Concepts and techniques: how to determine and identify the appropriate target segment in anatomical pulmonary segmentectomy?

Anatomical segmentectomy is gathering increasing interest among thoracic surgeons because of increased detection of pulmonary nodules with ground-glass opacity (GGO) as well as an increase in the number of compromised patients. Accurate determination of intersegmental planes is a challenge in anatomical segmentectomy, and multiple methods have been proposed including developing inflation/deflation lines and injecting indocyanine green either intravenously or intrabronchially. Considering resection margins, adding a localization technique to conventional methods, or conducting virtual-assisted lung mapping (bronchoscopic multi-spot dye marking) may be an optional approach for optimal anatomical segmentectomy to identify intersegmental planes and obtain adequate resection margins. To determine optimal resection lines in anatomical segmentectomy, surgeons must also consider oncological validity such as venous and lymph drainage, resection margins, and lung anatomy to avoid complications such as venous congestion, infarction, and air leakage. Although anatomical segmentectomy is an attractive approach to resect small early-stage lung cancer and some metastatic lung tumors, caution is needed to optimally perform this technically demanding surgery.