The use of energy devices for dividing the cutting plane in sublobectomy
Highlight box
Key findings
• In sublobectomy, cutting plane could be divided only by energy devices.
What is known and what is new?
• Dissecting the intersegmental plane in sublobectomies with energy devices could promote the residual lung expansion but increase the risk of complications.
• Our results indicate that when patient selection is optimized, this technique can be performed safely with a low complication rate, challenging previous concerns.
What is the implication, and what should change now?
• Our study demonstrates the feasibility and safety of using energy devices alone for plane dissection in a specific cohort. Future comparative studies are needed to definitively establish the optimal patient selection criteria for this technique.
Introduction
With the growing incidence of early-stage lung cancer (1,2), sublobar resection is now being used frequently in the surgical treatment of lung cancers (3,4). Previous studies have shown promising survival of clinical T1N0M0 lung cancer patients receiving sublobectomies, especially those with ground-glass opacity (GGO) dominant lesions (5-7). The results of JCOG0802/WJOG4607L trial released recently have shown the effect of segmentectomy for peripheral non-small cell lung cancer (NSCLC) of less than 2 cm (8).
In order to perform radical resection of the lesion, i.e., to maintain sufficient resection margin with the least loss of lung parenchyma, our institute has proposed the concept of anatomical partial lobectomy (APL). The details of this technique have been described in our previous publications (9,10). Briefly, this is a lesion-centered, anatomical approach with the resection of sublobar parts, in which resection range is based on both oncological margin and the distance from corresponding vessels or airways.
The dividing of cutting planes between resected and preserved lung parenchyma is challenging when performing APL. There are three main methods to dissect the cutting planes: using staplers (11,12), energy devices (electrocautery, harmonic scalpel, or LigaSure) (13-15), or the combination of both (16,17). Compared to staplers, dividing the cutting plane with energy devices has been reported to cause higher rate of complications, especially post-operative air leakage (16,18). In a randomized controlled trial by Chen and colleagues, the trial was stopped early for a significantly higher incidence of complications in the group using electrocautery (19). However, this issue remains controversial as some studies reported similar results with the other two methods (20,21). Meanwhile, when performed properly, using energy devices has the advantage of better preserving lung function for better expansion of the remnant parenchyma, especially for large-size cutting planes (22,23).
In the current study, we retrospectively summarized APL cases performed by a single senior thoracic surgeon in which the cutting planes were dissected only by energy devices and analyzed the short-term results. We sought to evaluate the feasibility and safety of this procedure. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1921/rc).
Methods
This is a retrospective, observational study performed in the National Cancer Center, Cancer Hospital, Chinese Academy of Medical Sciences (CHCAMS). All the patients who had received APL in CHCAMS performed by a single surgical team (Dr. J.Z. and his team) with the cutting planes divided only by energy devices from March 2020 to April 2022 were included in the study. Cases with cutting planes were dissected by the combination of staplers and energy devices were excluded to avoid bias. The patients were enrolled in an intention-to-treat method, thus those who underwent conversions to lobectomy were also included. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Medical Ethics Committee of CHCAMS (No. NCC-009462) and informed consent was obtained from each patient before surgery.
Study variables
Demographic and clinical features of the patients were obtained from medical records. Tumor size was defined by the largest diameter of the tumor measured by the pathologists. The definition of GGO, consolidation component and consolidation/tumor ratio (CTR) were in accordance with the Japan Clinical Oncology Group (JCOG) 0201 study (24). Surgery-related characteristics were gained from surgical records. Pathological variables were identified from pathological exams. The tumor node metastasis (TNM) stage of the patients was based on the American Joint Committee on Cancer Staging Manual (8th edition) (25). Prolonged air leakage was defined as an air leak that lasted for over 5 days after surgery. The patients were required to visit the outpatient clinic three and 6 months after surgery for follow-up and a chest computed tomography (CT) scan was done to evaluate the remnant lung expansion.
Preoperative evaluation
Before surgery, every patient had received complete blood count, biochemical profiles, enhanced chest CT scan, pulmonary functional test, and electrocardiogram. Positron emission tomography CT (PET-CT) scan, exercise electrocardiogram, coronary angiography, and 24-hour dynamic electrocardiogram were performed for selected patients. Preoperative planning (vessels and airways to be cut and parenchyma to be removed) was done by the surgeon and his team via careful examination of the CT images. For complex cases, three-dimensional reconstruction was applied (9).
Surgical procedures
All the surgeries were carried out by uni-portal video-assisted thoracoscopic surgery (VATS). Under double-lumen general anesthesia, the patient took lateral decubitus position. A 3–4 cm incision was taken between the middle and posterior axillary line on the fourth or fifth intercostal space according to the tumor location. The incision was covered by a wound protector without sparing the ribs. After cutting off pulmonary arteries, veins and airways according to preoperative planning, the cutting plane was determined by an inflation-deflation method. The lung was fully inflated and the cutting plane was depicted when the preserved parenchyma recollapsed (Figure 1A). A monopolar electrocoagulation hook or harmonic scalpel was used to divide the parenchyma along the inflation-deflation border (Figure 1B). The output of electrocautery was set at 60 W. No stapler was applied to dissect the parenchyma. The diseased parenchyma was taken out in a tissue retrieval bag and the raw surface of the remnant lung was covered by an absorbable polyglycolic acid felt (Neoveil; Japan Medical Planning Co., Kyoto, Japan) (Figure 1C). Frozen section was done for all cases. If frozen section confirmed malignancy, systematic or selective lymphadenectomy was performed. Finally, a 16 Fr chest tube was placed through a muscle tunnel at the posterior part of the incision.
Statistical analysis
Categorical variables were presented by number with percentage, while quantitative variables by average with range.
Results
Between March 2020 to April 2022, after excluding two patients who were converted to lobectomy during operation, both owing to poorly differentiated invasive adenocarcinoma by frozen section, a total of 69 patients received APL performed by the surgical team in our center. The cutting planes were divided only by electrocautery or harmonic scalpel in all cases. Sublobar resection was chosen intentionally for all the patients.
Clinical and pathological characteristics of the patients
The baseline and pathological features of the patients are shown in Table 1. The majority of the patients were female and non-smokers, with the mean age being 51.4 years. The average tumor size was 0.9 cm and nearly 90% of the lesions were GGO dominant (CTR ≤0.5). In the 69 patients, 65 (94.2%) were found to have primary lung cancer, among which 69.2% (45/65) were non-invasive diseases [adenocarcinoma in situ (AIS) or minimally invasive adenocarcinoma (MIA)]. All but one patient had TNM stage 0–IA tumors.
Table 1
| Feature | Values (n=69) |
|---|---|
| Age (years) | 51.4 [25–77] |
| Gender (male) | 17 (24.6) |
| Tobacco use | 4 (5.8) |
| Comorbidities | 14 (20.3) |
| Cardiovascular disease | 4 (5.8) |
| Hypertension | 8 (11.6) |
| Diabetes | 5 (7.2) |
| Arrhythmia | 3 (4.3) |
| Cerebrovascular disease | 1 (1.4) |
| Tumor diameter (cm) | 0.9 [0.5–2.4] |
| CTR | |
| 0 to 0.25 | 57 (82.6) |
| >0.25 to 0.5 | 4 (5.8) |
| >0.5 to 1 | 8 (11.6) |
| Pathological subtype | |
| AIS | 13 (18.8) |
| MIA | 32 (46.4) |
| Adenocarcinoma | 20 (30.0) |
| Benign lesion | 4 (5.8) |
| TNM stage† | |
| 0 | 13 (20.0) |
| IA1 | 37 (56.9) |
| IA2 | 13 (20.0) |
| IA3 | 1 (1.5) |
| IB | 1 (1.5) |
Data are presented as median [interquartile range] or n (%). †, calculated in lung cancer patients (n=65). AIS, adenocarcinoma in situ; CTR, consolidation/tumor ratio; MIA, minimally invasive adenocarcinoma; TNM, tumor-node-metastasis.
Surgery-related features
The feasibility and safety of the procedure were then evaluated by analyzing the surgical features. All the surgeries were done by uni-portal VATS without conversion to multi-portal or open surgery. Table 2 shows the types of APL performed. APL was performed in all the lobes except the middle lobe. The procedures included segmentectomies, combined segmentectomies, sub-segmentectomies, combined sub-segmentectomies, and segmentectomy + sub-segmentectomy. The resected segments or sub-segments are listed in Table 2.
Table 2
| Types | Number (%) |
|---|---|
| Right lung | 47 (68.1) |
| Upper lobe | 24 (34.8) |
| S1 | 5 (7.2) |
| S1 + S2 | 1 (1.4) |
| S1 + S3 | 1 (1.4) |
| S1a + S2a | 1 (1.4) |
| S1a + S2 | 2 (2.9) |
| S2 | 6 (8.7) |
| S2b + S3a | 1 (1.4) |
| S3 | 3 (4.3) |
| S3a | 1 (1.4) |
| S3b | 3 (4.3) |
| Lower lobe | 23 (33.3) |
| S6 | 2 (2.9) |
| S6 + S10a | 1 (1.4) |
| S6b + S8 + S9a | 1 (1.4) |
| S7 + S8 | 2 (2.9) |
| S7b + S8b | 1 (1.4) |
| S8 | 4 (5.8) |
| S8a | 1 (1.4) |
| S8b | 3 (4.3) |
| S8 + S9 | 1 (1.4) |
| S9 | 2 (2.9) |
| S9b + S10b + S10c | 2 (2.9) |
| S10 | 3 (4.3) |
| Left lung | 22 (31.9) |
| Upper lobe | 11 (15.9) |
| S1 + S2 | 2 (2.9) |
| S1 + S2c | 1 (1.4) |
| S3 | 3 (4.3) |
| S3c | 1 (1.4) |
| S4 + S5 | 4 (5.8) |
| Lower lobe | 11 (15.9) |
| S6 | 4 (5.8) |
| S8 | 1 (1.4) |
| S8 + S9b | 1 (1.4) |
| S8a + S9a | 1 (1.4) |
| S8a + S9 | 1 (1.4) |
| S10 | 2 (2.9) |
| S10b + S10c | 1 (1.4) |
The average duration of surgery was 124.9 minutes with a mean intraoperative blood loss of 25.9 mL (Table 3). There was no major hemorrhage or need for blood transfusion during surgery. On average, 4.8 lymph node stations and 8.3 lymph nodes were dissected in the 69 patients with lung cancer (Table 3).
Table 3
| Feature | Values (n=69) |
|---|---|
| Conversion to lobectomy | 2 (2.9) |
| Surgery time (min) | 124.9 [63–200] |
| Blood loss in operation (mL) | 25.9 [8–55] |
| Station of LND† | 4.8 [1–7] |
| No. of LND† | 8.3 [2–26] |
Data are presented as median [interquartile range] or n (%). †, calculated in lung cancer patients (n=65). LND, lymph node dissection.
Postoperative recovery of the patients
The safety of the procedure was further assessed by investigating the recovery of patients after surgery. There was no unplanned return to the operating room nor a patient who needed to stay in the intensive care unit after surgery. Complication was observed in nine (13%) patients after surgery, with prolonged air leakage being the most common one (5/69, 7.2%) (Table 4). The mean thorax drainage volume was 426.9 mL and the chest tube was removed 3.5 days after surgery, averagely. The average length of hospital stay after surgery was 3.8 days with the longest one being ten days due to chylothorax. One patient was readmitted within 3 months postoperatively for chest tube reinsertion owing to pneumothorax.
Table 4
| Feature | Values (n=69) |
|---|---|
| Complication | 9 (13.0) |
| Prolonged air leakage | 5 (7.2) |
| Chylothorax | 2 (2.9) |
| Atelectasis | 1 (1.4) |
| Pneumonia | 1 (1.4) |
| Drainage volume (mL) | 426.9 [60–1,830] |
| Time of chest tube removal (days)† | 3.5 [2–10] |
| Post-operative LOS (days) | 3.8 [2–10] |
| Remnant lung expansion‡ | |
| Full expansion | 41 (65.1) |
| Partial expansion | 2 (3.2) |
| Cavity | 11 (17.5) |
| Encapsulated effusion | 9 (14.3) |
†, including the day of surgery; ‡, calculated in patients with chest CT scan 3 months after surgery (n=63). CT, computed tomography; LOS, length of stay.
The expansion of the preserved lung parenchyma was evaluated by chest CT scan at 3 months after surgery, which was obtained for 63 patients. The other six patients were not included in this analysis for loss of follow-up. Among the 63 patients, full expansion of the remnant lung was observed in 41 (65.1%). Two patients had partly expanded lungs. Cavity and encapsulated effusion at the site of the resected lung were discovered in 11 (17.5%) and 9 (14.3%) patients, respectively (Table 4). Among the 11 patients with residual cavities, 8 were found to be resorbed by CT scan follow-up at 6 months after surgery (Figure 2A,2B). The cavities persisted in the other three cases, yet none of the patients complained of discomfort. For the nine patients with encapsulated effusion, complete resorption was observed in seven at 6 months after surgery (Figure 2C,2D). The encapsulated effusion transferred to a thin-walled cavity in one patient and persisted in the other. Similarly, these patients were all asymptomatic. Thus, at 6 months after surgery among the 63 patients, the remnant lung had full expansion in 57 (90.5%) of them, indicating the safety of the procedure.
Discussion
In the current study, we retrospectively analyzed the clinical and surgical features as well as postoperative recovery of 69 patients who had undergone APL with the cutting plain divided only by energy devices. The surgical data and perioperative outcomes of the patients showed that it is safe to dissect the cutting plaine by energy devices in APL for selected patients.
Without the compression of parenchyma by staplers along the cutting plane, the use of energy devices has been reported to have the advantage of better expansion of the residual parenchyma, which in turn preserves more pulmonary function (22,23,26). However, this technique has been questioned by a higher complication rate, especially air leakage, which has restricted its use (18,19). The cohort of our study showed a lower proportion of both overall complications and air leak compared with the previous studies (19,26). Plus, the surgical data of the study, including operation time and blood loss, also indicated the feasibility of this procedure.
Our data showed valid results for the use of energy devices in dissecting the cutting plane. However, it should be noticed that over 90% of the patients were non-smokers who never smoked, and that none of the patients had chronic obstructive pulmonary disease (COPD) or patients with history of tuberculosis. Thus, the selection of patients is critical for this procedure. For heavy smokers and patients with COPD or tuberculosis, the cutting plane would be difficult to distinguish by the inflation-deflation method. Also, healing of the raw surface of residual parenchyma would be slow, leading to a higher risk of complications. So, the use of this technique should be avoided in these patients.
To reduce the risk of complications, especially air leakage, clear demarcation of the cutting plane and precisely dividing through it are critical and could be a difficult part of the surgery. Here, we recommend the inflation-deflation method because this technique could develop a three-dimensional cutting plane. This would help to distinguish the resected and preserved parenchyma not only on the surface of the lung but also inside the parenchyma. In some circumstances, the intersegmental veins could also help to recognize the cutting plane around the hilum.
Follow-up at three months after surgery discovered cavity and encapsulated effusion at the surgery site in 11 and 9 patients, respectively. The cavity or effusion still persisted in a few patients at 6 months after surgery. This phenomenon has been reported in previous publications (27,28). In consistency with these reports, all these patients were asymptomatic, nor did they need special intervention.
Our study has analyzed the feasibility and safety of dissecting the cutting planes by energy devices in APL. However, the study has important limitations in that the change of pulmonary function after surgery was not assessed nor compared with the use of staplers. Also, this is a retrospective analysis and all the surgeries were performed by a single surgical team. Thus, the results need further validation by prospective studies and by different surgeons of multiple centers.
The results of the JCOG0802/WJOG4607L trial published recently showed superiority of segmentectomy to lobectomy in overall survival for peripheral, ≤2 cm lung cancers, even for the consolidation of dominant nodules (8). However, the surgeries of our study were performed before the report of the trial. Thus, the indication of intentional sublobar resection of our cohort was stricter. The majority of the lesions were GGO-dominant nodules and there was no pure solid nodule (CTR =1). Also, the majority of the patients had non-invasive adenocarcinoma, while others had invasive but well or moderately differentiated adenocarcinoma. The two cases of poorly differentiated adenocarcinoma were converted to a lobectomy during the operation. With the release of preferable results for sublobectomies and more frequent application of APL in early-stage lung cancers, the use of energy devices in cutting plane division might be more prevalent.
Conclusions
In conclusion, our study has revealed reasonable surgery data and postoperative recovery outcomes of patients who had undergone APL with the cutting planes dissected only by energy devices. Our results show the feasibility and safety of this this procedure in selected patients. Perspective trials are needed to further validate the results.
Acknowledgments
None.
Footnote
Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1921/rc
Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1921/dss
Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1921/prf
Funding: This work was supported by
Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1921/coif). The authors have no conflicts of interest to declare.
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. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Medical Ethics Committee of CHCAMS (No. NCC-009462) and informed consent was obtained from each patient before surgery.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
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