(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_3) contains supplementary material, which is available to authorized users.
The right upper lobectomy is most often done via an anterior approach with a primary control of the truncus anterior (TA) and the superior root of the superior pulmonary vein (SPV) as usually done during conventional open surgery. However, an anterior dissection can be hazardous, especially in some overweight patients in whom identification of vessels is not easy. Confusing the main PA and the TA or stapling the PA with the hilum has been reported.
For these reasons, we favor a full posterior dissection of bronchovascular elements that offers ease and safety. However, some anatomical conditions, e.g., fibrosis or adherent lymph nodes, may require switching to an anterior dissection of the SPV. If necessary, the two approaches can be combined. Mastering both techniques makes it possible to face most situations.
The right upper lobectomy can be a challenging endoscopic procedure. Difficulties are from several orders. The operative field is large and the scope has to switch from the anterior to the posterior mediastinum and from the apex to the diaphragm. In addition, the following difficulties may be faced:
The major fissure is frequently fused and crossed by venous posterior branches from the superior vein.
Lymph nodes are frequently present at the level of the upper bronchus and can lead to oozing or troublesome hemorrhage during dissection.
The superior vein and the truncus anterior may be close to each other, so their dissection must be prudent.
Identifying the interlobar plane between the right upper lobe and the middle lobe can be tedious.
Finally, once the upper lobectomy has been completed, securing the middle lobe to the lower lobe is not that simple, because of the lack of global view that makes the proper positioning of the middle lobe sometimes difficult, especially when the latter is fully mobile.
3.1 Anatomical Landmarks (◘ Fig. 3.1)
Bronchus
The division of the posterior segmental artery gives access to the lobar bronchus. The latter arises from the lateral aspect of the right main bronchus and separates into three independent bronchi (B1, B2, and B3) or into an anterior bronchus (B3) and an apicoposterior trunk (B1+2) or conversely (B1 and B2+3) (◘ Fig. 3.1a). Lymph nodes are frequently encountered at the intersegmental bifurcation as well as at the bifurcation between the upper lobe bronchus and the truncus intermedius.
Fig. 3.1
Anatomical landmarks. a Bronchi and arteries, b arteries, c veins (posterior view)
Arteries
The upper lobe arterial supply arises from two main vessels: the truncus anterior which originates from the hilum and an ascending artery (Asc.A2) originating within the fissure and supplying the posterior segment (S2) (◘ Fig. 3.1b). The truncus anterior gives the apical (A1) and anterior (A3) segmental arteries which can be divided separately or as a stem. The posterior segmental branch (Asc.A2) arises from the posterior aspect of the pulmonary artery, opposite the middle lobe artery, and is controlled within the fissure. In most patients, this artery is single but the number can vary from 0 to 3 branches. The artery is sometimes obscured by the posterior branch(es) of the superior pulmonary vein (V2t) which runs in the interlobar plane. One or several lymph nodes are frequently found at this level.
Veins
The superior pulmonary vein (SPV) is the most anterior element. The position of the middle lobe vein must be verified before any division of the three segmental veins that can be done separately or, more often, as a stem. The SPV has usually three main branches: the inferior root, i.e., (1) the middle lobe vein (V4+5), (2) the central vein which receives V2 and V3 venous branches and (3) the upper root (V1), that drains segment 1 (◘ Fig. 3.1c).
3.2 Anatomical Variations and Pitfalls (◘ Fig. 3.2)
The inferior root of the upper pulmonary vein is the middle lobe artery (◘ Fig. 3.1c). It must be clearly identified before stapling the upper lobe vein (ULV) when the vein is approached from the front side. However, in overweight patients or in patients presenting with fibrotic tissues, this identification can be tricky and dangerous. During a posterior approach, there is usually no need to identify the middle lobe vein.
The upper root of the superior pulmonary vein can have a full fissural path and receive tributaries from the lower lobe (◘ Fig. 3.2a). In this case, the vein must not be controlled within the fissure but only the branches from the upper lobe must be divided.
The ascending artery to segment 2 (Asc.A2) can have a common origin with A6. Therefore, the posterior part of the fissure must not be stapled before the root of A2 has been identified and dissected on a sufficient length (◘ Fig. 3.2b).
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