Thoracoscopic Anatomical Enucleation of GGO

Enucleation was commonly used in the surgery of the eye or prostate. The implication in the treatment of GGO is never reported.

In this multimedia article, we described a thoracoscopic enucleation of GGO between S7 and S8 in the right lower lobe. According to the pre-operative 3D-CTBA, few bronchovascular structures were passing through the border of RS7 and RS8-a primarily pulmonary parenchyma region. Therefore, an enucleation of GGO is feasible with a low risk of injuring adjacent structures. The main utility incision and observing port were inserted in the fourth and seventh intercostal space in the anterior axillary line. Two assistant incisions were made in the seventh intercostal space in the mid-axillary line and the ninth intercostal space in the posterior axillary line. The GGO is invisible and unpalpable, so it cannot be located intraoperatively. The surgery was initiated by dividing the lung parenchyma alongside the anatomic landmark of A7 on the left. On the right, the common trunk of A8-10 was dissected until A8 was identified. The last anatomic landmark is V8b, which lies posteriorly. The lung parenchyma was dissected by electrocautery hook along with the A7, A8, and V8b to the diaphragmatic surface. Using an electrocautery hook during dissection is preferable, whose terminal is sharper and more flexible. The ultrasonic scalpel is not recommended. A glove is utilized for the specimen retrieval to avoid implantation metastasis.

The operative time was 0.5 h with an estimated blood loss of 10 ml. With no chest tube, the patient was discharged on postoperative day 1. The final pathological finding was minimally invasive adenocarcinoma (pTmiN0M0).

Considering the natural history and excellent prognosis of GGO, the safe margin is the primary concern for GGO resection.^1,2 We use the anatomic landmark to secure a safe margin in enucleation. Besides, dissection of the anatomic intersegmental plane by electrocautery (but not by stapling) reduces unfavorable recurrent local failure at the margin and allows full expansion of the preserved adjacent segments to result in maximal pulmonary function.³.