Left Upper Lobe Apical Trisegmentectomy—Video 16-1

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CHAPTER 16 Left Upper Lobe Apical Trisegmentectomy—Video 16-1

Scott J. Swanson

Introduction

Segmentectomy is an option for a small, anatomically well-situated lung cancer. Creating the segmental fissure and dissecting out the segmental vessels can be done using a thoracoscopic technique. A left upper lobe apical trisegmentectomy (i.e., lingula-sparing left upper lobectomy) is similar to right upper lobectomy with preservation of the right middle lobe.

Approach to Video-Assisted Left Upper Lobe Apical Trisegmentectomy

Order of Operative Steps

The order of the steps of the operation is as follows: anterior, superior, and posterior pleurae over the hilum; upper division vein; anterior trunk; posterior artery; bronchus; and the fissure (Video 16-1).

Key Points

♦ The vessels help to determine the separation between the upper division and the lingula.
♦ Alternatively, the bronchus for the upper division can be divided and the lingula ventilated to determine where to place the staples to separate the upper division.

image Video-Assisted Left Upper Lobe Apical Trisegmentectomy

Step 1. Port Placement (Figure 16-1)

♦ Place the camera port in the seventh intercostal space in the anterior axillary line; it can be modified depending on heart size.
♦ Place the access port in the fourth intercostal space in the mid-axillary line.
♦ Place the posterior port in the sixth intercostal space, just inferior to the tip of the scapula.
image

Figure 16-1 The three ports for the left upper lobe apical trisegmentectomy are shown. The camera is placed in the seventh intercostal space in the anterior axillary line. The access port is in the fourth intercostal space in the mid-axillary line, and the posterior port is placed in the sixth intercostal space just inferior to the tip of the scapula.

Step 2. Dissect Anterior Hilum and Aortopulmonary Window (Figure 16-2)

♦ Exposure: Retract the lung posteriorly through the posterior port.
♦ Place the thoracoscope in the camera port with the side arm to the left to look at anterior hilar structures.
♦ Dissect through the access port.
♦ Open the mediastinal pleura over the anterior hilum with an endokittner and the suction irrigator. This defines the venous drainage from the upper division of the left upper lobe (LUL). Dissect superiorly to the level of the aortopulmonary window.
♦ Removal of the level 5 nodes facilitates exposure of the vessels and prepares the superior and posterior aspect of the anterior trunk for subsequent transection.
image

Figure 16-2 A, The surgeon dissects out the level 5 lymph nodes using an endokittner and suction irrigator through the anterior access port. The assistant gently retracts the lung posteriorly through the posterior port. B, The surgeon uses the harmonic scalpel to divide the small nodal vessels to the level 5 lymph nodes to ensure hemostasis through the anterior access port.

Step 3. Open Posterior Mediastinal Pleura (Figure 16-3)

♦ Exposure: Retract the lung anteriorly through the access incision.
♦ Place the thoracoscope in the camera port with the side arm to the right.
♦ Open the posterior mediastinal pleura using blunt dissection with endokittners through the posterior port. Continue opening the pleural superiorly until the dissection connects with the posterior pleural opening with the anterior pleural dissection from steps 1 and 2.
image

Figure 16-3 A, The lung is retracted anteriorly using a ring forceps through the anterior access port while the surgeon uses two endokittners through the posterior port to open the posterior mediastinal pleura, which exposes the level 6 lymph nodes, the vagus nerve, and the pulmonary artery where it enters the posterior fissure. B, The surgical assistant retracts the lung anteriorly through the anterior access port and uses the suction irrigator to further retract the lung. Suction as needed while the surgeon bluntly dissects out the pulmonary artery in the fissure using two endokittners through the posterior port.

Step 4. Tumor Palpation (Figure 16-4)

♦ Exposure: Move the lung toward the access port with a ringed forceps placed through the posterior port.
♦ Place the thoracoscope in the camera port with the side arm straight up.
♦ Carefully palpate and examine the tumor to be certain a sublobar resection constitutes optimal cancer treatment. This is done by corroborating the tumor size (T1, ideally less than 2 cm) and confirming that tumor is far enough away from the lingula so that the margins will be adequate if a trisegmentectomy is performed.
♦ When observing the LUL from an anterior position, the lingular vein helps to determine the superior aspect of the lingula. When retracting the LUL posteriorly, the upper division is just above the lingular vein. There is often a minimal fissure between the lingula and the upper division.
image

Figure 16-4 Through the anterior access port, the surgeon palpates the tumor to confirm its presence and determine that it is positioned centrally within the upper division.

Step 5. Upper Pulmonary Vein (Figure 16-5)

♦ Exposure: Retract the lung posteriorly with the ring forceps through the posterior port.
♦ Place the thoracoscope in the camera port with the side arm to the left.
♦ Mobilize the upper division pulmonary vein with the endokittner and scissors or right-angle clamp. Carefully identify and preserve the lingular vein or veins. In some instances, it is necessary to divide a middle central vein, although it drains the upper division and lingula.
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