To evaluate the feasibility and perioperative safety of three-dimensional computed tomography bronchography and angiography (3D-CTBA)-guided thoracoscopic split segmentectomy for deep pulmonary nodules.

Clinical data of consecutive patients screened for thoracoscopic split segmentectomy at a single center between Jan. 2020 and Dec. 2024 were retrospectively reviewed. A deep pulmonary nodule was defined as a nodule with a depth ratio >1/3. Preoperative thin-section computed tomography and three-dimensional reconstruction were used to assess the spatial relationships between the lesion and the segmental or subsegmental bronchi and vessels. A virtual 2-cm margin sphere was used to plan the individualized extent of resection. Intraoperatively, the lung parenchyma was split to establish an anatomical access route, followed by single segmentectomy or subsegmentectomy, or combined segmental and subsegmental resection. Outcomes included completion of the planned procedure, surgical margin distance, and perioperative outcomes.

Thirty patients were screened, of whom 6 with peripheral pulmonary nodules were excluded, leaving 24 patients for analysis. The mean lesion diameter was 0.99±0.27 cm, and the mean depth ratio was 0.40±0.06. Thirteen individualized resection combinations were performed. All 24 procedures were completed as planned, without extended resection or conversion to lobectomy. The mean surgical margin distance was 2.14±0.37 cm, operative time was 143.0±46.2 min, intraoperative blood loss was 44.2±17.5 mL, and postoperative hospital stay was 3.33±0.84 days. Prolonged air leak lasting >5 days occurred in 2 patients (8.3%). No reoperation, readmission, or 30-day mortality was observed.

With strict patient selection and three-dimensional reconstruction-based planning, split segmentectomy is safe and feasible for deep pulmonary nodules and can achieve adequate surgical margins.