Right VATS En Bloc S3, S4, S5 Segmentectomy

This video demonstrates a technique for VATS right en bloc S3, S4, S5 segmentectomy. The primary surgeon for this operation was Mr. Soon Sing Yang, a consultant cardiothoracic surgeon.  

The video shows an example of the CT thorax (in axial view) lung window. Surgeons always use the airways as a guide to identify the location of each segment. Therefore, labelling each airway from central to peripheral, while picturing it in your mind prior to surgery, is often helpful when it comes to performing a good segmentectomy. This includes the trachea, main bronchi, lobar bronchi, and segmental bronchi. 

The Patient 

A forty-year-old Malaysian Chinese woman who had no known medical illness or risk factors for lung cancer was presented to a health care clinic with an incidental finding of a right middle zone opacity on a chest radiograph. Her CT thorax showed a well-defined heterogeneously enhancing mass in the right middle lobe (RML) measuring 3.7 x 4.2 x 3.1 cm. The coronal view showed the mass crossing the transverse fissure and involving the anterior segment of the right upper lobe (RUP). The PET/CT showed intense FDG-avid tumor activity in the mass. 

The Technique 

Upon entering the right pleural cavity, we confirmed that the lobulated mass in the RML had crossed the fissure to involve the RUL. We visualized A2 (RUL posterior segmental artery) and A6 (artery supplying apical segment of RLL) as well as the arteries that supply the rest of right lower lobe (RLL). During the dissection of this area, it is possible to come across interlobar lymph nodes. Removal of the lymph nodes will provide better visualization of the structures underneath. Our attention was then turned to the hilar region. This approach revealed both the superior and inferior pulmonary veins, which are the most anterior structures in the hilum. We then proceeded to release the inferior pulmonary ligament up to the inferior pulmonary vein. 

The anterior oblique fissure was identified and isolated with a vascular sling. It was divided with staples. Another interlobar lymph node was identified and dissected. The right middle lobe was retracted upward, exposing the RML vein. With blunt dissection, we went around and isolated the RML vein. The vein was divided with a vascular stapler. 

Usually in the RML, the bronchus lies immediately behind the vein. This is different than other lobes of the lung, where the vein is the most anterior structure followed by the artery and then the bronchus.  The RML bronchus was isolated and divided with a stapler. This left the RML artery located just behind it. The RML artery was isolated and divided with a vascular stapler. With that, the right middle lobectomy was completed. 

We dissected along the RUL vein in an attempt to identify the first branch of the pulmonary artery.  With further dissection, we were able to visualize the segmental branches of the RUL pulmonary artery. A1 supplies the apical segment, whereas A3 supplies the anterior segment of the RUL. During the dissection, a station 12 lymph node was identified and removed. 

Next, we delineated the segmental branches of the RUL vein using blunt dissection. Vein 1a and b receive the venous drainage from apical segment, whereas V3 receives drainage from anterior segment of the RUL. By adjusting the position and retracting the RUL upward, we were able to see V2, which receives the venous drainage from the posterior segment of RUL. 

With further blunt dissection away from hilum, we created a magnificent visualization of the RUL segmental arteries and veins. We then took V3 and divided it with a vascular stapler. Lying behind the divided V3 and beneath the pulmonary artery branches, we identified the RUL bronchus. Further dissecting superior to it, A3 was isolated and divided with a vascular stapler.   

Finally, the dissection was continued along the RUL bronchus toward the lung parenchyma. With this, we identified the trifurcation of the RUL bronchus. B3 was encircled with a vascular sling and divided with a stapler.   

In this surgery, we employed the inflation-deflation technique to identify the intersegmental plane. The intersegmental plane was divided with caution to avoid the bronchovascular structures underneath.  With this, the S3 segmentectomy was completed. The specimen was retrieved using an endobag.  Finally, an air leak test showed no air leak along the stapler line and bronchial stump. 

Reference

1. Swanson SJ. Segmentectomy for lung cancer. Semin Thorac Cardiovasc Surg. 2010;22:244-249

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