S3 - Left upper lobe anterior anatomical segmentectomy (Uniportal VATS)

Anterior segmentectomies of the upper lobes are not uncommon procedures. Main difference with RUL S3 segmentectomy is the frequent division of S1+2 together and the presence of the lingulla.

It can be easilly performed through Uniportal VATS as you face all the structures from the front.

First dissect the upper vein in order to identify the division of the apico-posterior vein (S1+2) (the most superior branch), the lingular vein (S4+5)(the most inferior one), and between them you can identify a thick vein; most surgeons think this is the vein for the anterior segment (S3), but it's essential to highlight that this vein drains not only S3 (V3a, V3b, V3c), but also the posterior aspect of S1+2 (V1+2d), that usually branches from V3a. My recommendation is to dissect distally that V3 vein in order to identify the subsegmental veins and also to identify V1+2d, that is easilly dissected running towards S2 crossing through the lobe. Dividing the small branches of the vein for the S3 is better performed with endoscopic ligatures or energy devices (they are commonly small branches), because from the uniportal approach they are faced so from the front that introducing a vascular stapler has more safety and technical concerns.

Arterial vascularization for S3 is carried by 1-2 branches that come straight from the main artery in the superior hilum, and run behind V1+2 and V3. For dissecting and dividing the segmental artery, I find really useful to encircle the V1+2 vein and then use an endoclip, energy devices or even a vascular stapler.

After dividing the segmental veins and arteries, you can dissect the segmental bronchus (B3) just behind the stumps. Be careful to identify the lingular bronchus (B4+5) on the right, and the apicoposterior bronchus (B1+2) behind, in a more posterior location.

Although easy to identify and dissect, I find mandatory to divide first the intersegmental planes of S3 to make easier bronchial division. I always use endostaplers for the intersegmental plane because I find them safer for preventing air leaks.

When you approach the segmental bronchus with the intersegmental planes division, then you can easilly dissect it and divide (try with a tipped endostapler!). I do always check bronchial division by reventilating before firing the stapler, so you identify S1+2 and lingulla inflating but S3 remaining collapsed.

These are my main tips and tricks for S3 LUL Uniportal VATS anatomical segmentectomy.

Hope you find them useful!