Precision Lung Resection: A Video Guide to Thoracoscopic Segmentectomy of Segments 9 and 10 of the Lower Left Lobe

The authors present the case of a complex thoracoscopic segmentectomy of segments 9 and 10 of the left lower lobe in a 60-year-old male. 

Preoperative computed tomography (CT) imaging revealed a 1.5 cm lesion involving segments 9 and 10. Pulmonary function tests were within normal limits, and the positron emission tomography (PET) scan showed no evidence of metastatic disease. Therefore, a segmental resection was planned. 

On intraoperative inspection, no evidence of metastatic disease was identified. The inferior pulmonary ligament was released, and dissection began with the retrieval of the pulmonary ligament lymph node (station 9). Lymph node station 10, which was located between venous branches, was subsequently retrieved. 

The anterior portion of the fissure was divided, and the interlobar lymph nodes were dissected. Dissection then proceeded to the posterior hilum, allowing for the retrieval of posterior hilar lymph nodes. 

The vein to the basal pyramid was identified. The vein to segments 9 and 10 was isolated and divided, while the veins to segments 7 and 8 were preserved. 

Completion of the fissure provided clear exposure of the segmental branches of the pulmonary artery (artery six (A6), artery 10a, artery 9 and 10b, and artery 7 and 8). These branches were identifiable on CT scans. Segmental artery 10a was divided using a powered thoracoscopic stapler, followed by division of the second arterial branch, which comprised arteries to segments 9 and 10b. 

Attention was then turned to the segmental bronchus for segments 9 and 10. During dissection, care was taken to protect the posteriorly located arterial branches. A Prolene monofilament was placed for traction, and the bronchus was divided. 

A compression test confirmed adequate isolation of segments 9 and 10. The remaining basal segments inflated appropriately, confirming proper bronchial division. Segments 9 and 10 were then separated using a powered stapler, and the specimen was placed in a surgical glove for retrieval. 

Upon reinflation, the surrounding segments expanded fully, confirming good aeration of the residual lung. Additional lymph nodes were retrieved from the anterosuperior hilum. Final pathology confirmed a stage T1bN0 lung adenocarcinoma. 

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