(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_5) contains supplementary material, which is available to authorized users.
Difficulties of a right lower lobectomy mainly depend on the completeness of the major fissure. If the fissure is open, this lobectomy can be straightforward, with an easy dissection and control of the arterial trunk. If the fissure is fused and/or thick, dissection of the artery can be tedious. In these cases, it can be advisable to start the procedure by opening the anterior part of the fissure and approaching the arteries from the front.
5.1 Anatomical Landmarks (◘ Fig. 5.1)
Bronchus
The lower bronchus is the termination of the bronchus intermedius and is the latest element to be divided. It bifurcates in two main branches: the superior segmental bronchus and the basal bronchi that are usually four in number. The superior segmental bronchus B6 originates from the posterior surface of the truncus intermedius opposite to the middle lobe bronchus. Stapling B6 should not be done after having clearly visualized the origin of the middle lobe bronchus.
Fig. 5.1
Anatomical landmarks. a Lower lobe bronchus (lateral view), b arterial supply to the lower lobe (lateral view), and c inferior pulmonary vein (posterior view)
Arteries
The arteries to the lower lobe are approached at the confluence of the major and minor fissures. There are two main arteries: the basilar trunk which sends two to four branches to the basal segments and the superior segmental branch (A6), which can be single or double. The basilar trunk and the superior artery A6 can sometimes be stapled together, but they must usually be divided separately.
Vein
The inferior pulmonary vein is found by freeing the inferior pulmonary ligament.
5.2 Anatomical Variations and Pitfalls (◘ Fig. 5.2)
The anatomy is not always as clear as shown in ◘ Fig. 5.2a with a classical X-shape arterial pattern.
The middle lobe bronchus can arise from the lower part of the truncus intermedius or from B8. Stapling should not be done after having clearly visualized the origin of the middle lobe bronchus. When in doubt, a reventilation test must be performed before firing.
There are many variations in the origin and direction of arteries that require an extensive dissection of all arterial branches:
The posterior segmental artery to the upper lobe (Ascending A2) may arise from A6 (◘ Fig. 5.2b).
The origin of the middle lobe artery can be very close to the origin of A6 (◘ Fig. 5.2c).
An A4 artery to the middle lobe can arise from the basal trunk (◘ Fig. 5.2d) or even from A8 (◘ Fig. 5.2e).
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