Multiportal Robotic Left Upper Trisegmentectomy With Aberrant B3 Arising From the Lingula—Tips and Tricks

In this video, the authors present the performance of a trisegmentectomy in the context of an anatomical variation, where the B3 bronchus arose from the lingular bronchus. They described the surgical procedure and shared technical tips to facilitate the successful completion of the operation.  

This was a 73-year-old patient with three nodules in the left upper lobe, without nodal invasion. Pulmonary function tests showed a forced expiatory volume in one second (FEV1) of 59 percent predicted, a diffusion capacity for carbon monoxide (DLCO) of 50 percent predicted, and a peak volume of oxygen consumed (VO2) of 16.2 mL·kg⁻¹·min⁻¹. The patient therefore underwent a three-week course of preoperative respiratory rehabilitation. For the positive diagnosis, a computed tomography (CT)-guided biopsy of one of the three nodules confirmed adenocarcinoma.  

Although the tumor was classified as T3, a decision was made to opt for a segmentectomy in the form of a culminectomy rather than a left upper lobectomy, due to the presence of a contralateral nodule and the need for parenchymal preservation. 

The 3D reconstruction was performed as part of the planning process for all segmentectomies.  The S1 and S2 segments were selected in pink, followed by the S3 segment in purple, which arises from the lingular division, along with the B1–B2, B3, and B4–B5 bronchi. When selecting the arteries, two A2 arteries and an A3 artery arising from the lingular artery were observed. At the apical portion, two additional arteries, the A1, A2, and A3, were clearly identified.  

When focusing on the veins, normal anatomy was observed with V1, V2, V3, V4, and V5. The manipulation of V3 was avoided to reduce the risk of injuring the lingular vein. The first step, following the principles of the French lobectomy, involved the division of the pulmonary ligament with dissection of the station 9 lymph node. 

The authors always make sure to grasp the lymph node by its fatty attachments to avoid fragmentation during dissection. The surgeons then opened the posterior mediastinal pleura to expose the subcarinal space. The dissection was carried out medial to the vagus nerve. The dissection of the posterior mediastinal pleura continued to expose and remove the station 10 lymph node, which was located between the pulmonary artery and the bronchus, and to dissect part of the posterior fissure. 

Single-handed dissection was performed to avoid grasping the lymph node prematurely, as it had not yet been sufficiently mobilized. The posterior fissure and lymph node number 11 were addressed. Deep dissection into the posterior fissure exposed the arteries supplying the upper lobe, with the Nelson artery visible at the bottom of the screen and connected to the area for station 5 lymph node dissection.  

The dissection of the aortopulmonary window was proceeded with, beginning along the arterial plane to identify the emergence points of the mediastinal artery. 
 
Close attention was maintained to the lymph node to avoid injury to the recurrent laryngeal nerve. The fissure was completed, allowing for easy dissection of the posterior fissure, first exposing the A2 artery, followed by the A1–A2 artery.  
 
To facilitate arterial passage, a gauze pad may be placed in the field to help guide the fenestrated clamp. 

The dissection of the B1–B2 bronchus began by removing the lymph node located between the A3 artery and the B1–B2 bronchus, allowing for visualization of  
the A3 artery. The dissection of the B1–B2 bronchus continued, using the fenestrated clamp as needed, and carefully dissecting the posterior border to create an exit point. 

To avoid injuring the mediastinal A1 artery  while dissecting around the bronchus and to allow for more complete removal of the station 11 lymph node on the B1–B2 bronchus, division of the mediastinal A1 artery was preferred. The dissection of the A3 artery the proceeded, which, as shown in the 3D reconstructions, divided into several branches. The station 12 lymph node located on the A3 artery was removed, staying well within the arterial plane. Finally, the A3 artery was stapled.  

Based on the 3D reconstructions, it was noted that the B3 bronchus lies just behind the A3 artery. The arterial stump was held with fenestrated forceps to continue the dissection. Segmental bronchi are quite fragile, so careful handling with the forceps is essential to avoid bronchial injury. Unable to create a satisfactory posterior exit point, a decision was made to switch to the anterior approach to divide the vein and then proceed with the anterior dissection of the bronchi. 

On the 3D venous reconstructions, both a V3 vein and a lingular vein were identified. The decision was made not to divide the V3 vein to avoid the risk of injuring the lingular vein. Instead, the V3 vein was divided within the lung parenchyma. As with segments S1 and S2, there should be no hesitation to divide the veins within the parenchyma during stapling. 

The dissection was performed beneath the venous stumps, always aiming to remove the lymph nodes that served as the dissection landmarks for all structures. This allowed for  visualization of the exit points for the B1/B2 and B3 bronchi, as well as the V3 vein under tension. Parenchymal manipulation was then carried out to return to a fissure view. 

Stapling of the B1–B2 bronchus was initiated, which, due to the anterior approach, could be encircled very easily, taking care to leave the lymph node on the bronchus within the specimen. The stapling of the B3 bronchus followed, with the lingular bronchus clearly visible at the bottom. The injection of indocyanine green was then performed using a full 10 cc syringe, with the dose adjusted according to the patient’s weight. 

The staple line was marked by coagulation with the Maryland forceps. Parenchymal division was completed, working both anteriorly and posteriorly to ensure that the two staple lines met and to avoid leaving part of segment S3 attached to the lingula. A double-check was conducted with the fluorescence view to ensure that the area not receiving the indocyanine green injection had been completely removed.  

Key Points 

First, systematic 3D reconstruction was used for every segmentectomy, allowing for the mapping of arterial and venous variants. Second, a stepwise strategy was adopted, following the French lobectomy framework—the five-zone approach—which standardized exposure and improved safety. Third, gentle lymph-node handling was emphasized. Lymph nodes were grasped by their fatty attachments and care was taken to avoid crushing, which prevents fragmentation. Fourth, for a safe arterial passage, a small gauze pad was interposed to guide the fenestrated clamp and protect the vessel wall. 

Fifth, when posterior exposure was limited, an anterior approach was switched to for the bronchi to facilitate encirclement and stapling. Sixth, the vein strategy involved a preference for intraparenchymal division of the target vein when feasible, to safeguard adjacent venous structures. 

Lastly, air leak prevention was addressed by reinforcing the parenchymal staple line with aerostatic patches to reduce postoperative air leaks.  

References

1. Mordojovich G, Hugen N, Bottet B, Montagne F, Bouabdallah I, Pagès PB, Sarsam M, Thomas PA, Baste JM. New standardized five-zone lobectomy (“French lobectomy”). J Thorac Dis. 2025
2. Zhou N, et al. Robotic Surgery and Anatomic Segmentectomy (comparative outcomes). Clin Lung Cancer. 2022.

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