(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_6) contains supplementary material, which is available to authorized users.
Left upper lobectomies are reputed to be hazardous, because of the need to control the mediastinal branches of the pulmonary artery, which can be short and fragile. Any tear would cause massive hemorrhage and would require immediate conversion to thoracotomy. However, thanks to the close-up vision and magnification provided by the thoracoscope, dissection can be accurate and safe. Most of the dissection is performed from behind, including control of the truncus anterior. But the technique should be adapted to the anatomical conditions, and an anterior dissection can sometimes be required, for instance, when the truncus anterior is short.
Tip
As for any left pulmonary resection, performing the mediastinal lymph node dissection first may ease the procedure.
6.1 Anatomical Landmarks (◘ Fig. 6.1)
Fig. 6.1
Anatomical landmarks. a Bronchi (lateral view), b usual pattern of the pulmonary artery (lateral view), with three posterior arteries and the truncus anterior bifurcating into two main branches (A1+2 and A3 arteries). c Pulmonary vein (anterior view)
Bronchus
The bronchus provides an anterior bronchus for the lingula and three bronchi for the other segments. These have usually the following pattern: one trunk for segments 1 and 2 (B1+2) and one bronchus for the anterior segment (B3) (◘ Fig. 6.1a).
Arteries
The arterial supply to the left upper lobe is the most variable. The number of branches ranges from 1 to 7 (actually from 3 to 4 in most patients) (◘ Fig. 6.1b). There are two different supplies to the lobe: the truncus anterior (TA) and the posterior arteries. The TA is frequently broad and short, making its dissection hazardous. It supplies segments 1 to 3, usually via two separate branches, A1+2 and A3. The posterior segmental arteries originate in the fissure, along the curve of the pulmonary artery, and pass into the posterior aspect of the left upper lobe. Their number varies from 1 to 5, most often from 2 to 3.
Vein
The superior vein is the most anterior element. The most frequent pattern consists of three main tributaries: the superior one is V1+2, the middle one V3, and the inferior one V4+5 (◘ Fig. 6.1c).
6.2 Anatomical Variations and Pitfalls (◘ Fig. 6.2)
In 15–20% of the patients, the truncus anterior gives a deep and hidden branch to the lingula and S3 segment, also named mediastinal lingular artery or peribronchial artery (◘ Fig. 6.2a).
In rare cases, the left pulmonary vein can be single. This variation must be searched on preoperative CT and verified before stapling (◘ Fig. 6.2b).
Fig. 6.2
a Mediastinal lingular artery, b CT scan of a single pulmonary vein
When the vascular dissection is performed from the front to the back in a cephalad direction, the subaortic region (stations 5 and 6) is reached more easily and rapidly than expected, with a risk of inadvertent tear of the recurrent laryngeal nerve.
6.3 Technique
Depending on the ease of dissection and anatomical factors, e.g., length of the truncus anterior, fibrosis, or adherent lymph nodes, the lobectomy can be performed according to two different sequences:
First sequence (favorable anatomical conditions):
Division of the fissure and ascending arteries
Posterior dissection and division of the truncus anterior, if its length is sufficient and if it can be done safely
Anterior dissection and division of the superior pulmonary vein
Dissection and stapling of the bronchus
Second sequence (unfavorable anatomical conditions):
Division of the fissure and ascending arteries
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