Difficulty of Video-Assisted Thoracoscopic Surgery Segmentectomy: Proposal for a New Classification

Segmentectomy has classically been distinguished as "simple" or "complex" based on the number of intersegmental planes (ISPs) dissected. However, with the increasing variety and complexity of segmentectomies, it is clear that a classification based on the number of ISPs alone is inadequate. This study aimed to develop a new classification to predict the surgical difficulty of video-assisted thoracoscopic surgery (VATS) segmentectomy.

The study retrospectively reviewed 1868 patients who underwent VATS segmentectomy between January 2014 and December 2019. Uni- and multivariate analyses were performed to identify predictors associated with prolonged operative time (>140 min), and a scoring system was constructed to classify the surgical difficulty of VATS segmentectomy.

Altogether, 1868 VATS segmentectomies were divided into three groups: group 1 (low difficulty, including segmentectomy with only one intersegmental plane [ISP] dissection), group 2 (intermediate difficulty, including a single segmentectomy with more than one ISP dissection and a single subsegmentectomy), group 3 (high difficulty level, including combined resection with more than one ISP dissection). This classification effectively differentiated the three groups in terms of operative time, estimated blood loss, major complications, and overall complications (all p < 0.001). For receiver operating characteristic analysis, the new classification showed significantly better differentiation performance in terms of operative time (p < 0.001), estimated blood loss (p = 0.004), major complications (p = 0.002), and overall complications (p = 0.012) than the simple/complex classification.

This new three-level classification accurately predicted the surgical difficulty of VATS segmentectomy.