Lung Cancer Surgery Process and Case Studies

Hello, I am Dr. Ching-Yang Wu, a thoracic surgeon specializing in lung and chest surgery.

Lung Cancer Surgery Procedure and Steps

Today, I would like to share the lung cancer surgery process.

When a patient is hospitalized for surgery due to a lung tumor, the entire hospitalization process can be divided into four main parts: preoperative preparation, preoperative surgical simulation, preoperative localization, and single-port minimally invasive surgery.

1.Preoperative Preparation

As part of preoperative preparation for lung cancer surgery, patients usually receive biochemical examinations, lung rehabilitation training, echocardiography, and pulmonary function tests.

These evaluations help determine whether the patient’s overall health and cardiopulmonary function are suitable for surgery.

Since lung tissue does not regenerate after resection, lung cancer surgery is only considered when the patient’s general health and cardiopulmonary function are sufficient to tolerate the procedure.

2. Preoperative Surgical Simulation

Before lung cancer surgery, preoperative simulation is an essential process.

This step focuses on reviewing tumor imaging characteristics, locating the affected area, building anatomical models, and carefully planning the surgical resection margin.

• Confirm tumor imaging characteristics for lung cancer surgery: analyze the tumor’s shape, structure, and density.
• Accurately localize the tumor: apply imaging reconstruction technology to map the precise tumor site.
• Create an anatomical model: rebuild the lung anatomy to understand vascular and bronchial orientation.
• Plan the surgical resection margin: determine the safest resection distance while preserving adequate lung capacity.

3. Preoperative Tumor Localization

Because tumors may not be directly visible under thoracoscopy, preoperative tumor localization for lung cancer surgery is performed.

To ensure accurate identification during surgery, the tumor is marked using a dye with pigment.

In this case of lung cancer surgery, the tumor was positioned near the posterior region.

As illustrated in the image, after defining a reference point, the surgeon advanced a fine needle from the body surface to puncture adjacent to the tumor.

Once the puncture is completed, a fluorescent dye is injected under imaging to assist with accurate identification during lung cancer surgery.

For precise tumor localization in lung cancer surgery, a small amount of gas is often injected to verify that the dye has been correctly placed near the tumor, completing the localization step.

4. Single-Port Minimally Invasive Surgery

This single-port minimally invasive lung cancer surgery can be completed with either a thoracoscope or robotic-assisted technology.

The steps of the procedure are described below.

1. Identify the tumor site and the lobe anatomy before lung cancer surgery.
2. Carefully dissect and cut the related pulmonary arteries and bronchi.
3. Apply fluorescent dye to clearly mark the lung segment boundary.
4. Resect the lung segment following precise anatomical divisions.
5. The entire procedure is completed through a single small incision, about 3 cm in size.

Case Study: Steps of Lung Cancer Surgery and Resection Procedure

This lung cancer case features a patient diagnosed with a tumor in the left upper lobe of the lung.

In this lung cancer case study, imaging details and reconstruction confirmed that the tumor was located in the left upper lobe.

The tumor measured 2.4 cc, predominantly solid in structure: Figure B showed that the solid portion accounted for 85.2%, while the ground-glass opacity (GGO) represented only 14.8%.

CT scans from axial, coronal, and sagittal views further localized the tumor to segments 1 and 2 of the left upper lobe.

Therefore, this was identified as a relatively solid lung lesion, with a volume of approximately 2.4 cc and a precise location in the first and second segments.

Following this confirmation, advanced imaging reconstruction software was used to better visualize the anatomy.

By removing the pulmonary arteries and veins, the tumor’s exact position in the left upper lobe was clarified, along with its relationship to the bronchial structures.

In this lung cancer case study, once the pulmonary arteries and veins were visualized (Figure B), the anatomy initially appeared complex.

With further clarification of lung structures and re-labeling of the vessels, the tumor’s relative position within the entire lobe became clearly visible in Figure C.

From the integrated reconstruction of images A, B, and C, Figure D confirmed that the tumor was located in segment 1 of the left upper lobe.

In this lung cancer surgery case, the red area in Figure D represents the ascending pulmonary artery, while the green and black areas indicate the segmental bronchi extending toward the tumor.

The intersegmental fissures appeared relatively well developed, consistent with the reconstructed imaging findings.

Once these anatomical structures were verified, preoperative surgical simulation was carried out.

In this lung cancer surgery case, the purplish-red area on the image shows the tumor, the yellow zone indicates the planned resection area, and the red box marks the part of the left upper lobe to be preserved postoperatively.

The resection margin—the distance between the tumor and the surgical cut line—was measured at approximately 4 cm.

The estimated resected volume was 150.2 cc, corresponding to 15.7% of the left upper lung and 6% of total lung capacity.

Based on surgical simulation, the tumor was located in the left upper lobe, with resection planned for segments 1 and 2, achieving a margin of about 4.1 cm.

As the tumor was posteriorly located, Figure F demonstrates that, after defining a reference point, a fine needle was inserted near the tumor for puncture. Following puncture, fluorescent dye was injected, as illustrated in Figure G.

To ensure precise localization, a small amount of gas was injected to verify the dye placement adjacent to the tumor, thereby completing the localization step.

Before the lung cancer surgery started, the stained tumor area was observed in the left upper lobe, with a well-developed fissure in that region.

After confirming the tumor site during lung cancer surgery, the fissure between the upper and lower lobes was opened, and the pulmonary artery branches to the first and second segments of the left upper lobe were dissected.

These vessels were subsequently sealed and divided with an automatic stapler.

During lung cancer surgery, the bronchi of the first and second segments of the left upper lobe were identified, isolated, and then sealed and divided.

Once the pulmonary arteries had been cut and the resection area confirmed, fluorescent dye was injected at the planned boundary to clearly mark the surgical margin.

In the imaging for lung cancer surgery, regions with blood perfusion appeared green, while those without perfusion appeared pink.

The boundary between these areas indicated the natural anatomical separation of the lung segments.

This confirmed that a safe distance was maintained between the tumor dye-marked site and the planned surgical resection margin.

Once the confirmation was complete, the surgeon performed resection of the first and second segments of the left upper lobe using an automatic stapler, following the anatomical boundary.

After the resection, the white asterisk marked the pulmonary artery stump, the yellow asterisk indicated the bronchial stump, and the dark blue area represented the junction between segments 1, 2, and 3 of the left upper lobe in this lung cancer surgery case.

This lung cancer surgery can be completed through a single incision measuring around 3 cm, making it a minimally invasive procedure.