Thoracoscopic Pulmonary Sub-Subsegmentectomy Based on Three-Dimensional Images Wei-Bing Wu, MD, Xin-Feng Xu, MD, Wei Wen, MD, Jing Xu, MD, PhD, Quan.

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Thoracoscopic Pulmonary Sub-Subsegmentectomy Based on Three-Dimensional Images Wei-Bing Wu, MD, Xin-Feng Xu, MD, Wei Wen, MD, Jing Xu, MD, PhD, Quan Zhu, MD, Liang Chen, MD The Annals of Thoracic Surgery Volume 102, Issue 5, Pages e389-e391 (November 2016) DOI: 10.1016/j.athoracsur.2016.04.048 Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 1 Patient 1. (A) Computed tomographic (CT) image showing the primary lesion as a pure ground-glass opacity (white arrow) in left S1+2. (B) Three-dimensional CT angiographic left lateral posterior view showing the primary lesion (white arrow) in left S1+2aii. The grey area denotes the safety margin; the involved anatomic structures are A1+2aii, B1+2 aii, and two intersegmental veins that run between S1+2a and S3c (yellow triangles). The intersubsubsegmental vein (white triangle) that runs between S1+2aii and S1+2ai is outside the safety margin. (C) Intraoperative view showing the already divided A1 + 2aii, pulmonary veins (triangles), and the resected B1+2aii. (D) View of the hilum after removal of S1+2aii and showing the stumps of A1+2aii, B1+2aii, two intersegmental veins (yellow triangles), and the preserved intersubsubsegmental vein (white triangle). The Annals of Thoracic Surgery 2016 102, e389-e391DOI: (10.1016/j.athoracsur.2016.04.048) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 2 Patient 2. (A) Computed tomographic (CT) image showing a solid nodule (white arrow) in left S3. (B) Three-dimensional CT angiographic left anterior lateral view showing the lesion (white arrow) is in left S3cii. The grey area denotes the safety margin, and the involved anatomic structures are A3cii (green triangle), B3cii, and the intersubsubsegmental vein, which runs between S3cii and S3ci (yellow triangle). The A3ci (white triangle) and B3ci are outside the safety margin. (C) Intraoperative view depicting the already divided B3cii, the intersubsubsegmental vein (yellow triangle), A3ci (white triangle), and the resected A3cii. (D) View of the hilum after removal of S3cii and depicting the stumps of A3cii, B3cii, the intersubsubsegmental vein (yellow triangle), and the preserved A3ci (white triangle). The Annals of Thoracic Surgery 2016 102, e389-e391DOI: (10.1016/j.athoracsur.2016.04.048) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions

Fig 3 Schematic diagram of wedge resection for the two lesions (A. patient 1; B. patient 2). The boundary of the grey area represents the safety margin, and the green stubs indicate the stumps of vessels and the bronchus during subsubsegmentectomy. The pink curve (2) represents the ideal removal line of wedge resection, the light green curve (1) represents the insufficient line, and the blue curve (3) represents the excessive line. The removal lines are typically located between curves 1 and 3 during wedge resections. Owing to the lack of accurate intraoperative lesion detection, the removal line is difficult to maintain in curve 2. The area between curves 1 and 2 depicts the area of insufficient resection, and the area between curves 2 and 3 depicts the area of excessive resection, which may injure the adjacent vessels and bronchus (yellow triangles). The Annals of Thoracic Surgery 2016 102, e389-e391DOI: (10.1016/j.athoracsur.2016.04.048) Copyright © 2016 The Society of Thoracic Surgeons Terms and Conditions