Basilar sublobar resection LLL - Uniportal VATS
This post exposes some specific tricks for uniportal VATS basilar LLL sublobar anatomical resection, preserving the upper segment of LLL (S6). This is one of the most common sublobar resections and one of the easiests.
Pictures have been obtained from a pulmonary sequestration requiring this resection, what explains the huge lymph nodes.
For dissecting the lower vein, I find very useful to first divide the pulmonary ligament, and then, before embarking the anterior dissection, pulling the LLL anteriorly in order to divide the posterior mediastinal pleura till the subcarinal space. Then dissect the posterior aspect of the vein, and take the dissection distal to visualize the small segmental vein for the S6, and dissect with a curved dissector the space between that and the basilar vein.
Then I go anteriorly and pull the lobe towards 11pm to easilly dissect the basilar vein. The stapler probably fits without difficulty in a straight position from the utility.
In cases with incomplete fissure, dissect above the vein in the interlobar space, in the hilum, until you find the interlobar bronchial carina. In cases with enlarged lymph nodes like this, you can divide the anterior fissure more superficial than the lymph nodes to be safer in relation to the pulmonary artery. Just place the tip of the dissector between the parenchyma and the node and go upwards.
Basilar artery can usually be divided like a unique artery preserving the S6 segmental artery. It's easy to dissect it with a straight dissector (not a very curved one): just place the tip of the dissector between the lower bronchus and the artery, and go straight.
After dividing the artery, although easy to visualize the bronchus just below, try first to dissect gently the bronchus removing lymph nodes between the S6 artery and the basilar artery, and for that task you can assit with the suction pulling to the left the arterial stump while you dissect the nodes from the bronchus.
For dissecting completely the bronchus, pull the lobe towards 1 am, and use a almost straight dissector. Use the suction if necessary to pass the tip of the dissector/stapler above the S6 bronchus and artery.
Once finished the division of bronchovascular structures, just complete the fissure. Most important stapler is the first one: place the anvil between the S6 bronchus and below the distal basilar bronchus stump, point towards the division between S6 and basilar segments, and pull the basilar parenchyma towards the stapler.
If you hesitate about S6 bronchus, reventilate while the stapler remains closed but not fired to check S6 viability.
Then just continue that stapling line pulling the basilar parenchyma towards 2 pm
Finally complete the intersegmental plane and remove the specimen.
As you can see this is not a difficult procedure, and I reccommend you to start with these easier sublobar resections before embarking to more difficult ones.
Hope you find it useful, and if so, please share this post and our video (https://www.youtube.com/watch?v=0qIe0JowErI&t=26s)