S2 Right-upper lobe posterior segmentectomy (Uniportal)
Actualizado: 18 de sep de 2019
Right-upper lobe posterior segmentectomy (S2) is a nice procedure which requires some essential anatomical knowledge. Most surgeons identify the ascending posterior artery for S2 but avoid to identify the recurrent artery from the superior trunk, and include it in the intersegmental fissure. I recommend to know and preserve all the anatomical structures for the segment in order to be a delicate surgeon and avoid complications.
First step, arterial division: it depends whether the minor and major fissure are complete or not. I will describe both scenarios.
With complete fissure, first expose the pulmonary artery in the confluence of both fissures, and identify the posterior ascending artery for S2, very close to the right-lower lobe upper segmental artery (A6). You can easily divide it with endoscopic clips and energy devices.
Don't forget there is a recurrent artery from superior trunk that should later be divided.
After that, if you dissect more anterior than the divided S2 artery, you will identify the central vein that runs between the upper (RUL) and the middle lobes (RML), and you will identify an intersegmentak vein between S3 and S2, and then a vein for S2 that divides into 2 subsegmental branches. You can divide they all three together or separately.
If the minor fissure is incomplete, exposing the interlobar vein and the pulmonary artery becomes a bit more difficult. From the anterior hilum, you identify the upper vein, with an apical branch, an anterior segment vein and then the central vein that gets inside the parenchyma: this vein indicates the interlobar plane between RUL and RML. How to open that fissure? Just dissect above that interlobar vein, take the dissection as distal in the parenchyma as possible and you will create a kind of tunnel above the vein; as you get deeper, by using endostaplers you can divide the minor fissure and expose all that interlobar central vein, and identify anterior segment branches but also the aforementioned intersegmental vein between S3 and S2, and the veins that drain S2.
Once the artery has been divided, just belowe you will find some peribronchial lymph nodes and just below the arterial stump you discover the posterior segmental bronchus. You can normally visualize the anterior segment bronchus and the division between both of them. Apical segment bronchus can not be seen from this position. I prefer to carry the dissection belowe the arterial distal stump as far as possible to expose the segmental bronchus gently, and then dissect it.
I prefer to clamp the segmental bronchus all the times even though I'm sure it's the right one because it just takes a few seconds and prevents a mistake. After clamping and reventilating, apical and anterior segments inflate normally but the posterior one remains collapsed. Then I divide the segmental bronchus: I find quite useful the purple tip load of endoGIA Tristaple for dividing that bronchus, because the tip of th stapler makes really easy that step.
Once all this has been performed, keep in mind that behind the segmental bronchus stump you identify an arterial branch, which one? The recurrent artery from the superior trunk, that also vascularizes the S2 and should be divided. Be careful with the apical artery behind that because it should be preserved in this procedure.
After dividing all the bronchovascular structures and the intralobar lymph nodes, it's time to determine the intersegmental plane. By reventilating you can easily identify the plane, so I usually start the division from the fissure with consecutive endostaplers, initially between the anterior segment (S3) and the resected segment (S2), and finally between the apical segment (S1) and the resected segment. I prefer to reventilate very gently evary time I place an intersegmental endostapler load to check the preservation of the remaining segmental bronchus (B1 and B3).
Right-upper lobe posterior segmentectomy is a funny and nice procedure because has some variations depending on the fissure status and requires some technical details and anatomical knowledge amenable only for VATS experienced surgeons.
Thanks for your attention