Right Upper Lobe Anterior Segmentectomy—Video 19

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CHAPTER 19 Right Upper Lobe Anterior Segmentectomy—Video 19

Robert J. McKenna, Jr.

Introduction

This segmentectomy is infrequently performed. Many surgeons do not know how to perform it, but it is a straightforward procedure.

Approach to Video-Assisted Right Upper Lobe Anterior Segmentectomy

Order of Operative Steps

The order of the steps of the operation is as follows: minor fissure, anterior segment vein, anterior segmental artery, segmental bronchus, and the fissure.

Key Points

♦ Work anteriorly to posteriorly, with little manipulation of the lung.
♦ No posterior dissection is necessary. Very little lung manipulation is needed.

image Video-Assisted Right Upper Lobe Anterior Segmentectomy (Video 19)

Step 1. Incisions

♦ Use the standard incisions, with the utility incision placed directly up (lateral) from the superior pulmonary vein (see Figure 1-2 in Chapter 1).

Step 2. Minor Fissure

♦ Exposure: Retract the lung posteriorly and slightly inferiorly.
♦ Aim the thoracoscope anteriorly, and point the 30-degree lens posteriorly, but it is pulled back almost to the trocar.
♦ The landmarks for completion of the minor fissure are the junction of the minor and major fissures for the staple cartridge and at the confluence of the right upper lobe and right middle lobe veins for the anvil of the stapler.
♦ Point the anvil of the stapler toward that venous confluence. Do not move the stapler. With ring forceps, pull the lung parenchyma into the jaws of the 4.8-mm endoscopic stapler pointed toward the fissure. The first firing of the stapler usually completes about one half of the fissure.
♦ With the Metzenbaum scissors through the utility incision, dissect along the inferior aspect of the right upper lobe vein to expose the pulmonary artery that lies posterior and perpendicular to the vein. Dissect the surface of the artery.
♦ Place the anvil of the stapler between the veins and on the surface of the artery for additional firings of the stapler (Figure 19-1A). Do not move the stapler.
♦ Open the jaws of the stapler, and pull the lung parenchyma into the jaws of the stapler with ring forceps.
♦ Fire the stapler to complete the minor fissure (Figure 19-1B).
image

Figure 19-1 A, Positioning the cartridge of the stapler to complete the minor fissure. B, Positioning the anvil of the stapler to complete the minor fissure.

Step 3. Anterior Segmental Vein

♦ Exposure: Retract the lung directly posteriorly.
♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly.
♦ Dissect along the inferior aspect of the upper lobe vein. The inferior-most branch is the vein from the anterior segment (Figure 19-2).
♦ With Metzenbaum scissors through incision 3, dissect the vein, and widely spread a right-angle clamp to create a wide tunnel through which to pass the anvil of the stapler (Figure 19-3).
♦ Pass the vascular stapler through incision 4 (or 3) to transect the vein.
image

Figure 19-2 A, Veins from the upper lobe. B, A right-angle clamp passed around the anterior segmental vein exposes the artery behind the vein.

image

Figure 19-3 A, Scissors used to mobilize the anterior segmental artery. B, Right-angle clamp used to mobilize the anterior segmental artery.

Step 4. Anterior Segmental Artery

♦ Exposure: Retract the lung posteriorly and slightly inferiorly.
♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly. Rotate the camera slightly clockwise.
♦ The anterior segmental artery can be seen after the vein has been transected.
♦ Through incision 3, use Metzenbaum scissors to dissect the anterior segmental artery.
♦ The bronchus is directly behind the artery. Pass a right-angle clamp between the artery and the bronchus, and spread widely to create a tunnel for the stapler.
♦ Transect the artery with a vascular stapler from incision 3 or incision 4 (Figure 19-4).
image

Figure 19-4 Stapler used to transect the anterior segmental artery.

Step 5. Anterior Segmental Bronchus

♦ Exposure: Retract the lung posteriorly and slightly superiorly.
♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly.
♦ Remove the segmental (level 12) nodes from the surface of the segmental bronchus (Figure 19-5).
♦ Dissect the anterior segmental bronchus with Metzenbaum scissors through incision 3.
♦ Behind the bronchus is a small artery that goes to the apical segment. Pass a right-angle clamp between the artery and the bronchus, and spread the clamp widely to create a tunnel for the stapler.
♦ Transect the bronchus with a stapler from incision 4 (or incision 3) (Figure 19-6).
image

Figure 19-5 Segmental nodes on the anterior segmental bronchus.

image

Figure 19-6 The anterior segmental bronchus is mobilized with the scissors.

Step 6. Fissure between the Anterior and Apical Segments

♦ Exposure: Retract the lung directly posteriorly and apically.
♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed posteriorly.
♦ Separate the anterior segment from the apical segment with a 4.8-mm endoscopic stapler (Figure 19-7).
image

Figure 19-7 A, The stapler is used to complete the fissure between the anterior and apical segments. B, The posterior segmental vein should be preserved when transecting the anterior segmental artery. C, Completion of the fissure exposes the bronchus.

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