• Carlos Galvez Muñoz

Left-upper lobe trisegmentectomy (S1+2+3) by uniportal VATS

Left upper trisegmentectomy is one of the most common sublobar resections and not difficult to perform, but there are some concerns to keep in mind. It's usually performed to avoid more parenchyma resection for upper lobe tumors not invading the lingulla.


First of all, remember that left-upper lobe presents the most variable pattern of anatomical arterial vascularization: usually you will find at least 4 arterial branches, from whom 3 will be for the non-lingullar segments.


From anterior, just at the left of the upper vein you have the left pulmonary artery, which is branching in that position into: a most anterior (margin with the vein) branch that runs below the upper vein and anterior to the bronchus, which irrigates the anterior segment (S3). Just below that anterior branch, and sometimes diving together you find an apical artery for S1. If you dissect the mediastinal pleural above the pulmonary artery in this area, from the vein until the inclusion of the artery into the fissure (posterior mediastinum), you will be able to dissect both S3 and S1 branches, and most of the times I try to dissect and divide them together with a vascular stapler. For that purpose it's important that you dissect gently the division of the apical branch of the artery and posteriorly a small artery for the posterior segment (S2), just at the entrance of the PA into the fissure. If you do not identify first that branch, you can tear it while putting the vascular stapler. In fact, dividing that small artery for S2 with endoclips can be advisable first to apply safely the vascular stapler.



Another good option is dividing those arteries for S3 and S1 with Hem-o-locks that can be easilly applied from the uniportal incision. The posterior artery (S2) can be divided with Hem-o-lock then, but you can divide it first as aforementioned.


Are there more arterial branches for S1+2+3? For sure may be!It's quite common that you identify an additional small branch for the posterior segment (S2) while dissecting the artery in the fissure trying to identify the lingullar artery. Be careful until you check there is or not this additional branch, because if not you can accidentally tear it while dissecting the bronchus for S1+2+3.




I always divide first the arteries, and then I dissect the upper vein excluding the lingullar vein. This is not a difficult step, because you have behind the upper bronchus, but when you try to put a stapler for the vein, it is advisable having divided previously the arteries, so as the tip of the stapler doesn't crush the arteries with bleeeding risk. It's the same for the left-upper lobectomy. The use of vessel loop is specially useful for vein division.




It's not necessary to open the fissure in this procedure (you can do it in a fissure last or fissure first aproach): as you can see, you can develop all steps from the hilum, but if a complete fissure, you can check the arterial branches for the posterior segment and the preservation of the lingullar artery/ies, but it's not a need.


After vascular division, last step is bronchial dissection and division. Vein and arterial stumps embrace the culmen bronchus (B1+2+3) anterior and posteriorly.



Just dissect lung parenchyma and lymph nodes distally in the bronchus to identify the division with the lingullar bronchus. When dissecting the bronchus, just keep in mind always the lingullar artery behind so as the tip of the dissector doesn't tear it. Although unnecessary in my opinion for this sublobar resection, but if you feel not sure, I recommend you to perform intraoperative fiberbronchoscopy to assess bronchial anatomy before dividing it.


Last step consists on completing the fissure with the lingulla: start anteriorly after insuflating the collapsed left lung, which will determine the lingulla insuflating and the culmen will remain collapsed. By using endostaplers just follow the line towards the fissure dividing completely the culmen.


Hope you find this post interesting, specially for those initiating in sublobar conventional/frequent resections. Let me know your comments here or at https://www.facebook.com/vats4all/



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Designed, edited and published in Alicante, Spain

Diseñada, editada y publicada en Alicante, España

ISSN 2603-963X

Background

Medicine Degree at Miguel Hernández University, Elche, Spain, 2001-2007.

Extraordinary University Award in Medicine Degree, 2001-2007.

Thoracic Surgery Residency at University General Hospital Alicante, 2008- 2013.

Thoracic Surgeon Consultant at University General Hospital Alicante, from 2013-nowadays.

Thoracic Surgeon Consultant and Cofounder at CITMIA, Minimally Invasive Thoracic Surgery Unit, from 2013-nowadays.

PhD in Medicine, Miguel Hernández University, Elche, Spain, 2013-2017.

Tutor of Residents at University General Hospital Alicante, 2018-nowadays

Member of Teaching Committee of the Spanish Society of Thoracic Surgery (SECT), 2018-nowadays

Member of Thoracic Surgery Section at Spanish Association of Surgeons (AEC), 2019.

Thoracic Surgeon Observer at Massachussets General Hospital, Boston (USA), 2012.

Thoracic Surgeon Observer at Memorial Sloan-Kettering Cancer Center, Nueva York (USA), 2012.

Thoracic Surgeon Observer at National Taiwan University Hospital, Taipei (Taiwan), 2016.

Thoracic Surgery Director, XIV Congress of the Spanish Society of Laparoscopic and Robotic Surgery (SECLA). 2016 

Reviewer of “European Journal of Cardiothoracic Surgery”, "Revista Española de Anestesiologia y Reanimacion" and "Journal of Thoracic Disease".

Editorial Board Member of “Journal of Respiratory Research”.

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