(1)
IMM, Curie-Montsouris Thorax Institute, Paris, France
Electronic Supplementary Material
The online version of this chapter (doi:10.1007/978-3-319-55901-8_7) contains supplementary material, which is available to authorized users.
The left lower lobectomy is usually the most straightforward endoscopic lobectomy. However, it can be difficult and tedious when the fissure is fused. In addition, when the procedure is done for lung carcinoma, lymph node dissection of station 7 can be difficult because the venous and bronchial stumps can hamper the approach to the subcarinal region (see page 38). It may be preferable performing lymph node dissection before the lobectomy.
7.1 Anatomical Landmarks (◘ Fig. 7.1)
Bronchus
The lower lobe bronchus arises with the upper bronchus at the termination of the left main bronchus. It lies beneath the arterial branches and is easily exposed once these have been divided (◘ Fig. 7.1a).
Fig. 7.1
Anatomical landmarks; a lower lobe bronchus and arteries (lateral view), b arteries (lateral view), c inferior pulmonary vein (posterior view)
Arteries
Both the basal trunk and superior segmental artery (A6) must be controlled. A6 is either single or double. It comes from the posterior aspect of the pulmonary artery. The lingular artery (A4+5) can arise from the basal trunk and must be clearly identified before stapling (◘ Fig. 7.1b).
Vein
The inferior pulmonary vein (IPV) is approached from below, by freeing the pulmonary ligament (◘ Fig. 7.1c).
7.2 Anatomical Variations and Pitfalls (◘ Fig. 7.2)
Although the classical X-shape pattern is quite frequently encountered in the fissure (◘ Fig. 7.2a), there are some variations in the distribution of arteries. The most frequent one is the lingular artery (A4+5) rising from the basilar trunk. It could be injured or stapled during fissure division (◘ Fig. 7.2b).
A common mouth of the two pulmonary veins is encountered in about 10% of the patients. Failing to recognize this variation would lead converting the lobectomy into a pneumonectomy. It must always be looked for by preoperative examination of CT (◘ Fig. 7.2c, d).
The pulmonary ligament can be very loose in some slim patients so that IPV can be reached more rapidly than expected during dissection with a risk of venous injury.
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