Overall (n=302) | CS (n=151) | SS (n=151) | P | ES |
|---|---|---|---|---|---|
| Drain duration, days | 2 (2–4) | 3 (2–5) | 2 (2–3) | <0.001* | 0.218 |
| Length of stay, days | 4 (2–5) | 4 (3–6) | 3 (2–5) | <0.001* | 0.088 |
| Air leak | 47 (16) | 35 (23) | 12 (8) | <0.001* | 0.210 |
| Conversion† | 3 (1) | 1 (0.6) | 2 (1) | 0.31 | 0.033 |
| Major complications | 10 (3) | 2 (1) | 8 (5) | 0.052 | 0.111 |
| Mortality | 1 (0.3) | 0 | 1 (1) | >0.99 | 0.056 |
| ICU admission | 2 (1) | 0 | 2 (1) | 0.16 | 0.082 |
| Flutter bag at discharge | 19 (6) | 14 (9) | 5 (3) | 0.03* | 0.123 |
Data are presented as median (interquartile range) or n (%). †, conversion from u-VATS to thoracotomy. *, statistically significant. CS, complex segmentectomy; ICU, intensive care unit; ES, effect size; SS, simple segmentectomy.
Discussion
Our study demonstrated the feasibility and safety of both CS and SS through a u-VATS approach. Even though we encountered slight differences between the two, these did not substantially impact the early postoperative course of patients. A synthesis of early postoperative outcomes from comparative studies of CS versus SS is presented in Table 5. Since the first u-VATS lung resections were reported, growing interest in minimally invasive thoracic surgery has increased (18-20). This is primarily associated with the better postoperative outcomes shown in u-VATS, such as less postoperative pain, shorter operative time, and hospital stay (21). As such, segmentectomies have been implemented in u-VATS, with safe and reproducible outcomes (22,23).
Table 5. Summary of the current literature regarding postoperative outcomes of simple and complex anatomical segmentectomies.
| Study | pAL, n (%) | LOS, days, median (IQR) | Drain duration, days, median (IQR) |
Major complications, n (%) | |||||||
|---|---|---|---|---|---|---|---|---|---|---|---|
| SS | CS | SS | CS | SS | CS | SS | CS | ||||
| Okubo et al. (1) | 10 (3.5) | 2 (0.8) | 4 (3–5) | 3 (3–4) | NR | NR | 3 (1.1) | 0 | |||
| Ahn et al. (8) | 1 (1.5) | 1 (0.8) | 7 (4.5–8) | 6 (4–7) | 1 (1–2) | 1 (1–2) | 3 (4.5) | 4 (3) | |||
| Bédat et al. (9) | 9 (7) | 12 (11) | 7 (2–31) | 5 (1–36) | 2 (1–19) | 1 (0–33) | NR | NR | |||
| Homma et al. (12) | 3 (5.5) | 2 (4.4) | 5 (4–6) | 5 (4–7) | 1 (0–1) | 1 (0–1) | NR | NR | |||
CS, complex segmentectomy; IQR, interquartile range; LOS, length of stay; NR, not reported; pAL, prolonged air leak; SS, simple segmentectomy.
We observed a 16% incidence of pAL, with a higher prevalence in the CS group, consistent with recent reports on u-VATS segmentectomy (24,25). This finding is likely attributable to the high proportion of patients with a history of COPD and elevated pack-years index in our cohort. Furthermore, CSs themselves have also been identified as an independent risk factor for pAL in previous studies (24,25). Concerning major complications, the 3% rate observed in our cohort was similar to that reported in other series assessing postoperative outcomes after u-VATS segmentectomy (12,26-28).
Regarding hospitalisation, patients in the CS group experienced a longer length of stay. Interestingly, postoperative hospitalisation duration varies across studies, with some reporting longer stays for SS and others for CS. However, it is essential to acknowledge that while such differences may reach statistical significance, the small magnitude of these differences, combined with the relatively large sample size and modest effect size, may not necessarily reflect clinical relevance. In most cases, reported differences in length of stay amount to only a one-day variation (8,9,12,14).
In terms of tumour characterisation, we observed a 22% rate of benign lesions, which is consistent with prior reports. As exemplified in the studies by Hung et al. and Bédat et al., who reported a 22% incidence of benign lesions, with the former providing detailed characterisation of these findings (9,29). Although resecting benign lung lesions may initially seem like a radical intervention, this is rarely the case, as most patients ultimately derive substantial benefit from surgical removal. This is illustrated in the study by Grogan et al., which analysed 278 pulmonary nodule resections and found a 23% prevalence of benign lesions. The authors further evaluated the clinical impact of these resections and reported that 85% of patients experienced direct benefits, including new diagnoses, changes in treatment plans, or definitive treatment achieved through surgery. Notably, the majority of these cases involved minimally invasive sublobar resections, similar to those performed in our study (30).
At our centre, patients are typically offered upfront surgery following a thorough discussion of the risks and benefits of long-term surveillance, along with an individualised review of all available management options. While advances in lung cancer screening and preoperative tumour characterisation continue to evolve, there remains a paucity of data specifically addressing the incidence of benign lesions found during resections performed for suspected malignancy. Future research should prioritise improving the accuracy of preoperative diagnostic strategies to better distinguish benign from malignant lesions.
Our study has several limitations. Firstly, even though we presented a relatively large sample size, our results reflect a single institution; furthermore, operator bias may have been introduced, given that only two senior surgeons performed the cases. Our analysis was conducted using a prospectively maintained database; nonetheless, patients were not randomised to treatment groups, which may introduce selection bias. We attempted to mitigate this through PSM; however, the possibility of residual confounding cannot be entirely excluded. Finally, we did not assess the long-term effects of segmentectomy on cancer remission and survival outcomes.
Conclusions
Although upfront segmentectomy may initially appear to be a radical intervention, our objective is to deliver an effective cancer treatment using a minimally invasive, lung-preserving approach while working in close collaboration with patients and aligned with their treatment preferences.
In our practice, both CS and SS yield comparable early postoperative outcomes. Although minor differences were noted between CS and SS, these did not translate into meaningful variations in early postoperative outcomes. Surgeons should not be discouraged from performing CS due to concerns over higher morbidity or mortality, which are often attributed to the increased number of planes dissected. Instead, the distinction between CS and SS appears to be more closely related to the frequency with which they are performed. In this context, CS may be performed more easily than SS when the surgeon is well-acquainted with a particular “complex” segment. Whereas SS can be more challenging when there is a paucity of experience in a surgeon’s performance of a specific “simple” segment. Ultimately, the complexity of segmentectomies is often determined by the surgeon’s practical experience with each specific segment.
Supplementary
The article’s supplementary files as
Acknowledgments
We appreciate the support provided by University Hospitals Coventry and Warwickshire.
Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of University Hospitals Coventry and Warwickshire under the following number: GF0972. Individual consent for this retrospective analysis was waived.
Footnotes
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1762/rc
Funding: None.
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1762/coif). The authors have no conflicts of interest to declare.
Data Sharing Statement
Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1762/dss
References
- 1.Okubo Y, Yoshida Y, Yotsukura M, et al. Complex segmentectomy is not a complex procedure relative to simple segmentectomy. Eur J Cardiothorac Surg 2021;61:100-7. 10.1093/ejcts/ezab367 [DOI] [PubMed] [Google Scholar]
- 2.Ginsberg RJ, Rubinstein LV. Randomized trial of lobectomy versus limited resection for T1 N0 non-small cell lung cancer. Lung Cancer Study Group. Ann Thorac Surg 1995;60:615-22; discussion 622-3. 10.1016/0003-4975(95)00537-u [DOI] [PubMed] [Google Scholar]
- 3.Martin-Ucar AE, Nakas A, Pilling JE, et al. A case-matched study of anatomical segmentectomy versus lobectomy for stage I lung cancer in high-risk patients. Eur J Cardiothorac Surg 2005;27:675-9. 10.1016/j.ejcts.2005.01.006 [DOI] [PubMed] [Google Scholar]
- 4.Tsutani Y, Miyata Y, Nakayama H, et al. Oncologic outcomes of segmentectomy compared with lobectomy for clinical stage IA lung adenocarcinoma: propensity score-matched analysis in a multicenter study. J Thorac Cardiovasc Surg 2013;146:358-64. 10.1016/j.jtcvs.2013.02.008 [DOI] [PubMed] [Google Scholar]
- 5.Sesma J, Bolufer S, García-Valentín A, et al. Thoracoscopic segmentectomy versus lobectomy: A propensity score-matched analysis. JTCVS Open 2022;9:268-78. 10.1016/j.xjon.2022.01.009 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Saji H, Okada M, Tsuboi M, et al. Segmentectomy versus lobectomy in small-sized peripheral non-small-cell lung cancer (JCOG0802/WJOG4607L): a multicentre, open-label, phase 3, randomised, controlled, non-inferiority trial. Lancet 2022;399:1607-17. 10.1016/S0140-6736(21)02333-3 [DOI] [PubMed] [Google Scholar]
- 7.Altorki N, Wang X, Kozono D, et al. Lobar or Sublobar Resection for Peripheral Stage IA Non-Small-Cell Lung Cancer. N Engl J Med 2023;388:489-98. 10.1056/NEJMoa2212083 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Ahn S, Moon Y. A comparison of the short-term outcomes of simple and complex segmentectomy via uniportal video-assisted thoracoscopic surgery. J Thorac Dis 2023;15:5386-95. 10.21037/jtd-23-627 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Bédat B, Abdelnour-Berchtold E, Krueger T, et al. Impact of complex segmentectomies by video-assisted thoracic surgery on peri-operative outcomes. J Thorac Dis 2019;11:4109-18. 10.21037/jtd.2019.10.07 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Surendrakumar V, Martin-Ucar AE, Edwards JG, et al. Evaluation of surgical approaches to anatomical segmentectomies: the transition to minimal invasive surgery improves hospital outcomes. J Thorac Dis 2017;9:3896-902. 10.21037/jtd.2017.09.91 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Suzuki K, Saji H, Aokage K, et al. Comparison of pulmonary segmentectomy and lobectomy: Safety results of a randomized trial. J Thorac Cardiovasc Surg 2019;158:895-907. 10.1016/j.jtcvs.2019.03.090 [DOI] [PubMed] [Google Scholar]
- 12.Homma T, Saji H, Shimada Y, et al. Surgical outcomes and learning curve of complex versus simple segmentectomy for uniportal video-assisted thoracoscopic surgery: an initial experience of 100 cases of a single experienced surgeon. J Thorac Dis 2024;16:7361-71. 10.21037/jtd-24-1028 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 13.Bongiolatti S, Salvicchi A, Indino R, et al. Post-operative and early oncological results of simple and complex full thoracoscopic segmentectomies for non-small-cell lung cancer. Asian Cardiovasc Thorac Ann 2023;31:123-32. 10.1177/02184923221138502 [DOI] [PubMed] [Google Scholar]
- 14.Handa Y, Tsutani Y, Mimae T, et al. Complex segmentectomy in the treatment of stage IA non-small-cell lung cancer. Eur J Cardiothorac Surg 2020;57:114-21. 10.1093/ejcts/ezz185 [DOI] [PubMed] [Google Scholar]
- 15.Brunelli A, Decaluwe H, Gonzalez M, et al. European Society of Thoracic Surgeons expert consensus recommendations on technical standards of segmentectomy for primary lung cancer. Eur J Cardiothorac Surg 2023;63:ezad224. 10.1093/ejcts/ezad224 [DOI] [PubMed] [Google Scholar]
- 16.Hofman MS, Hicks RJ. How We Read Oncologic FDG PET/CT. Cancer Imaging 2016;16:35. 10.1186/s40644-016-0091-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17.Lardinois D, De Leyn P, Van Schil P, et al. ESTS guidelines for intraoperative lymph node staging in non-small cell lung cancer. Eur J Cardiothorac Surg 2006;30:787-92. 10.1016/j.ejcts.2006.08.008 [DOI] [PubMed] [Google Scholar]
- 18.Rocco G, Martin-Ucar A, Passera E. Uniportal VATS wedge pulmonary resections. Ann Thorac Surg 2004;77:726-8. 10.1016/S0003-4975(03)01219-0 [DOI] [PubMed] [Google Scholar]
- 19.Gonzalez-Rivas D, Paradela M, Fieira E, et al. Single-incision video-assisted thoracoscopic lobectomy: initial results. J Thorac Cardiovasc Surg 2012;143:745-7. 10.1016/j.jtcvs.2011.07.049 [DOI] [PubMed] [Google Scholar]
- 20.Martin-Ucar AE, Delgado Roel M. Indication for VATS sublobar resections in early lung cancer. J Thorac Dis 2013;5 Suppl 3:S194-9. 10.3978/j.issn.2072-1439.2013.08.41 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 21.Watanabe T, Tanahashi M, Suzuki E, et al. Uniportal Video-Assisted Thoracoscopic Segmentectomy for Early-Stage Non-Small Cell Lung Cancer: Overview, Indications, and Techniques. Cancers (Basel) 2024;16:2343. 10.3390/cancers16132343 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22.Li S, Wu J, Wan Z, et al. The learning curve for uniportal video-assisted thoracoscopic anatomical segmentectomy. J Surg Oncol 2021;124:441-52. 10.1002/jso.26517 [DOI] [PubMed] [Google Scholar]
- 23.Hernandez-Arenas LA, Purmessur RD, Gonzalez-Rivas D. Uniportal video-assisted thoracoscopic segmentectomy. J Thorac Dis 2018;10:S1205-14. 10.21037/jtd.2018.02.47 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24.Gooseman MR, Brunelli A, Chaudhuri N, et al. Prolonged air leak after segmentectomy: incidence and risk factors. J Thorac Dis 2023;15:858-65. 10.21037/jtd-22-623 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25.Gioutsos K, Rieder O, Galanis M, et al. Risk factors for prolonged air leak after uniportal anatomical segmentectomy†. Eur J Cardiothorac Surg 2025;67:ezaf030. 10.1093/ejcts/ezaf030 [DOI] [PubMed] [Google Scholar]
- 26.Numajiri K, Matsuura N, Igai H, et al. Uniportal thoracoscopic pulmonary segmentectomy provides good perioperative results and early postoperative recovery. J Thorac Dis 2022;14:2908-16. 10.21037/jtd-22-555 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Sachs E, Jackson V, Al-Ameri M, et al. Uniportal video-assisted thoracic surgery: segmentectomy versus lobectomy-early outcomes. Eur J Cardiothorac Surg 2024;65:ezae127. 10.1093/ejcts/ezae127 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28.Venkitaraman B, Cai J, Ma X, et al. Uniportal video-assisted thoracoscopic pulmonary segmentectomy: a systematic review. Video-assist Thorac Surg 2021;6:4. [Google Scholar]
- 29.Hung YP, Hunninghake GM, Miller ER, et al. Incidental nonneoplastic parenchymal findings in patients undergoing lung resection for mass lesions. Hum Pathol 2019;86:93-101. 10.1016/j.humpath.2019.01.002 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Grogan EL, Weinstein JJ, Deppen SA, et al. Thoracic operations for pulmonary nodules are frequently not futile in patients with benign disease. J Thorac Oncol 2011;6:1720-5. 10.1097/JTO.0b013e318226b48a [DOI] [PMC free article] [PubMed] [Google Scholar]