Step-by-Step Thoracoscopic Right Upper Lobe Posterior Segmentectomy

The posterior segment of the right upper lobe lends itself to a straightforward anatomic resection. Understanding the anatomy is key, and the authors present two cases that illustrate a stepwise approach.

The general steps of a posterior segmentectomy of the right upper lobe:

1. Perform a bronchoscopy prior to the procedure to understand the segmental anatomy, as not all patients will have a typical trifurcated right upper lobe.
2. Begin with a posterior dissection. Identify the bronchus and the take-off of the right upper lobe.
3. Dissect the major fissure and identify the pulmonary artery. Follow this plane toward the dissection point in step 2.
4. Complete the division of the major fissure using a stapler.
5. Dissect vascular structures to the posterior segment. The vein is generally the first structure to present in the fissure.
6. Dissect and divide the posterior ascending branch of the pulmonary artery.
7. Dissect and retrieve lymph nodes during the course of the procedure to optimize the N1 yield.
8. Inspect the bronchus and divide the appropriate posterior bronchus. Bronchoscopy can be helpful at this point.
9. Identify the division point within the parenchyma. Traditionally, this is achieved by gentle ventilation after division of the bronchus, however this has the disadvantage of reducing working space in the chest. A more optimal solution, and one which better respects vascular supply, is some form of perfusion-based imaging.
10. Divide the parenchyma using staples that are appropriate for thicker tissue.