Septum-Guided Segmentectomy

Septum-Guided Segmentectomy for Deep Early-Stage Non-Small Cell Lung Cancer: Equivalent Outcomes to Lobectomy Without Margin Dependence

Objective
Segmentectomy has emerged as a lung-preserving alternative to lobectomy for peripheral early-stage non-small cell lung cancer (NSCLC). However, its role in tumors located in the inner two-thirds of the lung parenchyma remains controversial under margin-dependent paradigms. This study evaluated the oncological safety and feasibility of uniportal video-assisted thoracoscopic surgery (VATS) septum-guided segmentectomy, a novel approach utilizing intersegmental septa and membranous venous sheaths as natural anatomical boundaries.
Methods
We retrospectively analyzed 492 patients with cT1abN0M0 non-small cell lung cancer in the inner two-thirds of the lung parenchyma who underwent uniportal VATS septum-guided segmentectomy or lobectomy between January 2019 and March 2025. For septum-guided segmentectomy, the intersegmental plane was delineated with meticulous dissection of intersegmental veins and membranous sheaths serving as natural boundaries. Segmental bronchus and artery were divided at the hilum, and parenchymal dissection was performed along venous planes using energy devices centrally and staplers peripherally to preserve lung tissue. After applying inclusion criteria and propensity score matching (PSM), 344 patients (before PSM) and 260 matched patients (after PSM) were included. Perioperative outcomes, recurrence-free survival (RFS), and overall survival (OS) were assessed with a median follow-up of 24 months.
Results
Before PSM, 7 recurrences or deaths occurred in the lobectomy group, whereas none were observed in the segmentectomy group. Survival analysis showed no significant difference in RFS or OS between groups (p = 0.11 and 0.20 before PSM; p = 0.24 and 0.41 after PSM). Segmentectomy required longer operative time (131 vs. 98 minutes; p < 0.001), but all cases achieved R0 resection. In the segmentectomy group, 92 margin distances were recorded, 32 of which did not meet NCCN criteria (>20 mm or tumor diameter); distances ranged from 2–40 mm (median 15 mm). Perioperative complications and hospital stay were comparable between groups (all p > 0.05).

                               
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Conclusions
Uniportal VATS septum-guided segmentectomy provides oncological outcomes equivalent to lobectomy for deeply located early-stage NSCLC. By leveraging intersegmental veins and membranous septa as anatomical boundaries, this approach eliminates reliance on fixed margin distances and establishes a precise, tissue-preserving paradigm for complex parenchymal resections.




Qing Wang (1), Xinshu Wu (2), Zhexu Wen (1), Ling Lin (1), Feng Yao (1), Zhigang Li (1), Junfeng Geng (1), (1) Shanghai Chest Hospital, Shanghai, China, (2) Zibo Central Hospital, Zibo, China