The Safety and Efficacy of the Seeking Anatomical Conditions for Creating Tunneling Technique with Precise Resection of Lung Segments at Complex Setting

The Safety and Efficacy of the Seeking Anatomical Conditions for Creating Tunneling Technique with Precise Resection of Lung Segments at Complex Setting | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Safety and Efficacy of the Seeking Anatomical Conditions for Creating Tunneling Technique with Precise Resection of Lung Segments at Complex Setting Kexin Cao, Jian Zhu, Jianan Zheng, Ke Wei, Zhihua Li, Zhijun Chen, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5248701/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 21 Dec, 2024 Read the published version in BMC Surgery → Version 1 posted 13 You are reading this latest preprint version Abstract Background Thoracoscopic segmentectomy is the main surgical method for the treatment of early lung cancer. With the promotion of technology and increasingly accurate criteria for lung subsegments, lung nodules with complex positions involving intersegmental and multisegments have become technical bottlenecks. This study aimed to verify whether seeking anatomical conditions for creating tunneling technique with precise resection of lung segments could solve this bottleneck problem. Methods The clinical data of patients with lung nodules ≤ 2 cm located in the complex position in the Department of Thoracic Surgery of Jiangsu Provincial People's Hospital from January 2019 to August 2023 were collected. Date analyzed the characteristics of patients who underwent seeking anatomical conditions for creating tunneling technique with precise resection of lung segments (segment group) at complex setting and compared the surgical outcomes and complications between these lobectomy patients (lobectomy group) at similar locations. Results A total of 22 patients were included segment group and 47 patients were included lobectomy group. Patients in segment group received a satisfactory surgical margin. Compared to the lobectomy group, surgical outcomes were better ( p < 0.05 for postoperative hospital stay and the number of resected subsegments). Conclusion Seeking anatomical conditions for creating tunneling technique is a promising technique for performing precise resection of lung segments with a safe resection margin for patients with lung nodules at complex positions involving multiple segments. It can be used as a precise resection of lung segments technique. Lobar split cone-shaped subsegmentectomy Lobectomy Intersegmental lung nodules Multisegment lung nodules Video-assisted thoracoscopic surgery Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Introduction Designed by the American Lung Cancer Study Group (LCSG) in 1982, the world's first multicenter randomized controlled prospective trial, LCSG821, on sublobectomy for the treatment of early lung cancer established lobectomy as the standard surgical treatment for early lung cancer [ 1 ]. With the spread of computerized tomography (CT) imaging of the lungs and advances in staging methods, smaller and earlier tumors are being detected, which has led to renewed interest in sublobectomy in patients with early lung cancer [ 2 , 3 ]. After more than 40 years of comparative studies on the effects of different surgical methods for early lung cancer, it was found that for peripheral lung nodules ≤ 2 cm and pure ground glass opacity, it is feasible to perform thoracoscopic lung segmentectomy, which can achieve the same effect as radical lobectomy [ 4 , 5 ]. The latest and influential research results of CALGB140503, JCOG0802 and JCOG0804 suggest that lung sublobectomy can replace lobectomy for the treatment of pure solid peripheral early lung cancer with a diameter less than 2 cm [ 6 , 7 , 8 ] and that sublobectomy can be used to lengthen the tumor height to a new height. However, 'not a true segmentectomy' often results in inadequate surgical margins, especially in complex settings [ 9 , 10 ]. In addition, studies comparing 'Not a true segmentectomy' and lobectomy have yielded conflicting results [ 9 , 10 ]. A true lung segmentectomy should not involve the pursuit of the external volume of the lung segment. Ultimately, the volume of the lung segmentectomy can be replaced by a large wedge resection [ 10 ]. Therefore, surgical methods for true lung segmentectomy, which are specific to the anatomy of specific structures and satisfy the incisal margin, are worthy of further research. In our last research report, precise resection of lung segments was defined as (1) having a safe surgical margin distance which more than the maximum diameter of the tumor or 2 cm; (2) divided and severed the arterial, bronchial, and main venous structures (three are indispensable); (3) using the unit for lung subsegment, reduce the counts of resected subsegments as much as possible [ 5 ]. So, is lobectomy the only way to obtain a perfect anatomical structure and a satisfactory incisional margin for lung nodules at complex setting involving multiple segments? Therefore, this study aimed to verify whether seeking anatomical conditions for creating tunneling technique with precise resection of lung segments could solve this bottleneck problem. Methods Study Design and Participants We retrospectively screened patients with lung nodules in complex positions involving intersegmental and multisegmental regions ( Figure 1 ) who underwent creating tunneling technique with precise resection of lung segments and lobectomy at our center between January 2019 and August 2023. The patients were named the segment group and lobectomy group, respectively. Inclusion criteria: (1) the operation was performed by the surgeon with more than five years related experience in performing segmentectomy independently; (2) the number of segmentectomy operations performed by the surgeon in the past five years was more than 1000; (3) the lung segmentectomy operation was performed by precise resection of lung segments as our defined; (4) the collected data should have intact surgical videos. Exclusion criteria: (1) dealing with unplanned events for more than 30 minutes during the operation; (2) there are two or more lesions that need to be treated in the different anatomical fields; (3) cases with radiographic data were not considered suitable for lung segmentectomy; (4) cases with incomplete data, such as lack of key surgical details; (5) cases converted to lobectomy during the operation. The included patients were divided into two groups according to the surgical way, segment group and lobectomy group. The specific case screening process is shown in Figure 2 . Surgical procedures Before the operation, three-dimensional (3D) reconstruction was performed for patients seeking anatomical conditions for creating tunneling technique with precise resection of lung segments at complex setting. 3D reconstruction accurately simulated lung segmentation and lesions and was planned according to the tracheal branches, arteries, and veins. The positions and adjacent tissue (blood vessels, bronchus) lung nodules were labeled to guide the lung segmentation, and resection margin spheres were generated 2 cm from the lesion edge. The reconstruction results were reviewed by comparison with the preoperative CT images, and the resection schemes were planned jointly by experienced surgeons with three associate director titles or above. The positions in the segment group included LS1+2c+S3a, LS3, LS3a+b, LS1+2c+S3, RS1+S3a, RS1b+S2b+S3a, RS1b+S3a, S9, RS8a+S9, and RS6+S9. The method of establishing the tunneling technique for LS1+2c+S3a, LS3, LS3a+b, and LS1+2c+S3 involved dissecting A4+5 at the oblique fissure and opening the posterior mediastinal pleura to dissect A1+2c ( Figure 3 ). In this way, the spacings between A4+5 and A1+2c are used to establish splitting hatchway 1. Then, opening the anterior mediastinal pleura for dissecting V3b exposes the space between B4+5 and B3, which splits Hatchway 2. Lobar splitting between hatchway 1 and hatchway 2 was performed using a stapler. For RS1S+3a, RS1b+S2b+S3a, and RS1b+S3a ( Figure 4 ), dissection of the target vein, target artery and target bronchus were performed first. Then, the spacings between B1b and B3b were exposed, which was splitting hatchway 1. The spacings between B3a and B3b were determined by splitting hatchway 2. Additionally, for S9 and S8a+S9 (left lung for Figure 5 , right lung for Figure 6 ), dissection of the target vein, target artery and target bronchus were performed. Then, the spacings between B8a and B8b were exposed, which was tunneling hatchway 1. The spacings between B9 and B8 were split into hatchway 2. Tunneling technique between Hatchway 1 and Hatchway 2 was also performed using a stapler. The structures of hatchway 1 and hatchway 2 to be severed in both directions were determined during the preoperative simulation according to 3D reconstruction. During establishing the tunneling, it is necessary to check whether there are still vessels or bronchi. If these abnormalities are found, there may be errors in the surgical anatomy. Before tunneling technique, the inflation‒deflation method for distinguishing the intersegmental plane is also necessary. The combination of sharp-blunt dissection, "work-plane extension", and the "gate" opening technique contributes to the accuracy of tunneling technique [11, 12, 13]. The lung lobe was subsequently divided into normal lung tissue and contained the lesion target lung tissue after tunneling technique. The target arteries and bronchus of the target segment and the adjacent segment were exposed, and the internal veins of the target segmentectomy were removed to preserve the intersegmental veins so that the resection of multiple subsegments could be combined into one resection unit [5, 13]. For the tissue with lesions surgically resected, we measured the surgical margins in all patients. The surgical margins were calculated based on the shortest distance between the tumor boundary and the line connecting the clip on the pleura with the staples on the bronchial stump [14]. Our minimum requirement is that the surgical margin distance be ≥ the maximum diameter of the tumor or 2 cm; otherwise, lung lobectomy will be performed. Other surgical procedures and routine pulmonary segmentectomy. Data collection and analysis The eligible medical records were compared and analyzed in terms of age, sex, nodule size (cm), nodule location, nodule type, nodule depth ratio, consolidation tumor ratio (CTR), surgical margin distance, operation time (min), intraoperative blood loss (ml), postoperative hospital stay (days), and postoperative lung air leakage. According to the depth ratio method, the bronchial cross-section center of each unit was set as the starting point, and the center of the lesion extended to the endpoint on the pleura. Trisection of the lung field was conducted into the outer third lung field (0-33.3%), middle third lung field (33.4-66.6%), and inner third lung field (66.7-100%) [15]. The data are presented as the mean ± standard deviation for continuous variables and as absolute numbers and percentages for categorical variables. Categorical variables were assessed using χ2 tests or Fisher's exact tests as appropriate, while t tests were conducted for continuous variables with independent samples. The nonnormally distributed data were compared between groups by the U test. A p value ≤0.05 indicated statistical significance. All the statistical analyses were performed using SPSS version 26.0 software. Results Patient characteristics Our study included 69 patients ( Table 1 ), of whom the mean age was 56.19±10.71 years, 46 (66.7%) patients were female, and 22 (31.9%) patients were smokers. The mean tumor size was 1.32±0.40 cm. Twenty-two patients were included in the segment group, and 47 were included in the lobectomy group. In total, four lobes and three pathological types of lung nodules from patients who underwent segmentectomy were evaluated. Surgical outcomes between the segment group and lobectomy group Compared with those of the lobectomy group, the main surgical evaluation indices of the segment group, including operation time (146.91±47.04 min vs 124.36±31.83 min, p =0.0501), intraoperative bleeding (44.55±26.68 mL vs 48.30±33.90 mL, p =0.649) and the occurrence of air leakage (9.09% vs 4.26%, p =0.956), were not disadvantageous. The postoperative hospital stay decreased in the segment group (3.36±0.66 days vs 4.74±2.19 days, p < 0.001). Seeking anatomical conditions for creating tunneling technique with precise resection of lung segments for patients with intersegmental and multisegment lung nodules received a satisfactory surgical margin. The detailed data are given in Table 1 . The mean counts of resected subsegments in the segment group was less than that in the lobectomy group (2.45 vs 8.64, p < 0.001; see Figure 7 ). The mean counts of resected subsegments with the left upper lung in the segment group was less than that in the lobectomy group (2.75 vs 10), and the mean counts of resected subsegments with the right upper lung in the splitting group was less than that in the lobectomy group (2.33 vs 6). Similarly, the mean counts of resected subsegments with the lower lung in the segment group was less than that in the lobectomy group (2.38 vs 9.67). The specific details of patients with seeking anatomical conditions for creating tunneling technique with precise resection of lung segments at complex setting The operation was successfully completed in all patients. The area of resection included LS1+2c+S3a, LS3, LS3a+b, LS1+2c+S3, RS1+S3a, RS1b+S2b+S3a, RS1b+S3a, S9, RS8a+S9, and RS6+S9. The specific details are shown in Table 2 . The patients were all discharged smoothly, and no deaths or pulmonary complications, including pulmonary infection, lung torsion, or bronchopleural fistulas, were observed. Three months after surgical treatment, there was no evidence of pleural effusion, secondary admission, or secondary surgery. During the three-month follow‐up period, postoperative lung CT scan revealed well-inflated preserved lung tissues without obvious atelectasis. Discussion With the popularity of thin-slice CT scans and the extensive application of artificial intelligence and three-dimensional reconstruction techniques, an increasing number of small lung nodules have been detected [ 16 , 17 ]. The main treatment for small lung nodules is surgery, which includes lobectomy, segmentectomy and wedge resection [ 18 , 19 ]. Recently, segmentectomy has been regarded as a common type of surgery [ 20 , 21 ]. In this study, we demonstrated the seeking anatomical conditions for creating tunneling technique with precise resection of lung segments at complex setting. This expands the scope of lung segmentectomy for patients with lung nodules in complex positions involving multiple segments. Avoiding the removal of additional lung tissue to protect lung function (only a small part of the lung lobe is removed) is conducive to postoperative rehabilitation. Moreover, we should note that the implementation of this type of segmentectomy had a threshold for the location, size and CTR of the nodules. Seeking anatomical conditions for creating tunneling technique with precise resection of lung segments cannot be easily understood but can be explained by this approach. To explain this technique, we must mention the thoracoscopic tunnel technique. It was originally developed by Katsuyuki Endo in the 1990s and is called the “tunneling stapler technique” [ 22 ]. Consequently, how to comprehend the tunneling technique and create a tunnel during surgical thoracic operation actually correspond to three stages. First, when performing lobectomy on a patient with an incomplete interlobar fissure, the tunnel technique is utilized if the interlobar fissure approach is still preferred [ 5 , 23 ]. Second, distinct gaps can be observed between the superior segment and the basal segment, as well as between the lingular segment and the intrinsic segment, even in the absence of a fissure. Additionally, the spaces between RS3 and RS1 + RS2, LS3 and LS1 + 2, and S9 + S10 and S7 + S8/S7 + 8 may also be anatomically separated by tunneling techniques. Seeking anatomical conditions for creating tunneling technique highlights its anatomy. After all, the spaces between RS3 and RS1 + RS2, LS3 and LS1 + 2, and S9 + S10 and S7 + S8/S7 + 8 is minimal. So, accurate 3D reconstruction results and a skilled anatomical basis for the surgeon are needed. In the tunneling approach, it is crucial to accurately identify hatchway 1 and hatchway 2. Once the two hatchways are identified correctly, the tunneling technique allows the surgeon to perform a deep dissection of the arteries to precisely identify the subsegmental branches and thus avoid misidentification. Then, the target arteries and bronchus of the target segment and the adjacent segment were exposed. An additional advantage of the tunneling technique is that early division of the intersegmental plane significantly facilitates completion of the division of the intersegmental plane of the adjacent lung subsegment [ 24 ]. After obtaining such an anatomical plane extension, precise anatomical details such as lung subsegments, surgical margins, and intrapulmonary lymph nodes are exposed to the visual field. Here, this tunneling technique presented the new concept of atypical segmentectomy, which centers on the lesion to obtain adequate surgical margins. The location of the tumor determines the surgical type. Sufficient surgical margins were obtained in all patients in this study. In our experience, our data analysis revealed that there are prerequisites for implementing the tunneling technique at these complex setting. The patients were selected if they had an early pathological stage, a small tumor diameter, or a depth ratio that was not deep. Firstly, our indications for segmentectomy were strictly controlled, and we did not select patients who were considered to have no benefit in the JCOG0802 study. Secondly, in the early period of this technique, we were slightly conservative in our selection of patients. Due to a poor medical environment, lobectomy was not guaranteed. Now, that attitude has gradually changed, the technology has matured, and confidence has increased. At the technical maturity stage, in patients with a tumor diameter of 1.7 cm, a CTR of 60% and a pathological type of invasive adenocarcinoma, we also performed satisfactorily this tunneling technique with a surgical margin of 2 cm. Thirdly, tunneling technique at these complex setting also has certain requirements for the position of lung nodules. When the nodule is located in the inner third lung field, satisfying the surgical margin may damage the arteriovenous space of the hilar. However, when the nodules are located in the outer third lung field, wedge resection of the lung may be used to achieve good surgical results. Considering the complexity of the procedure and the presence of more than one intricate intersegmental plane, creating tunneling technique with precise resection of lung segments is considered complex. Special anatomical marks, V6, A8, A1 + 2c, A2b, A3b, the lingual vein and the bronchus has a good guide to the hatchways [ 24 , 25 , 26 , 27 , 28 ]. Limitations This was not a prospective randomized controlled study because of the necessity of reviewing the specifics of surgical video replays. To mitigate confounding factors, the study exclusively enrolled patients who underwent surgeries at a single center and who underwent a single operation. Consequently, the generalizability and applicability of the study's findings may be subject to some deviation. Conclusions In conclusion, seeking anatomical conditions for creating tunneling technique is a promising technique for performing precise resection of lung segments with a safe resection margin for patients with lung nodules at complex positions involving multiple segments, and it can reduce the count of resected subsegments. Furthermore, patients experienced expedited postoperative recuperation. Significantly, the tunneling technique facilitates clearer visualization of the hilus structure, which includes the lung vessels and bronchus, thereby enhancing the success rate of surgery for beginner thoracic surgeons. Abbreviations LCSG: Lung Cancer Study Group CT: Computerized tomography 3D: Three-dimensional CTR: Consolidation tumor ratio RUL: Right upper lung RLL: Right lower lung LUL: Left upper lung LLL: Left lower lung AIS: adenocarcinoma in situ MIA: Minimally invasive adenocarcinoma IAC: invasive adenocarcinoma cancer Declarations Author Contribution (I) Conception and design: JZ, WW, LC and ZC; (II) Administrative support: LC; (III) Provision of study materials or patients: JNZ, KW and ZL; (IV) Collection and assembly of data and interpretation: KC JNZ, KW, ZL and WW; (V) Manuscript writing, data analysis, figures and tables making: JZ; (VI) Manuscript review and final approval of manuscript: All authors. Data Availability The datasets used and analyzed during the current study are available from the corresponding author on reasonable request. Funding This work is supported by grants from the Young Scholars Plan with Growth Project of General Hospital of Central Theater Command of the People’s Liberation Army (2023-1692). Conflict of interest All authors declare that they have no conflicts of interest or financial ties to disclose. Ethical approval Informed consent was obtained from all subjects involved in this study. Written informed con-sent has been obtained from the patients to publish this paper. The ethics review committee of the First Affiliated Hospital of Nanjing Medical University approved the use of the data from these participants in this study. Date and Materials Statement The original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding authors. References Ginsberg RJ, Rubinstein L. 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The baseline characteristics and surgical outcomes of segment group versus lobectomy group Variable Total N=69 segment group n=22 lobectomy group n=47 p Age (year) 56.19±10.71 52.59±11.27 57.87±10.13 0.056 Sex (M/F) 23/46 7/15 16/31 0.855 Smoking (no/yes) 47/22 15/7 32/15 0.9936 Comorbidity* (no/yes) Heart disease COPD Diabetes Hypertension Cerebrovascular 57/12 52/17 58/11 49/20 59/10 17/5 17/5 18/4 16/6 18/4 40/7 35/12 40/7 33/14 41/6 0.5010 0.8011 0.7345 0.8301 0.7152 Tumor size (cm) 1.32±0.40 0.98±0.31 1.49±0.34 < 0.001 CTR 0.41±0.31 0.27±0.19 0.47±0.33 0.003 Position RUL RLL LUL LLL 21 12 27 9 6 4 8 4 15 8 19 5 0.841 Nodule type pGGO mGGO 25 44 10 12 15 32 0.276 Depth ratio 0.52±0.14 0.43±0.13 0.56±0.13 < 0.001 Pathology results AIS or others noncancerous nodule MIA IAC 10 12 47 10 8 4 0 4 43 < 0.001 Surgical margin (cm) 2.15±0.31 Operative time (min) 131.55±38.48 146.91±47.04 124.36±31.83 0.050 Intraoperative drainage (mL) 47.10±31.63 44.55±26.68 48.30±33.90 0.649 Postoperative hospital stays (day) 4.30±1.95 3.36±0.66 4.74±2.19 < 0.001 Air leakage (no/yes) 65/4 20/2 45/2 0.956 CTR, consolidation tumor ratio; RUL, right upper lung; RLL, right lower lung; LUL, left upper lung; LLL, left lower lung; AIS, adenocarcinoma in situ; MIA, minimally invasive adenocarcinoma; IAC, invasive adenocarcinoma cancer; *, had been hospitalized for the disease or had been treated by uninterrupted treatment more than 2 weeks TABLE 2. Baseline Characteristics of Patients with seeking anatomical conditions for creating tunneling technique with precise resection of lung segments at complex setting Patient Age (years) Sex Area of resection Tumor size (cm) Depth ratio CTR Pathology Surgical margin (cm) 1 43 male LS1+2c+S3a 0.6 0.46 0.30 1 2.0 2 41 male RS9 0.6 0.46 0.40 1 2.0 3 56 female LS9 1.2 0.59 0.40 1 1.8 4 55 female LS9 1.0 0.30 0.36 3 2.0 5 65 female LS1+2c+S3a 0.9 0.53 0.20 2 2.0 6 48 male RS1+S3a 1.0 0.32 0.14 1 2.2 7 61 male RS9 1.5 0.50 0.10 3 2.0 8 34 male LS1+2c+S3a 0.7 0.28 0.60 1 3.0 9 55 female LS1+2c+S3 1.3 0.43 0.10 1 3.0 10 41 female RS1+S3a 0.6 0.67 0.10 2 2.0 11 73 male LS3a+b 1.1 0.32 0.10 1 2.5 12 46 female RS8a+S9 1.1 0.45 0.30 2 2.3 13 58 male RS1b+S3a 1.3 0.31 0.60 3 2.0 14 58 female LS1+2c+S3 0.7 0.46 0.30 2 2.0 15 50 female LS3 1.0 0.50 0.10 1 2.0 16 44 female RS6+S9 1.0 0.38 0.10 2 2.2 17 71 female LS9 1.7 0.75 0.60 3 2.0 18 33 female RS1+S3a 0.8 0.17 0.10 2 2.0 19 51 female RS1+S3a 0.7 0.37 0.60 2 2.3 20 48 female LS9 0.9 0.40 0.10 1 2.0 21 55 female RS1b+S2b+S3a 0.6 0.43 0.20 1 2.0 22 71 female LS1+2c+S3a 1.2 0.38 0.20 2 2.0 1=adenocarcinoma in situ or others noncancerous nodule; 2=minimally invasive adenocarcinoma; 3=invasive adenocarcinoma cancer Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 21 Dec, 2024 Read the published version in BMC Surgery → Version 1 posted Editorial decision: Revision requested 13 Nov, 2024 Reviews received at journal 12 Nov, 2024 Reviews received at journal 07 Nov, 2024 Reviews received at journal 07 Nov, 2024 Reviewers agreed at journal 06 Nov, 2024 Reviewers agreed at journal 06 Nov, 2024 Reviewers agreed at journal 04 Nov, 2024 Reviewers agreed at journal 04 Nov, 2024 Reviewers invited by journal 04 Nov, 2024 Editor invited by journal 18 Oct, 2024 Editor assigned by journal 17 Oct, 2024 Submission checks completed at journal 17 Oct, 2024 First submitted to journal 11 Oct, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5248701","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":377567041,"identity":"9d031e72-dd41-467b-8a8b-de9a3187983d","order_by":0,"name":"Kexin Cao","email":"","orcid":"","institution":"The First Affiliated Hospital with Xinxiang Medical University","correspondingAuthor":false,"prefix":"","firstName":"Kexin","middleName":"","lastName":"Cao","suffix":""},{"id":377567042,"identity":"20268ba6-23fc-4782-ae1f-427d7d8f96ed","order_by":1,"name":"Jian Zhu","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA40lEQVRIie3PoWvDQBTH8TcenDqIvUJJ/4VXCrH7V+4RiFohMiJiJaMR7aYL2x9RNWbLQWauzEZUpGa+pkSVJXU1SWRh99W/D7wH4HLdYwqANIB8NLirdJIOJz58i5AqWwwjbTP4kcHo+IL9YvK+prhKD7zIRJTwswAvX+lO8vBhiXTxyxliUfLXGJTdbzsJqqeGCMNLFFHJVgCpeTcRV3IxvEYZxA3sJ7IlvDQz1RAYRJSKYuI34xOKUGlbyN5fJpvwc1qfjSTP7E51kvpe/tpN2nfo5tK+eRtWQ1Yul8v1j/sDTnJGvlONIbEAAAAASUVORK5CYII=","orcid":"","institution":"General Hospital of Central Theater Command of the People's Liberation Army","correspondingAuthor":true,"prefix":"","firstName":"Jian","middleName":"","lastName":"Zhu","suffix":""},{"id":377567043,"identity":"8366f91c-fa57-46e9-a02d-92b0bfc481e6","order_by":2,"name":"Jianan Zheng","email":"","orcid":"","institution":"The First Affiliated Hospital with Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Jianan","middleName":"","lastName":"Zheng","suffix":""},{"id":377567044,"identity":"202c89aa-1ae5-49e8-80d5-84cb04c5146a","order_by":3,"name":"Ke Wei","email":"","orcid":"","institution":"The First Affiliated Hospital with Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Ke","middleName":"","lastName":"Wei","suffix":""},{"id":377567045,"identity":"27a6d1ca-8d2f-4a6b-bc89-9e36872a81d6","order_by":4,"name":"Zhihua Li","email":"","orcid":"","institution":"The First Affiliated Hospital with Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhihua","middleName":"","lastName":"Li","suffix":""},{"id":377567046,"identity":"b966bc05-8956-4d88-8161-f54934363193","order_by":5,"name":"Zhijun Chen","email":"","orcid":"","institution":"The First Affiliated Hospital with Xinxiang Medical University","correspondingAuthor":false,"prefix":"","firstName":"Zhijun","middleName":"","lastName":"Chen","suffix":""},{"id":377567047,"identity":"a751717b-4011-45b4-8c1b-a0133ece1387","order_by":6,"name":"Liang Chen","email":"","orcid":"","institution":"The First Affiliated Hospital with Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Liang","middleName":"","lastName":"Chen","suffix":""},{"id":377567048,"identity":"d7bcc7dc-bacc-46e7-931c-401e6f55cfb7","order_by":7,"name":"Weibing Wu","email":"","orcid":"","institution":"The First Affiliated Hospital with Nanjing Medical University","correspondingAuthor":false,"prefix":"","firstName":"Weibing","middleName":"","lastName":"Wu","suffix":""}],"badges":[],"createdAt":"2024-10-12 00:53:03","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5248701/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5248701/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12893-024-02719-2","type":"published","date":"2024-12-21T15:57:32+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":69238364,"identity":"3d4a4cfb-097b-4878-bcae-e288aa95813d","added_by":"auto","created_at":"2024-11-18 09:55:56","extension":"jpeg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":125377,"visible":true,"origin":"","legend":"\u003cp\u003eLung nodule location map.\u003c/p\u003e","description":"","filename":"floatimage1.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5248701/v1/483c4f2604bcf4565353ba8d.jpeg"},{"id":69238358,"identity":"2954c649-b991-4b26-86fa-bc63c169d666","added_by":"auto","created_at":"2024-11-18 09:55:56","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":199081,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of patients. A total of 117 patients met the inclusion and exclusion criteria, and 69 patients were included in this study.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5248701/v1/5ef84017f941c8b7dcaa4595.jpeg"},{"id":69238362,"identity":"cea8a5c9-e917-4bde-a2cb-987cb7805999","added_by":"auto","created_at":"2024-11-18 09:55:56","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":698871,"visible":true,"origin":"","legend":"\u003cp\u003eRadiological images and surgical procedure images of a left superior lobe lung nodule (A) Lung window from computed tomography; (B) Three-dimensional images of bronchography and vasculature computed tomography; (C) Tunneling hatchway 1; (D) Tunneling hatchway 2; (E) Surgical field after creating tunneling technique with precise resection of lung segments.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5248701/v1/2a8015037174fc99e29205df.jpeg"},{"id":69238872,"identity":"d77ab6c1-0a8c-4a5c-8e42-e722206648a1","added_by":"auto","created_at":"2024-11-18 10:03:56","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":597452,"visible":true,"origin":"","legend":"\u003cp\u003eRadiological images and surgical procedure images of right superior lobe lung nodules (A) Lung window from computed tomography; (B) Three-dimensional image of the bronchography and vasculature from computed tomography; (C) Tunneling hatchway 1; (D) Tunneling hatchway 2; (E) Lung tissue required for creating tunneling technique with precise resection of lung segments.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5248701/v1/9b2671fa49b7cbe7812114b4.jpeg"},{"id":69238361,"identity":"7fc83a45-436a-492f-85aa-d568c246ad98","added_by":"auto","created_at":"2024-11-18 09:55:56","extension":"jpeg","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":662098,"visible":true,"origin":"","legend":"\u003cp\u003eRadiological images and surgical procedure images of a left lower lobe lung nodule. (A) Lung window obtained via computed tomography; (B) Three-dimensional images of bronchography and vasculature obtained via computed tomography; (C) Tunneling Hatchway 1; (D) Tunneling Hatchway 2; (E) Surgical field after creating tunneling technique with precise resection of lung segments.\u003c/p\u003e","description":"","filename":"floatimage5.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5248701/v1/a13f15d863927b43d15b78c0.jpeg"},{"id":69238874,"identity":"bb82f7ec-be7a-49c1-b339-bfdcd96ba38c","added_by":"auto","created_at":"2024-11-18 10:03:56","extension":"jpeg","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":697337,"visible":true,"origin":"","legend":"\u003cp\u003eRadiological images and surgical procedure images of a right lower lobe lung nodule. (A) Lung window obtained via computed tomography; (B) Three-dimensional image of the bronchography and vasculature obtained via computed tomography; (C) Tunneling hatchway 1; (D) Tunneling hatchway 2; (E) Surgical field after creating tunneling technique with precise resection of lung segments.\u003c/p\u003e","description":"","filename":"floatimage6.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5248701/v1/cb4d14b1f517015fa93fcbd2.jpeg"},{"id":69240058,"identity":"1eef7752-b59c-410e-a218-d8e9a7dcb2f0","added_by":"auto","created_at":"2024-11-18 10:11:56","extension":"jpeg","order_by":7,"title":"Figure 7","display":"","copyAsset":false,"role":"figure","size":118279,"visible":true,"origin":"","legend":"\u003cp\u003eThe counts of resected subsegments in the two groups.\u003c/p\u003e","description":"","filename":"floatimage7.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5248701/v1/e409cda644330bddcb715304.jpeg"},{"id":72202742,"identity":"bae32bf5-ce99-4189-b949-70bbb15cdcaa","added_by":"auto","created_at":"2024-12-23 16:15:54","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":3856438,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5248701/v1/bc9b00de-8452-4520-a9c7-1577b1d688dd.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Safety and Efficacy of the Seeking Anatomical Conditions for Creating Tunneling Technique with Precise Resection of Lung Segments at Complex Setting","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDesigned by the American Lung Cancer Study Group (LCSG) in 1982, the world's first multicenter randomized controlled prospective trial, LCSG821, on sublobectomy for the treatment of early lung cancer established lobectomy as the standard surgical treatment for early lung cancer [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. With the spread of computerized tomography (CT) imaging of the lungs and advances in staging methods, smaller and earlier tumors are being detected, which has led to renewed interest in sublobectomy in patients with early lung cancer [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. After more than 40 years of comparative studies on the effects of different surgical methods for early lung cancer, it was found that for peripheral lung nodules\u0026thinsp;\u0026le;\u0026thinsp;2 cm and pure ground glass opacity, it is feasible to perform thoracoscopic lung segmentectomy, which can achieve the same effect as radical lobectomy [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. The latest and influential research results of CALGB140503, JCOG0802 and JCOG0804 suggest that lung sublobectomy can replace lobectomy for the treatment of pure solid peripheral early lung cancer with a diameter less than 2 cm [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e] and that sublobectomy can be used to lengthen the tumor height to a new height.\u003c/p\u003e \u003cp\u003eHowever, 'not a true segmentectomy' often results in inadequate surgical margins, especially in complex settings [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In addition, studies comparing 'Not a true segmentectomy' and lobectomy have yielded conflicting results [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. A true lung segmentectomy should not involve the pursuit of the external volume of the lung segment. Ultimately, the volume of the lung segmentectomy can be replaced by a large wedge resection [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Therefore, surgical methods for true lung segmentectomy, which are specific to the anatomy of specific structures and satisfy the incisal margin, are worthy of further research. In our last research report, precise resection of lung segments was defined as (1) having a safe surgical margin distance which more than the maximum diameter of the tumor or 2 cm; (2) divided and severed the arterial, bronchial, and main venous structures (three are indispensable); (3) using the unit for lung subsegment, reduce the counts of resected subsegments as much as possible [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. So, is lobectomy the only way to obtain a perfect anatomical structure and a satisfactory incisional margin for lung nodules at complex setting involving multiple segments?\u003c/p\u003e \u003cp\u003eTherefore, this study aimed to verify whether seeking anatomical conditions for creating tunneling technique with precise resection of lung segments could solve this bottleneck problem.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eStudy Design and Participants\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe retrospectively screened patients\u0026nbsp;with lung nodules in complex positions involving intersegmental and multisegmental regions (\u003cstrong\u003eFigure 1\u003c/strong\u003e) who underwent\u0026nbsp;creating tunneling technique with precise resection of lung segments and lobectomy at our center between January 2019 and August 2023. The patients were named the segment group and lobectomy group, respectively.\u003c/p\u003e\n\u003cp\u003eInclusion criteria: (1) the operation was performed by the surgeon with more than five years related experience in performing segmentectomy independently; (2) the number of segmentectomy operations performed by the surgeon in the past five years was more than 1000; (3) the lung segmentectomy operation was performed by precise resection of lung segments as our defined; (4) the collected data should have intact surgical videos.\u003c/p\u003e\n\u003cp\u003eExclusion criteria: (1) dealing with unplanned events for more than 30 minutes during the operation; (2) there are two or more lesions that need to be treated in the different anatomical fields; (3) cases with radiographic data were not considered suitable for lung segmentectomy; (4) cases with incomplete data, such as lack of key surgical details; (5) cases converted to lobectomy during the operation.\u003c/p\u003e\n\u003cp\u003eThe included patients were divided into two groups according to the surgical way, segment group and lobectomy group. The specific case screening process is shown in \u003cstrong\u003eFigure 2\u003c/strong\u003e.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSurgical procedures\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBefore the operation, three-dimensional\u0026nbsp;(3D)\u0026nbsp;reconstruction was performed for patients seeking anatomical conditions for creating tunneling technique with precise resection of lung segments\u0026nbsp;at complex setting. 3D reconstruction accurately simulated lung segmentation and lesions and was planned according to the tracheal branches, arteries, and veins. The positions and adjacent tissue (blood vessels, bronchus) lung nodules were labeled to guide the lung segmentation, and resection margin spheres were generated 2 cm from the lesion edge. The reconstruction results were reviewed by comparison with the preoperative CT images, and the resection schemes were planned jointly by experienced surgeons with three associate director titles or above.\u003c/p\u003e\n\u003cp\u003eThe positions in the\u0026nbsp;segment group\u0026nbsp;included LS1+2c+S3a, LS3, LS3a+b, LS1+2c+S3, RS1+S3a, RS1b+S2b+S3a, RS1b+S3a, S9, RS8a+S9, and RS6+S9. The method of establishing the tunneling technique for\u0026nbsp;LS1+2c+S3a, LS3, LS3a+b, and LS1+2c+S3 involved dissecting A4+5 at the oblique fissure and opening the posterior mediastinal pleura to dissect A1+2c (\u003cstrong\u003eFigure 3\u003c/strong\u003e). In this way, the spacings between A4+5 and A1+2c are used to establish splitting hatchway 1. Then, opening the anterior mediastinal pleura for dissecting V3b exposes the space between B4+5 and B3, which splits Hatchway 2. Lobar splitting between hatchway 1 and hatchway 2 was performed using a stapler. For RS1S+3a, RS1b+S2b+S3a, and RS1b+S3a (\u003cstrong\u003eFigure 4\u003c/strong\u003e), dissection of the target vein, target artery and target bronchus\u0026nbsp;were performed first. Then, the spacings between B1b and B3b were exposed, which was splitting hatchway 1. The spacings between B3a and B3b were determined by splitting hatchway 2. Additionally, for S9 and S8a+S9 (left lung for \u003cstrong\u003eFigure 5\u003c/strong\u003e, right lung for \u003cstrong\u003eFigure 6\u003c/strong\u003e), dissection of the target vein, target artery and target bronchus were performed. Then, the spacings between B8a and B8b were exposed, which was tunneling hatchway 1. The spacings between B9 and B8 were split into hatchway 2.\u0026nbsp;Tunneling technique between Hatchway 1 and\u0026nbsp;Hatchway 2 was also performed using a stapler.\u003c/p\u003e\n\u003cp\u003eThe structures of hatchway 1 and hatchway 2 to be severed in both directions were determined during the preoperative simulation according to 3D reconstruction. During establishing the tunneling, it is necessary to check whether there are still vessels or bronchi. If these abnormalities are found, there may be errors in the surgical anatomy. Before tunneling technique, the inflation‒deflation method for distinguishing the intersegmental plane is also necessary. The combination of sharp-blunt dissection, \u0026quot;work-plane extension\u0026quot;, and the \u0026quot;gate\u0026quot; opening technique\u0026nbsp;contributes to the accuracy of tunneling technique [11, 12, 13]. The lung lobe was subsequently divided into normal lung tissue and contained the lesion target lung tissue after tunneling technique. The target arteries and bronchus of the target segment and the adjacent segment were exposed, and the internal veins of the target segmentectomy were removed to preserve the intersegmental veins so that the resection of multiple subsegments could be combined into one resection unit [5, 13].\u003c/p\u003e\n\u003cp\u003eFor the tissue with\u0026nbsp;lesions surgically resected, we measured the surgical margins in all patients. The surgical margins were calculated based on the shortest distance between the tumor boundary and the line connecting the clip on the pleura with the staples on the bronchial stump [14]. Our minimum requirement is that the surgical margin distance\u0026nbsp;be \u0026ge; the maximum diameter of the tumor or 2 cm; otherwise, lung lobectomy will be performed. Other surgical procedures and routine pulmonary segmentectomy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData collection and analysis\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe eligible medical records were compared and analyzed in terms of age, sex, nodule size (cm), nodule location, nodule type, nodule depth ratio, consolidation tumor ratio (CTR), surgical margin distance, operation time (min), intraoperative blood loss (ml), postoperative hospital stay (days), and postoperative lung air leakage.\u003c/p\u003e\n\u003cp\u003eAccording to the depth ratio\u0026nbsp;method, the bronchial cross-section center of each unit was set as the starting point, and the center of the lesion extended to the endpoint on the pleura. Trisection of the lung field was conducted into the outer third lung field (0-33.3%), middle third lung field (33.4-66.6%), and inner third lung field (66.7-100%) [15].\u003c/p\u003e\n\u003cp\u003eThe data are presented as the mean \u0026plusmn; standard deviation for continuous variables and as absolute numbers and percentages for categorical variables. Categorical variables were assessed using \u0026chi;2 tests or Fisher\u0026apos;s exact tests as appropriate, while \u003cem\u003et\u0026nbsp;\u003c/em\u003etests were conducted for continuous variables with independent samples. The nonnormally distributed data were compared between groups by \u003cem\u003ethe\u003c/em\u003e U test. A \u003cem\u003ep\u003c/em\u003e value \u0026le;0.05 indicated statistical significance. All the statistical analyses were performed using SPSS version 26.0 software.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePatient characteristics\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOur study included 69 patients (\u003cstrong\u003eTable 1\u003c/strong\u003e), of whom the mean age was 56.19\u0026plusmn;10.71 years, 46 (66.7%) patients were female, and 22 (31.9%) patients were smokers. The mean tumor size was 1.32\u0026plusmn;0.40 cm. Twenty-two patients were included in the segment group, and 47 were included in the lobectomy group. In total, four lobes and three pathological types of lung nodules from patients who underwent segmentectomy were evaluated.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eSurgical outcomes between the\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003esegment group\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;and lobectomy group\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCompared with those of the lobectomy group, the main surgical evaluation indices of the\u0026nbsp;segment group, including operation time (146.91\u0026plusmn;47.04\u0026nbsp;min vs 124.36\u0026plusmn;31.83 min, \u003cem\u003ep\u003c/em\u003e=0.0501), intraoperative bleeding (44.55\u0026plusmn;26.68 mL vs 48.30\u0026plusmn;33.90 mL, \u003cem\u003ep\u003c/em\u003e=0.649) and the occurrence of air leakage (9.09% vs 4.26%, \u003cem\u003ep\u003c/em\u003e=0.956), were not disadvantageous. The postoperative hospital stay decreased in the segment group (3.36\u0026plusmn;0.66 days vs 4.74\u0026plusmn;2.19 days,\u0026nbsp;\u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001). Seeking anatomical conditions for creating tunneling technique with precise resection of lung segments for patients with intersegmental and multisegment lung nodules received a satisfactory surgical margin. The detailed data are given in \u003cstrong\u003eTable 1\u003c/strong\u003e. The mean counts of resected subsegments in the segment group was less than that in the lobectomy group (2.45 vs 8.64, \u003cem\u003ep\u003c/em\u003e \u0026lt; 0.001; see \u003cstrong\u003eFigure 7\u003c/strong\u003e). The mean counts\u0026nbsp;of resected subsegments with the left upper lung in the segment group was less than that in the lobectomy group (2.75 vs 10), and the mean counts of resected subsegments with the right upper lung in the splitting group was less than that in the lobectomy group (2.33 vs 6). Similarly, the mean counts of resected subsegments with the lower lung in the segment group was less than that in the lobectomy group (2.38 vs 9.67).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eThe specific details\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u003cem\u003e\u0026nbsp;of patients with seeking anatomical conditions for creating tunneling technique with precise resection of lung segments at complex setting\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe operation was successfully completed in all\u0026nbsp;patients. The area of resection included LS1+2c+S3a, LS3, LS3a+b, LS1+2c+S3, RS1+S3a, RS1b+S2b+S3a, RS1b+S3a, S9, RS8a+S9, and RS6+S9. The specific details are shown in \u003cstrong\u003eTable 2\u003c/strong\u003e. The patients were all discharged smoothly, and no deaths or pulmonary complications, including pulmonary infection, lung torsion, or bronchopleural fistulas, were observed. Three months after surgical treatment, there was no evidence of pleural effusion, secondary admission, or secondary surgery. During the three-month follow‐up period, postoperative lung CT scan revealed well-inflated preserved lung tissues without obvious atelectasis.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWith the popularity of thin-slice CT scans and the extensive application of artificial intelligence and three-dimensional reconstruction techniques, an increasing number of small lung nodules have been detected [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The main treatment for small lung nodules is surgery, which includes lobectomy, segmentectomy and wedge resection [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Recently, segmentectomy has been regarded as a common type of surgery [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. In this study, we demonstrated the seeking anatomical conditions for creating tunneling technique with precise resection of lung segments at complex setting. This expands the scope of lung segmentectomy for patients with lung nodules in complex positions involving multiple segments. Avoiding the removal of additional lung tissue to protect lung function (only a small part of the lung lobe is removed) is conducive to postoperative rehabilitation. Moreover, we should note that the implementation of this type of segmentectomy had a threshold for the location, size and CTR of the nodules.\u003c/p\u003e \u003cp\u003eSeeking anatomical conditions for creating tunneling technique with precise resection of lung segments cannot be easily understood but can be explained by this approach. To explain this technique, we must mention the thoracoscopic tunnel technique. It was originally developed by Katsuyuki Endo in the 1990s and is called the \u0026ldquo;tunneling stapler technique\u0026rdquo; [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. Consequently, how to comprehend the tunneling technique and create a tunnel during surgical thoracic operation actually correspond to three stages. First, when performing lobectomy on a patient with an incomplete interlobar fissure, the tunnel technique is utilized if the interlobar fissure approach is still preferred [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Second, distinct gaps can be observed between the superior segment and the basal segment, as well as between the lingular segment and the intrinsic segment, even in the absence of a fissure. Additionally, the spaces between RS3 and RS1\u0026thinsp;+\u0026thinsp;RS2, LS3 and LS1\u0026thinsp;+\u0026thinsp;2, and S9\u0026thinsp;+\u0026thinsp;S10 and S7\u0026thinsp;+\u0026thinsp;S8/S7\u0026thinsp;+\u0026thinsp;8 may also be anatomically separated by tunneling techniques.\u003c/p\u003e \u003cp\u003eSeeking anatomical conditions for creating tunneling technique highlights its anatomy. After all, the spaces between RS3 and RS1\u0026thinsp;+\u0026thinsp;RS2, LS3 and LS1\u0026thinsp;+\u0026thinsp;2, and S9\u0026thinsp;+\u0026thinsp;S10 and S7\u0026thinsp;+\u0026thinsp;S8/S7\u0026thinsp;+\u0026thinsp;8 is minimal. So, accurate 3D reconstruction results and a skilled anatomical basis for the surgeon are needed. In the tunneling approach, it is crucial to accurately identify hatchway 1 and hatchway 2. Once the two hatchways are identified correctly, the tunneling technique allows the surgeon to perform a deep dissection of the arteries to precisely identify the subsegmental branches and thus avoid misidentification. Then, the target arteries and bronchus of the target segment and the adjacent segment were exposed. An additional advantage of the tunneling technique is that early division of the intersegmental plane significantly facilitates completion of the division of the intersegmental plane of the adjacent lung subsegment [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. After obtaining such an anatomical plane extension, precise anatomical details such as lung subsegments, surgical margins, and intrapulmonary lymph nodes are exposed to the visual field. Here, this tunneling technique presented the new concept of atypical segmentectomy, which centers on the lesion to obtain adequate surgical margins. The location of the tumor determines the surgical type. Sufficient surgical margins were obtained in all patients in this study.\u003c/p\u003e \u003cp\u003eIn our experience, our data analysis revealed that there are prerequisites for implementing the tunneling technique at these complex setting. The patients were selected if they had an early pathological stage, a small tumor diameter, or a depth ratio that was not deep. Firstly, our indications for segmentectomy were strictly controlled, and we did not select patients who were considered to have no benefit in the JCOG0802 study. Secondly, in the early period of this technique, we were slightly conservative in our selection of patients. Due to a poor medical environment, lobectomy was not guaranteed. Now, that attitude has gradually changed, the technology has matured, and confidence has increased. At the technical maturity stage, in patients with a tumor diameter of 1.7 cm, a CTR of 60% and a pathological type of invasive adenocarcinoma, we also performed satisfactorily this tunneling technique with a surgical margin of 2 cm. Thirdly, tunneling technique at these complex setting also has certain requirements for the position of lung nodules. When the nodule is located in the inner third lung field, satisfying the surgical margin may damage the arteriovenous space of the hilar. However, when the nodules are located in the outer third lung field, wedge resection of the lung may be used to achieve good surgical results.\u003c/p\u003e \u003cp\u003eConsidering the complexity of the procedure and the presence of more than one intricate intersegmental plane, creating tunneling technique with precise resection of lung segments is considered complex. Special anatomical marks, V6, A8, A1\u0026thinsp;+\u0026thinsp;2c, A2b, A3b, the lingual vein and the bronchus has a good guide to the hatchways [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eThis was not a prospective randomized controlled study because of the necessity of reviewing the specifics of surgical video replays. To mitigate confounding factors, the study exclusively enrolled patients who underwent surgeries at a single center and who underwent a single operation. Consequently, the generalizability and applicability of the study's findings may be subject to some deviation.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn conclusion, seeking anatomical conditions for creating tunneling technique is a promising technique for performing precise resection of lung segments with a safe resection margin for patients with lung nodules at complex positions involving multiple segments, and it can reduce the count of resected subsegments. Furthermore, patients experienced expedited postoperative recuperation. Significantly, the tunneling technique facilitates clearer visualization of the hilus structure, which includes the lung vessels and bronchus, thereby enhancing the success rate of surgery for beginner thoracic surgeons.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eLCSG: Lung Cancer Study Group\u003c/p\u003e\n\u003cp\u003eCT: Computerized tomography\u003c/p\u003e\n\u003cp\u003e3D: Three-dimensional\u003c/p\u003e\n\u003cp\u003eCTR: Consolidation tumor ratio\u003c/p\u003e\n\u003cp\u003eRUL: Right upper lung\u003c/p\u003e\n\u003cp\u003eRLL: Right lower lung\u003c/p\u003e\n\u003cp\u003eLUL: Left upper lung\u003c/p\u003e\n\u003cp\u003eLLL: Left lower lung\u003c/p\u003e\n\u003cp\u003eAIS: adenocarcinoma in situ\u003c/p\u003e\n\u003cp\u003eMIA: Minimally invasive adenocarcinoma\u003c/p\u003e\n\u003cp\u003eIAC: invasive adenocarcinoma cancer\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003e(I) Conception and design: JZ, WW, LC and ZC; (II) Administrative support: LC; (III) Provision of study materials or patients: JNZ, KW and ZL; (IV) Collection and assembly of data and interpretation: KC JNZ, KW, ZL and WW; (V) Manuscript writing, data analysis, figures and tables making: JZ; (VI) Manuscript review and final approval of manuscript: All authors.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work is supported by grants from the Young Scholars Plan with Growth Project of General Hospital of Central Theater Command of the People\u0026rsquo;s Liberation Army (2023-1692).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors declare that they have no conflicts of interest or financial ties to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthical approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eInformed consent was obtained from all subjects involved in this study. Written informed con-sent has been obtained from the patients to publish this paper. The ethics review committee of the First Affiliated Hospital of Nanjing Medical University approved the use of the data from these participants in this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDate and Materials Statement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original contributions presented in the study are included in the article, further inquiries can be directed to the corresponding authors.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eGinsberg RJ, Rubinstein L. The comparison of limited resection to lobectomy for T1N0 non-small cell lung cancer. LCSG 821 Chest. 1994;106(6 Suppl):S318\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJang HJ, Lee KS, Kwon OJ, et al. Bronchioloalveolar carcinoma: focal area of ground-glass attenuation at thin-section CT as an early sign. 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J Thorac Dis. 2021;13(10):5933\u0026ndash;41. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.21037/jtd-21-985\u003c/span\u003e\u003cspan address=\"10.21037/jtd-21-985\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cdiv align=\"\"\u003e\n \u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"589\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 589px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTABLE 1. The baseline characteristics and surgical outcomes of\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003esegment group\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;versus\u003c/strong\u003e \u003cstrong\u003elobectomy group\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 228px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eVariable\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTotal\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eN=69\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u003cstrong\u003esegment group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=22\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e\u003cstrong\u003elobectomy\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;group\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=47\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep\u003c/em\u003e\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 228px;\"\u003e\n \u003cp\u003eAge (year)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 101px;\"\u003e\n \u003cp\u003e56.19\u0026plusmn;10.71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e52.59\u0026plusmn;11.27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 105px;\"\u003e\n \u003cp\u003e57.87\u0026plusmn;10.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e0.056\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eSex (M/F)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e23/46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e7/15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e16/31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.855\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eSmoking (no/yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e47/22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e15/7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e32/15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.9936\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eComorbidity* (no/yes)\u003c/p\u003e\n \u003cp\u003eHeart disease\u003c/p\u003e\n \u003cp\u003eCOPD\u003c/p\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003cp\u003eCerebrovascular\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e57/12\u003c/p\u003e\n \u003cp\u003e52/17\u003c/p\u003e\n \u003cp\u003e58/11\u003c/p\u003e\n \u003cp\u003e49/20\u003c/p\u003e\n \u003cp\u003e59/10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e17/5\u003c/p\u003e\n \u003cp\u003e17/5\u003c/p\u003e\n \u003cp\u003e18/4\u003c/p\u003e\n \u003cp\u003e16/6\u003c/p\u003e\n \u003cp\u003e18/4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e40/7\u003c/p\u003e\n \u003cp\u003e35/12\u003c/p\u003e\n \u003cp\u003e40/7\u003c/p\u003e\n \u003cp\u003e33/14\u003c/p\u003e\n \u003cp\u003e41/6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.5010\u003c/p\u003e\n \u003cp\u003e0.8011\u003c/p\u003e\n \u003cp\u003e0.7345\u003c/p\u003e\n \u003cp\u003e0.8301\u003c/p\u003e\n \u003cp\u003e0.7152\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eTumor size (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e1.32\u0026plusmn;0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.98\u0026plusmn;0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e1.49\u0026plusmn;0.34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eCTR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.41\u0026plusmn;0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.27\u0026plusmn;0.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e0.47\u0026plusmn;0.33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003ePosition\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; RUL\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; RLL\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; LUL\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; LLL\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.841\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eNodule type\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; pGGO\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; mGGO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003cp\u003e32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0.276\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eDepth ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e0.52\u0026plusmn;0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e0.43\u0026plusmn;0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e0.56\u0026plusmn;0.13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003ePathology\u0026nbsp;results\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; AIS or others noncancerous nodule\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; MIA\u003c/p\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; IAC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e0\u003c/p\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eSurgical margin (cm)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e2.15\u0026plusmn;0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eOperative time (min)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e131.55\u0026plusmn;38.48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e146.91\u0026plusmn;47.04\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e124.36\u0026plusmn;31.83\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.050\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eIntraoperative drainage (mL)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e47.10\u0026plusmn;31.63\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e44.55\u0026plusmn;26.68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e48.30\u0026plusmn;33.90\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.649\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003ePostoperative hospital stays (day)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e4.30\u0026plusmn;1.95\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e3.36\u0026plusmn;0.66\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e4.74\u0026plusmn;2.19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e\u0026lt; 0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 228px;\"\u003e\n \u003cp\u003eAir leakage (no/yes)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 101px;\"\u003e\n \u003cp\u003e65/4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 94px;\"\u003e\n \u003cp\u003e20/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 105px;\"\u003e\n \u003cp\u003e45/2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 62px;\"\u003e\n \u003cp\u003e0.956\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 589px;\"\u003e\n \u003cp\u003eCTR, consolidation tumor ratio; RUL, right upper lung; RLL, right lower lung; LUL, left upper lung; LLL, left lower lung; AIS, adenocarcinoma in situ; MIA, minimally invasive adenocarcinoma; IAC, invasive adenocarcinoma cancer; *, had been hospitalized for the disease or had been treated by uninterrupted treatment more than 2 weeks\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n \u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" align=\"\" width=\"576\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTABLE 2. Baseline Characteristics of Patients with\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;seeking anatomical conditions for creating tunneling technique with precise resection of lung segments at complex setting\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePatient\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(years)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 104px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eArea\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eof resection\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 56px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTumor size (cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 57px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDepth ratio\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 47px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCTR\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 76px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePathology\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 66px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSurgical margin (cm)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLS1+2c+S3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eRS9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLS9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e1.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLS9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e65\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLS1+2c+S3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.53\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eRS1+S3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e61\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eRS9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLS1+2c+S3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.28\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLS1+2c+S3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e3.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eRS1+S3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.67\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e73\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLS3a+b\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.32\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eRS8a+S9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e1.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003emale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eRS1b+S3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e1.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.31\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e58\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLS1+2c+S3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.46\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.30\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLS3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.50\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eRS6+S9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e1.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLS9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e1.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.75\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e18\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e33\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eRS1+S3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eRS1+S3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.37\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.60\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e48\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLS9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.40\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e55\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eRS1b+S2b+S3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.43\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e22\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e71\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003efemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 104px;\"\u003e\n \u003cp\u003eLS1+2c+S3a\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 56px;\"\u003e\n \u003cp\u003e1.2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 57px;\"\u003e\n \u003cp\u003e0.38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 47px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 76px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 66px;\"\u003e\n \u003cp\u003e2.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"9\" valign=\"top\" style=\"width: 576px;\"\u003e\n \u003cp\u003e1=adenocarcinoma in situ\u0026nbsp;or others noncancerous nodule; 2=minimally invasive adenocarcinoma; 3=invasive adenocarcinoma cancer\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Lobar split cone-shaped subsegmentectomy, Lobectomy, Intersegmental lung nodules, Multisegment lung nodules, Video-assisted thoracoscopic surgery","lastPublishedDoi":"10.21203/rs.3.rs-5248701/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5248701/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThoracoscopic segmentectomy is the main surgical method for the treatment of early lung cancer. With the promotion of technology and increasingly accurate criteria for lung subsegments, lung nodules with complex positions involving intersegmental and multisegments have become technical bottlenecks. This study aimed to verify whether seeking anatomical conditions for creating tunneling technique with precise resection of lung segments could solve this bottleneck problem.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThe clinical data of patients with lung nodules\u0026thinsp;\u0026le;\u0026thinsp;2 cm located in the complex position in the Department of Thoracic Surgery of Jiangsu Provincial People's Hospital from January 2019 to August 2023 were collected. Date analyzed the characteristics of patients who underwent seeking anatomical conditions for creating tunneling technique with precise resection of lung segments (segment group) at complex setting and compared the surgical outcomes and complications between these lobectomy patients (lobectomy group) at similar locations.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 22 patients were included segment group and 47 patients were included lobectomy group. Patients in segment group received a satisfactory surgical margin. Compared to the lobectomy group, surgical outcomes were better (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.05 for postoperative hospital stay and the number of resected subsegments).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eSeeking anatomical conditions for creating tunneling technique is a promising technique for performing precise resection of lung segments with a safe resection margin for patients with lung nodules at complex positions involving multiple segments. It can be used as a precise resection of lung segments technique.\u003c/p\u003e","manuscriptTitle":"The Safety and Efficacy of the Seeking Anatomical Conditions for Creating Tunneling Technique with Precise Resection of Lung Segments at Complex Setting","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-11-18 09:55:51","doi":"10.21203/rs.3.rs-5248701/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2024-11-13T08:48:53+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-12T11:16:53+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-08T03:00:05+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2024-11-07T06:56:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"142705915603078627312682504348368299744","date":"2024-11-07T01:04:10+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"70369040224431302681004252394781930438","date":"2024-11-06T06:50:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"234240547132354067971143848786680180228","date":"2024-11-04T11:35:52+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"20525624091030291407145885211552275310","date":"2024-11-04T07:28:50+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2024-11-04T06:45:39+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2024-10-18T19:23:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-10-17T06:57:23+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-10-17T06:56:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2024-10-12T00:38:42+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"527b6d1b-d924-4da0-8aed-9adc1a5dc3c9","owner":[],"postedDate":"November 18th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-12-23T16:10:19+00:00","versionOfRecord":{"articleIdentity":"rs-5248701","link":"https://doi.org/10.1186/s12893-024-02719-2","journal":{"identity":"bmc-surgery","isVorOnly":false,"title":"BMC Surgery"},"publishedOn":"2024-12-21 15:57:32","publishedOnDateReadable":"December 21st, 2024"},"versionCreatedAt":"2024-11-18 09:55:51","video":"","vorDoi":"10.1186/s12893-024-02719-2","vorDoiUrl":"https://doi.org/10.1186/s12893-024-02719-2","workflowStages":[]},"version":"v1","identity":"rs-5248701","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5248701","identity":"rs-5248701","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}