Chapter 65

Segmental resection, or segmentectomy, describes a technique of excising lung tissue that proceeds along anatomic planes based on the bronchovascular anatomy. It involves division and closure of the segmental bronchus along with the corresponding blood supply, followed by dissection and removal of the lung along the intersegmental planes. A wedge resection, sometimes referred to as a segmentectomy owing to its sublobar status, is not an anatomic resection and should not be confused with a segmentectomy. This is an important distinction because this confusion likely has tainted the data used to recommend segmental resection as an adequate cancer operation. In the setting of node-negative disease (N0), a segmentectomy is likely an adequate cancer operation, whereas a wedge resection would be suboptimal.

Although early work by Ewart in the late 1800s characterized the bronchial and vascular anatomy of the lung,1 the term bronchopulmonary segment was coined by Kramer and Glass in 1932.2 A few years later, in 1939, the technique of a segmental resection was described by Churchill and Belsey.3 Their pioneering surgeries were performed for bronchiectasis and tuberculosis, however, not cancer. Shortly thereafter, surgeons began performing limited resections for bronchogenic carcinoma. Until 1973, there were no large group studies comparing the efficacy of segmental resection versus lobectomy for non-small cell lung cancer (NSCLC).4 Since then, limited resection for cancer has continued to be an area of controversy and has been plagued by conflicting studies comparing the technique with standard lobectomy and pneumonectomy. Segmentectomy consequently is used in limited situations in the clinical realm, and lobectomy and pneumonectomy continue to be favored as the curative procedures of choice.

Although there are no absolute indications for performing segmentectomy, the technique has been used for a myriad of lung disorders. As mentioned earlier, the operation was performed initially for bronchiectasis and tuberculosis. Other conditions for which the procedure has been used include aspergilloma, pulmonary sequestration, other pulmonary infections, pulmonary abscesses, benign tumors of the lung (e.g., hamartomas, papillomas, etc.), and metastatic lesions involving the lung. In the modern era of pulmonary surgery, the advent of antibiotic therapy led to a decrease in segmentectomies performed for infectious lung processes and an increase in their use for primary malignancies of the lung.5

Limited resections (segmentectomy and wedge resection) are also performed as curative resections for cancers in selected patients, including two major groups, as described by Jensik.6 These are patients with physical contraindications and patients with limited disease who otherwise would tolerate a lobectomy. The former group consists primarily of patients with limited pulmonary reserve and is not an area of controversy. Segmental resections for patients who would tolerate a larger resection remains an area of debate, likely a result of the Lung Cancer Study Group trial published in 1995.7 The results of this trial showed a threefold increase in local recurrence rate and a 50% increase in number of patients who died with cancer ...

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