Left Uniportal VATS Left Upper Lobe Trisegmentectomy (Lingula Sparing): Showcasing the Mediastinal Lingular Artery Variant

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This video features a left uniportal video-assisted thoracoscopic surgery (VATS) left upper lobe trisegmentectomy, also known as a lingular-sparing S1–3 segmentectomy, performed for a metastatic lung nodule.  

This case is notable for two reasons: First, a complex anatomical resection was completed through a 3 cm uniportal incision, demonstrating a precise minimally invasive technique. Second, the patient had a rare mediastinal lingular artery (A4–5) variant, observed in only 25 to 30 percent of left upper lobe surgeries. The operating surgeon was Dr. Kan Chan Siang. 

Case Summary 

The patient was a 35-year-old woman with no significant comorbidities. She had previously undergone an anterior resection for rectal carcinoma. Routine surveillance computed tomography (CT) identified a new spiculated nodule in the apicoposterior segment of the left upper lobe, and she was otherwise asymptomatic. CT imaging also showed that the lingular artery (A4–5) arose proximally above the left upper lobe bronchus, confirming the presence of a mediastinal lingular artery with no branches in the fissure. 

Operative Technique 

Upon entering the thoracic cavity, the lesion was identified by pleural puckering. The inferior pulmonary ligament was divided, and the fissure was partially developed. Due to the incomplete fissure, the approach was shifted to the hilar (anterior) technique. The left upper lobe pulmonary vein was dissected, and branches V1–3 were isolated and divided with a vascular stapler. The pulmonary artery adventitia was then dissected using an advanced bipolar device.  

The mediastinal lingular artery (A4–5) was exposed, followed by the isolation and division of A3. Further dissection revealed A1+2a and A1+2b, which were double-hemolocked, clipped, and divided, followed by A1+2c. The B1–3 bronchus was isolated and clamped. An inflation–deflation technique delineated the intersegmental plane, and the bronchus was stapled. Parenchymal division along this plane completed the trisegmentectomy. 

The specimen was retrieved, and the divided and preserved structures were confirmed. An air-leak test was negative, and a pigtail catheter was inserted. 

Postoperative Course

The final uniportal incision is shown at closure. The postoperative chest X-ray on day one demonstrated excellent lung expansion, which remained well-maintained at the one-month follow-up.

References

1. Chen Liang, Zhu Quan, et al. The Atlas of Thoracoscopic Anatomical Pulmonary Segmentectomy.
2. Nanjing: Southeast University Press / Southeast University Electronic Audio-Visual Press, Jiangsu Provincial People’s Hospital & The First Affiliated Hospital of Nanjing Medical University.

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