(1)
IMM, Curie-Montsouris Thorax Institute, Paris, France
Most steps are similar to a left basilar segmentectomy (see page 134), but arterial and venous dissection has to be conducted with care. The most difficult and challenging part of the procedure is the demarcation and stapling of the intersegmental plane. This may require preoperative planning of segmental bronchi or intraoperative dye marking.
13.1 Anatomical Landmarks (◘ Fig. 13.1)
Fig. 13.1
Anatomical landmarks; a bronchus B9+10(front view), b arteries A9+10 (front view), c veins
Bronchus
The basilar bronchial trunk usually separates in two branches, B7+8 and B9+10, that run posterior to the segmental arteries (◘ Fig. 13.1a).
Arteries
The basilar arterial trunk branches in most cases in two arteries: A7+8 and A9+10. But all the arteries to the lower lobe must be clearly visualized in order to avoid misidentification (◘ Fig. 13.1b).
Vein
The inferior basal vein (IBV), which is the lower root of the IPV, does not always represent the venous drainage of segments 9 and 10. One of its branches can drain S8. If with any doubt, only the lowermost branch of the IBV must be divided (◘ Fig. 13.1c). Another solution that is preferable is controlling the vein inside the parenchyma, once the segmental bronchus has been divided.
13.2 Technique
The most difficult part of the procedure is determining the adequate plane between S9+10 and S7+8 and S6. With respect to the intersegmental plane between S6 and S9+10, two methods can be used.
Stapling the parenchyma from its diaphragmatic aspect to the apex and progressively curving the direction to the rear in order to respect S6 (◘ Fig. 13.2a)
Creating a tunnel between S6 and S9+10 (◘ Fig. 13.2b), as described below, to separate S6 from S9+10 and dividing the plane between S9+10 and S7+8 in a second stage
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
