Superior Segmentectomy—Video 18

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CHAPTER 18 Superior Segmentectomy—Video 18

Robert J. McKenna, Jr.

Introduction

The approach to a superior segmentectomy varies with the completeness of the fissure. If the fissure is complete, I prefer an anterior approach because the artery can be easily visualized in the fissure. If the fissure is incomplete, the entire fissure can be completed (as for a lower lobectomy [see Chapter 11]) so the anterior to posterior approach can be performed. Alternatively, the segmentectomy can be approached posteriorly.

Approach to Video-Assisted Superior Segmentectomy

Order of Operative Steps

The order of the steps for an anterior approach is as follows: major fissure, superior segmental artery, superior segmental bronchus, superior segmental vein, and the fissure. The order of the steps for a posterior approach is as follows: superior segmental bronchus, superior segmental vein, superior segmental artery, and the fissure. For a posterior approach, the order is vein, bronchus, and then artery.

Key Points

• Determine whether the artery can be seen in the fissure to decide which approach to take.

image Anterior Approach for Superior Segmentectomy (Video 18)

Step 1. Identifying the Artery in a Major Fissure: Complete Fissure

• Exposure: Retract the lung directly posteriorly.
• Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly toward the hilum.
• Use the standard incisions (see Figure 1-2 in Chapter 1).
• Elevate the lower lobe with a ring forceps introduced posteriorly, and elevate the middle lobe or upper lobe (or both) with a ring forceps introduced anteriorly. If the fissure is complete, open the pleura with Metzenbaum scissors or electrocautery through the anterior incision to identify the artery (Figure 18-1).
• Through the lower anterior incision, dissect on the surface of the artery with Metzenbaum scissors. This creates a tunnel for the stapler to complete the fissure (Figure 18-2).
• Place the anvil of the stapler on the surface of the artery; it is not moved because ring forceps anteriorly and posteriorly pull the lung parenchyma of the fissure into the stapler.
• With this approach, the artery to the superior segment is exposed (Figure 18-3).
• Directly below the fissure, continue to dissect with the Metzenbaum scissors beyond the superior segmental artery (Figure 18-4). The bronchus can be felt with the scissors. Continue this dissection through the posterior pleura to complete the remainder of the fissure.
• Place an endoscopic stapler through the anteroinferior incision to complete the fissure.
image

Figure 18-1 The artery is identified in the fissure.

image

Figure 18-2 Dissection on the artery with scissors dissecting creates a tunnel for the stapler to complete the fissure.

image

Figure 18-3 Superior segmental artery after completion of the fissure.

image

Figure 18-4 Dissection on the pulmonary artery posteriorly creates a tunnel to complete the remainder of the fissure.

Step 2. Identifying the Artery in a Major Fissure: Incomplete Fissure

• If the fissure is very incomplete, the entire fissure can be opened with a stapler to avoid the air leaks created by dissecting in the fissure (see Chapter 11).

Step 3. Superior Segmental Artery

• Exposure: Retract the lower lobe slightly posteriorly and inferiorly.
• Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly down the fissure.
• Through the anterior incision, use Metzenbaum scissors and DeBakey pickups to dissect the superior segmental artery (Figure 18-5).
• With a vascular stapler through the anteroinferior incision, transect the superior segmental artery (Figure 18-6).
image

Figure 18-5 A and B, Dissection of the superior segmental artery.

image

Figure 18-6 Stapling the superior segmental artery.

Step 4. Superior Segmental Bronchus

• Exposure: Retract the lung directly posteriorly and slightly inferiorly.
• Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly toward the bronchus.
• If the fissure has not been completed, dissect along the superior aspect of the bronchus with the Metzenbaum scissors introduced through the inferior incision. Push with the scissors posteriorly. Except the spine, there is no significant structure posteriorly. After the tunnel is complete, staple the remainder of the fissure with a stapler through the anteroinferior incision. Place the anvil of the stapler in the tunnel and line up the cartridge with the fissure (Figure 18-7).
• Dissect the bronchus with scissors through the anterior incision.
• Transect the bronchus with a stapler through the anteroinferior incision (Figure 18-8).
image

Figure 18-7 A and B, Mobilization of the superior segmental bronchus.

image

Figure 18-8 Stapling of the superior segmental bronchus.

Step 5. Superior Segmental Vein

• Exposure: Retract the lung directly posteriorly and inferiorly.
• Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly toward the vein.
• Dissect the vein with scissors through the anterior incision.
• Transect the vein with a stapler through the anteroinferior incision.

Step 6. Separating the Superior Segment

• Exposure: Retract the segment superiorly.
• Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly toward the lung.
• Pass the stapler through the anteroinferior incision. Place the anvil of the stapler just above the artery. Pull the superior segment superiorly with a ring forceps through the anterior incision (Figure 18-9).
• Occasionally, there is a small fissure between the superior segment and the basilar segments, which helps with identifying the proper location for the separation of the superior segment from the basilar segments. If not, place the stapler to provide adequate margins away from the tumor in the segment. Subsequently, place the stapler so that the anvil of the stapler is positioned in front of the artery to avoid compromising it (Figure 18-10).
image

Figure 18-9 A and B, Starting to complete the fissure to separate the superior segment.

image

Figure 18-10 Completion of the fissure to separate the superior segment.

Step 7. Segment Removal

• Remove the segment as described for other resections (see Chapter 1).

Posterior Approach for Superior Segmentectomy

An alternate approach for the superior segmentectomy is a posterior approach. It can be the surgeon’s standard approach for a superior segmentectomy or used when there is an incomplete fissure.

• Retract the lung anteriorly.
• Dissect the vein from the superior segment, and staple it.
• Identify the bronchus found just superior to the vein. After transecting the bronchus, the artery can be seen and stapled.
• Staple the fissure.

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CHAPTER 18 Superior Segmentectomy—Video 18

Robert J. McKenna, Jr.

Introduction

The approach to a superior segmentectomy varies with the completeness of the fissure. If the fissure is complete, I prefer an anterior approach because the artery can be easily visualized in the fissure. If the fissure is incomplete, the entire fissure can be completed (as for a lower lobectomy [see Chapter 11]) so the anterior to posterior approach can be performed. Alternatively, the segmentectomy can be approached posteriorly.

Approach to Video-Assisted Superior Segmentectomy

Order of Operative Steps

The order of the steps for an anterior approach is as follows: major fissure, superior segmental artery, superior segmental bronchus, superior segmental vein, and the fissure. The order of the steps for a posterior approach is as follows: superior segmental bronchus, superior segmental vein, superior segmental artery, and the fissure. For a posterior approach, the order is vein, bronchus, and then artery.

Key Points

• Determine whether the artery can be seen in the fissure to decide which approach to take.

image Anterior Approach for Superior Segmentectomy (Video 18)

Step 1. Identifying the Artery in a Major Fissure: Complete Fissure

• Exposure: Retract the lung directly posteriorly.
• Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly toward the hilum.
• Use the standard incisions (see Figure 1-2 in Chapter 1).
• Elevate the lower lobe with a ring forceps introduced posteriorly, and elevate the middle lobe or upper lobe (or both) with a ring forceps introduced anteriorly. If the fissure is complete, open the pleura with Metzenbaum scissors or electrocautery through the anterior incision to identify the artery (Figure 18-1).
• Through the lower anterior incision, dissect on the surface of the artery with Metzenbaum scissors. This creates a tunnel for the stapler to complete the fissure (Figure 18-2).
• Place the anvil of the stapler on the surface of the artery; it is not moved because ring forceps anteriorly and posteriorly pull the lung parenchyma of the fissure into the stapler.
• With this approach, the artery to the superior segment is exposed (Figure 18-3).
• Directly below the fissure, continue to dissect with the Metzenbaum scissors beyond the superior segmental artery (Figure 18-4). The bronchus can be felt with the scissors. Continue this dissection through the posterior pleura to complete the remainder of the fissure.
• Place an endoscopic stapler through the anteroinferior incision to complete the fissure.
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