(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_14) contains supplementary material, which is available to authorized users.
Upper division segmentectomy is quite similar to a left upper lobectomy and is more and more performed, as it seems that its oncological results are equivalent to those of a left upper lobectomy. This segmentectomy can be tricky because the bronchial trunk is in close contact with the truncus anterior, especially if adherent lymph nodes are present.
14.1 Anatomical Landmarks (◘ Fig. 14.1)
Bronchi
The upper lobe bronchus splits immediately into the lingular bronchus and a common stem that usually separates into an anterior bronchus (B3) and an apicoposterior bronchus (B1+2) (◘ Fig. 14.1a). These three segmental bronchi have a short course that can make their identification and dissection difficult.
Fig. 14.1
Anatomical landmarks. a bronchi for segments 1-2-3. b arteries, with a regular interlobar lingular artery. c usual venous pattern with three main branches. d thoracoscopic corresponding view
Arteries
There are two different supplies to the left upper lobe: the truncus anterior (TA) and the posterior arteries. The TA is often broad and short. It usually gives two main tributaries, the uppermost (A1+2) for S1 and S2 and the lowermost (A3) for S3 (◘ Fig. 14.1b).
The posterior arteries originate in the fissure and distribute themselves over the curve of the pulmonary artery. Their number varies from 1 to 5 but most often from 2 to 3. All but the lingular artery (A4+5) must be divided.
Veins
The superior pulmonary vein has usually three major tributaries (◘ Fig. 14.1c and d). The superior branch (V1+2) drains S1 and S2 segments. The middle branch (V3) drains S3, and the lowermost branch drains the lingula. The later must be preserved.
14.2 Variations and Pitfalls (◘ Fig. 14.2)
The number of segmental posterior arteries is highly variable. Thorough examination of preoperative 3D reconstruction helps determining the number and distribution of arteries and makes dissection safer.
The presence of a mediastinal lingular artery (15–20%) should be searched on 3D reconstruction (◘ Fig. 14.2a). If present, dissection of the truncus anterior must be conducted with caution as this artery runs anterior to B1+2+3 and is in close contact with the bronchus. Dissecting around the bronchus must be done smoothly.
In some rare cases, V1+2 can form a common trunk with V3.
Even when 3D reconstruction demonstrates a clear pattern of the venous anatomy with a distribution of the lowermost venous branch to the lingula, V4+5 can be tiny. It can be preferable to preserve the inferior branch of V3. In some cases, it is almost impossible to determine if the adjacent vein to the lingular one comes from the lingula or from S3. It seems prudent to preserve this vein, especially if the lingular vein is tiny (◘ Fig. 14.2b).
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