(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_17) contains supplementary material, which is available to authorized users.
Thoracoscopic S6 segmentectomy is seen as one the most straightforward sublobar resections and is frequently the one to start with when experience with thoracoscopic sublobar resections is still limited. However, there are many variations in the anatomy that can make the procedure more difficult than expected.
17.1 Anatomical Landmarks
Bronchus
The superior segmental bronchus B6 is the first branch of the lower lobe bronchus (◘ Fig. 17.1a). It arises laterally and posteriorly and lies posterior to the segmental artery.
Fig. 17.1
Anatomical landmarks. a B6 bronchus; b A6 artery, in its most common pattern, i.e., early bifurcation in two branches; c double A6 artery (3D reconstruction); d double A6 artery (thoracoscopic view); e V6 in its most common pattern
Arteries
The superior segment of the left lower lobe is supplied by a single (80%) (◘ Fig. 17.1b), double (18%) (◘ Fig. 17.1c and d), or even triple (2%) artery that originates from the posterior surface of the pulmonary artery in the posterior portion of the fissure. When single, A6 artery bifurcates in two or three branches. The artery runs anterior to the segmental bronchus.
Vein
The superior segment is drained by the superior branch of the inferior pulmonary vein (V6) (◘ Fig. 17.1e).
17.2 Anatomical Variations and Pitfalls
In some cases, the origin of A2 is close to the origin of A6. An arterial branch to S2 can even arise from A6 (◘ Fig. 17.2a and b).
Branches to segments 9 and 10 can be close to A6 (◘ Fig. 17.2c)
V6 can receive a venous branch from the basilar segments (◘ Fig. 17.2d). In this case, only the uppermost tributary of V6 must be clipped.
A lymph node is frequently encountered close to the posterior aspect of A6. It can tightly adhere to the artery and exposes to a vascular tear during dissection.
In obese or in some kyphotic patients, the bronchus is located deeply and remote from A6, so that its identification and dissection can be difficult, especially when dissection is conducted from the front. In these cases, it can be advisable to approach B6 from the back and from below, after division of V6.
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