Adenocarcinoma in situ
Carcinoid
<2 cm tumor
Pulmonary met
Localized bronchiectasis
Tb
Perfect location in lung
The size of the tumor affects the choice of segmentectomy versus lobectomy. (Table 5.2) Tumors >3 cm are generally better treated with a lobectomy [1].
Table 5.2
Five year survival for different size tumors in lobectomy, segmentectomy and wedge resection (Okada)
Procedure | <20 mm | 21–30 mm | >30 mm |
Lobectomy | 92.40 % | 87.40 % | 81.30 % |
Segmentectomy | 96.70 % | 84.60 % | 62.90 % |
Wedge | 85.70 % | 39.40 % | 0 % |
In cancer cases, positive nodes would be an indication for conversion to a lobectomy.
5.1.3 Comparison of Segmentectomy and Lobectomy
Shuchert (Table 5.3) reported comparable morbidity and mortality for Lobectomy and Segmentectomy [1].
Table 5.3
Experience with segmentectomy and lobectomy at University of Pittsburgh (Schuchert)
VATS segmentectomy vs. VATS lobectomy
VATS segmentectomy
VATS lobectomy
Significance
(n = 109)
(n = 127)
(p value)
Operative time (min)
125
219
0.001
Estimated blood loss (ml)
100
150
0.08
Length of stay (days)
5
6
0.18
Morbidity (%)
20.2
15.7
0.4
Mortality (%)
0
0
1
Recurrence (%)
15.6
15
1
Survival (%)
87.9
90.6
0.67
We compared our experience with left upper lobectomy versus left upper lobe tri-segmentectomy to evaluate the complication rates and the survival [3].
Table 5.4 shows that the mortality rates and the length of stay were the same [3].
Table 5.4
The mortality, conversion to thoracotomy, complication rate, and med LOS (median length of stay) for segmentectomy and lobectomy (Soukiasian, McKenna)
Factor
Segment
Lobectomy
Mortality
1 %
1 %
Convert
1 %
1 %
Complications
34 %
15 %
Med LOS
4 days
5 days
Table 5.5 shows that the incidence of air leak is the same for tri-segmectomy and upper lobectomy is the same [3].
Table 5.5
The rates of air leak, AF (atrial fibrillation), UTI (urinary tract infection), and readmission rate for segmentectomy and lobectomy (Soukiasian, McKenna)
Complication
Segmentectomy (%)
Lobectomy (%)
Air leak
7
6
AF
8
2
UTI
5
0.10
Readmit
3
0.60
Complication rates are slightly higher for tri-segmentectomy, but they were minor and, despite that, the length of stay was 1 day shorter for tri-segmentectomy (Table 5.5) [3].
Survival is the most important measure of a cancer operation. Okada (Fig. 5.1) compares the survival for different sized tumors and different operative procedures [2].
Fig. 5.1
Survival for wedge resection, segmentectomy, and lobectomy for patients with (a) <2 cm tumors, (b) 2–3 cm tumors, and (c) >3 cm tumors
5.1.4 Comparison of Open and Minimally Invasive (VATS) Segmentectomy
Leshnower compared the Emory experience with thoracotomy versus VATS for segmentectomy. Video-assisted thoracoscopic surgery segmentectomy is a safe procedure which has fewer complications and a reduced hospital stay when compared with an open segmentectomy. This approach may be the ideal oncologic procedure for patients with small lung cancers (<2 cm) and (or) limited cardiopulmonary reserve and significant comorbidities [4].
Video Assisted Thoracic Surgery (VATS) is on the increase in the management of benign and malignant processes. Large experiences have convinced the surgical community not only of the safety and possibilities of VATS surgery in early lung cancer, but of the benefits when compared to open surgery in terms of postoperative pain, length of recovery, return to activities, immune response to surgery and oncological results [5–8].
In elderly patients, VATS segmentectomy can be safely performed among elderly patients with early stage NSCLC and is associated with equivalent postoperative and long-term oncologic outcomes [9].
5.1.5 Conclusions
Anatomic segmentectomy is being performed with increasing frequency. In selected cases, segmentectomy appears to provide the same survival rates as a lobectomy, with the same morbidity and mortality and with greater preservation of pulmonary function. Compared to open procedures, a VATS segmentectomy can be performed without compromising the operation and with providing patients with all the benefits of a minimally invasive procedure. VATS segmentectomy should be in the armamentarium of a thoracic surgeon.
5.2 VATS Apical and Posterior Segmental Resections
(10)
General Thoracic Surgery, Allegheny Health Network, Pittsburgh, PA 15212, USA
- 1.
Technical Points
Anatomic apical and posterior segmental resections of the upper lobes can be relatively straight forward procedures. However, understanding the “three dimensional” upper lobe anatomy is required to accurately accomplish these resections.
When using the Video-Assisted Thoracic Surgical (VATS) approach, careful consideration of the best incisional site for the primary “intercostals access” to conduct dissection about hilar structures and to introduce endostapling device/thermo ablative/vascular fusion devices is critical.
During the course of the hilar bronchovascular dissection, the thoracic surgeon should maintain flexible strategy for addressing the order of vascular and bronchial ligation and division rather than persisting with a fixed order of handling these bronchovascular structures.
- 2.
Anatomic landmarks for posterior segmentectomy (Fig. 5.3)
Begin dissection in the fissure at the thinnest aspect of the pleura covering the interlobar pulmonary artery to minimize possible lung parenchymal injury leading to bleeding and postoperative air leak.
Extend the dissection over the pulmonary artery to completely divide the oblique fissure, thus separating the posterior segment of the upper lobe from the superior segment of the lower lobe.
Careful blunt sucker dissection about the base of the posterior segment pulmonary parenchyma will expose the trunk of the posterior segmental artery.
The bronchus to the posterior segment will be anterior and beneath the posterior segmental artery.
The posterior segmental vein will be noted anterior and slightly inferior to the posterior segmental bronchus.
- 3.
Operative procedure for Posterior Segmentectomy
A “Bi-Port” VATS approach is preferred by our team. The patient is placed in a lateral decubitus position with the ipsilateral arm held high and touching the patient’s cheek. Right sided resections accomplished with use of selective ventilation with double lumen tube. The “Bi-Port” approach combines a 3–4 cm primary operative access site in the mid axillary line through the fifth or sixth intercostal space depending on the lobar location of the pulmonary pathology. Upper lobe lesions are accordingly approached through a fifth intercostal space site. Lower lobe and middle lobe lesions are approached using a sixth intercostal access site. A 5 mm intercostal access site is established two to three interspaces below the primary operative intercostal access site in the posterior axillary line for the videoscope and subsequent tube thoracostomy tube drainage. We favor this “Bi-Port” approach to the “Uniport” approach due to our preference of videoscopic visualization from a more oblique point of view, reduction in instrument crowding during dissection, and our aversion to establishing a tube thoracostomy drainage of the chest through the operative incision (Fig. 5.4).
Fig. 5.3
Anatomic landmarks of right upper lobe posterior segment. (a) Posterior bronchus (right lateral view). (b) Posterior artery (right lateral view). (c) Relationships between arteries and veins of the posterior segment (anterior view). (d) Relationships between arteries and veins of the superior segment (right lateral view)
After inspection of the pulmonary hilum for important adenopathy and to accomplish nodal staging, attention is directed to the interlobar fissure. The thinnest area of the fissure is chosen to begin dissection within the fissure. Complete fissures are rarely noted. The most consistent location for obvious parenchymal separation and direct pulmonary arterial trunk visualization in the fissure is in its mid hilar location.
Right lung anatomy usually has this parenchymal separation will most commonly be just beyond the take of the middle lobe pulmonary artery and before the take offs of the posterior segmental artery of the upper lobe and the superior segmental artery of the lower lobe.
Fig. 5.4
Biport incision for left side procedures
When fissure is totally fused/incomplete oblique fissure could be divided via endoscopic stapler. The parenchymal division is carried superiorly to completely expose the interlobar artery and thus completely separate the lung parenchyma of the upper and lower lobes in this oblique interlobarfissure plane.
Once the interlobar pulmonary artrery is exposed, further blunt dissection is carried out along the upper aspect of the artery on the upper lobe side of the fissure to expose the posterior segmental arterial trunk. It is not uncommon to encounter lymph nodes about the base of the posterior segmental artery – also associated with the deeper posterior segmental bronchus. Blunt and sharp dissection will be required to free the tissue about posterior segmental arterial trunk (Fig. 5.5a–c).
Fig. 5.5
(a) Dividing the incomplete oblique fissure. (b) Lymph nodes about the base of the posterior segmental artery (c) Exposing the posterior segmental artery
It is common the posterior segmental vein runs over the posterior segmental artery, which makes it difficult to dissect the posterior segmental artery freely. So divide the horizontal fissure and expose the posterior segmental vein, then ligate and divide the vein before cutting off the artery is usually needed (Fig. 5.6a–c).
The endostapler with a vascular staple load or the ligasure vessel fusion device is introduced through the “Biport” access incision, brought around the posterior segmental arterial trunk to ligate and divide the vessel (Fig. 5.7a–d).
Fig. 5.6
Dividing and ligating the posterior segmental vein
Blunt and sharp dissection with scissors and harmonic scalpel is then performed about the posterior segmental bronchus. Clearance of associated lymph nodes is commonly required.
Fig. 5.7
Dividing and ligating the posterior segmental artery
The endostapler with longer length bronchial staples is introduced through the access incision and placed about the posterior segmental bronchus which is then ligated and divided (Fig. 5.8a–d).
Fig. 5.8
Dividing and ligating the posterior segmental bronchus
Fig. 5.9
The endostapler is introduced through the access incision and applied across the pulmonary parenchyma
The posterior segmental parenchyma is then elevated to anticipate the line of parenchymal resection along the base of the transected bronchovascular pedicle. The use of a non-crushing “Masher” forceps (PillingWeck, USA) applied across the proposed line of resection assists in proper alignment of the stapler across the tissue and segmental pedicle. Assessment of parenchymal thickness and “compression” of the parenchyma at the proposed staple line is also facilitated with the Masher forceps. The endostapler is then introduced through the access incision and applied across the pulmonary parenchyma (Fig. 5.9a).
Fig. 5.10
Inspecting the specimen on the operative field
The masher is then reapplied across the proposed line of parenchymal resection to further insure the complete resection of the base of the posterior segment along with the lung parenchyma. Once passed this bronchovascular base of the posterior segment, the endostapler resection proceeds with care to insure a proper parenchymal margin of resection of the lung lesion (Fig. 5.9b–d).
The specimen is retrieved in a protective bag and inspected on the operative field. Adequate surgical margins are assured (Fig. 5.10).
5.3 VATS Resection of the Right Lower Lobe Superior Segment
(11)
Division of Thoracic Surgery, Boston University, School of Medicine, 88 East Newton Street, Robinson Building R-402, Boston, MA 20118, USA
5.3.1 Technical Point
The technique for a VATS resection of the right lower lobe superior segment is described in this chapter. The patient is in a lateral decubitus position, with the bed flexed at the hips. The surgeon will stand in front of the patient and one assistant will stand posterior to the patient. A monitor is placed at the head of the bed on either side, for the surgeon and assistant respectively. We use the same 4-port technique for anatomical resections of the lung as previously described by McKenna [18] (Fig. 5.11). These are as follows:
Fig. 5.11
Standard port placement. (a) Anterior incision. (b) Camera incision. (c) Access incision. (d) Posterior incision
- 1.
A 1 cm incision is made as far anteriorly and inferiorly as possible (usually the sixth intercostal space in the mid-clavicular line).
- 2.
A 1 cm incision is made in the eighth intercostal space in the mid-axillary line for the cameral port. Generally we use a 10 mm, 30-degree camera.
- 3.
A 4 cm access incision is made starting at the anterior border of the latissimus dorsi muscle and extends anteriorly. The incision is made one interspace below the superior pulmonary vein. We use a soft tissue retractor (Alexis®, Applied Medical, Rancho Santa Margarita, CA 92688), which is especially useful in obese patients to help with visualization and placement of instruments.
- 4.
A 1 cm incision is made posterior and inferior to the tip of the scapula.
5.3.2 Instrumentation
We do not use standard open instruments, as these will be difficult to open and close through the 1 cm port incisions with the hinge-point usually close to the chest wall. We prefer VATS scissors, right angles, and lung graspers such as those produced by Thoramet® (Rutherford, NJ, 07070, USA) or Scanlan International Inc.® (Saint Paul, Minnesota, 55107, USA) (Fig. 5.12). The exception to this will be the use of standard ring forceps (to grab and retract the lung), peanut dissectors, and electrocautery (with an extended insulated flat tip). We will occasionally use a harmonic scalpel, especially when adhesions are present, or in obese or tall patients where reach may be an issue with standard electrocautery.
Fig. 5.12
(a) Thoramet VATS instruments. (b) Landreneau masher grasping forceps (Pilling Surgical®, Horsham, PA, 19044, USA)
5.3.3 Operative Steps
Anatomical landmarks are shown in Fig. 5.13 to be better understanding the procedures.
Fig. 5.13
Anatomical landmarks for right lower lobe superior segment
- 1.
The inferior pulmonary ligament is taken down using electrocautery or harmonic scalpel dissection (Fig. 5.14). Level 8 and 9 lymph nodes are removed as this is done. The inferior pulmonary vein and its superior segmental branch are identified (Fig. 5.15).
Fig. 5.14
Division of the right inferior pulmonary ligament (IPL)
Fig. 5.15
(a) Inferior pulmonary vein (IPV) and superior segmental vein (SSV). (b) Isolation of the superior segmental branch
- 2.
The dissection then continues superiorly, opening the mediastinal pleura above the inferior pulmonary vein. This allows identification and removal of the subcarinal lymph nodes. The right main bronchus is then identified. As the lung is retracted forward, peanut dissection on the bronchus is performed to expose the bifurcation between the bronchus intermedius and right upper lobe bronchi. The level 11 node at this bifurcation can be removed.
- 3.
The arterial dissection and division is then performed. If the fissure is complete this will be easily identified and dissected at this point. If the fissure is incomplete (Fig. 5.16), attention is turned anteriorly to the fissure between the middle lobe and lower lobe bronchus. The lower pulmonary artery is usually easily identified in this area. Once the artery is identified dissection along the anterior aspect of the artery is performed from an inferior to superior direction, so exposing the arterial branches to the middle lobe and the lower lobes. The superior segmental artery is then encircled and divided using a vascular load endostapler (Fig. 5.17). Our preference is to use the curve-tip staple loads for vascular structures. The superior segmental artery is usually more easily divided from the anterior incision.
Fig. 5.16
Incomplete fissure (F) has been developed with stapler exposing PA
Fig. 5.17
Superior segmental artery (arrow). (a) Dissection and (b) Ligation with curve-tip vascular stapler
- 4.
The superior segmental branch of the inferior pulmonary vein is then divided in a similar fashion to the artery. This is usually divided from the anterior incision (Fig. 5.18).
Fig. 5.18
Division of the superior segmental vein (SSV) branch of the inferior pulmonary vein (IPV)
- 5.
The superior segmental bronchus is usually easily exposed at this point. This is then encircled and divided. Our preference is to use the curve-tip purple-load stapler (Fig. 5.19).
Fig. 5.19
Superior segmental bronchus. (a) Isolation and (b) Division. (SSV divided superior segmental vein)
- 6.
A standard (non-curved-tip) stapler is then used to separate the superior segment from the basilar segments (Fig. 5.20). Upwards traction on the divided superior segmental stump will facilitate this (Fig. 5.21).
Fig. 5.20
Lung clamp is applied to delineate staple line for division of superior segment from basilar segments
Fig. 5.21
Stapling and resection of the right lower lobe superior segment
- 7.
The specimen is placed into an endo-bag and removed from the access incision.
- 8.
Usually one chest-tube is used. We do not use an epidural catheter. An intercostal block and extrapleural catheter (with continuous lidocaine infusion) are used for post-operative analgesia [19].
5.4 Left Upper Lobe: Trisegments
(12)
Division of Thoracic Surgery, University of British Columbia, Vancouver, BC, 98104, Canada
(13)
Division of Thoracic Surgery, Swedish Medical Center and Cancer Institute, 1101 Madison Street, Suite 900, Seattle, WA 98104, USA
5.4.1 Technical Tips
VATS left upper lobe trisegmentectomy, also known lingula-sparing left upper lobectomy, is a potentially challenging thoracoscopic procedure. It requires a thorough understanding of the relational anatomy, particularly the juxtaposition of the anterior and apicoposterior segments of the pulmonary artery, the bronchus of the upper lobe proper and the pulmonary veins [20–27]. Although we describe our preferred VATS approach, we use the same approach when conducting a robotic trisegmentectomy. The following key points should be kept in mind:
The left upper lobe has more direct branches originating off the main pulmonary artery than any other lobe, which creates more potential for injury during dissection of these vessels.
The surgeon must be prepared to approach the relevant arterial anatomy from a variety of different ports and potentially with several methods to secure the vessels including clips, energy sealing and endo-stapling.
The upper lobe bronchus can be approached from posterior after division of the apicoposterior artery branches or from anterior after division of the upper lobe vein branches
Identification of the most proximal lingular branch of the pulmonary artery is required before parenchymal division to avoid division of an aberrant lingular artery arising proximally and running deep to the pulmonary vein.
5.4.2 Anatomical Landmarks (Fig. 5.22a–d)
Veins: The left superior pulmonary vein is the most anterior structure in the left hilum, lying just inferior to the first upper lobe arterial branches and just anterior to the left upper lobe bronchus. The first division of this vein is into the apical branch, superiorly, which drains the anterior and apicoposterior segments, and the lingular branch, inferiorly.
Fig. 5.22
Anatomical landmarks for left upper lober trisegments
Arteries: The anterior trunks of the left pulmonary artery can generally be found at, or just superior to, the upper border of the left superior pulmonary vein. These branches may be short, wide and multiple. The upper division of the lobe is also supplied by a variable number of apicoposterior branches. These are most easily identified by a posterior approach to the hilum at the level of the fissure. When identified, these are preferentially divided first to improve access to the truncal branch, which can be divided from the either a posterior or anterior approach.
The lingular arteries, which are preserved during trisegmentectomy, are most often found distally and superficially within the anterior aspect of the fissure. However, an important anatomic variant to be aware of is a proximal origin of the lingular artery, arising near the anterior branches and running deep to the superior pulmonary vein. This anomalous branch is at risk for injury during dissection of the vein or may be inappropriately divided, eliminating the possibility of sparing the lingula. Thorough review of the pre-operative CT scan can help to avoid such complications.
Bronchus: The left upper lobe bronchus is largely surrounded by vascular structures. The superior pulmonary vein overlies the bronchus, while the anterior and apicoposterior arterial branches are adjacent to the superior and posterior surfaces of the bronchus, respectively. These structures, with the possible exception of the apicoposterior arterial branches, must be divided prior to fully dissecting the branches of the bronchus. The first major division of the upper lobe bronchus is into the upper division superiorly and the lingular division inferiorly.
5.4.3 Operating Procedure
- 1.
The patient positioned in right lateral decubitus with the bed flexed to ensure the hip is level with the chest wall. Ports are placed as follows: (A) 10 mm in the seventh intercostal space, posterior axillary line; (B) 5 or 10 mm in the line of the scapular tip, at the level of the dome of diaphragm, which approximates the ninth interspace, for the 5 or 10 mm, 30° camera; (C) 10 mm placed inferior and slightly posterior to the scapula, lining up one rib space below the tip of the superior segment; and, (D) 10 mm in the posterior axillary line in the fourth intercostal space, directed at the superior pulmonary vein (Fig. 5.23). It is not necessary to create a large working incision, as the entire procedure can usually be conducted through these small ports. The specimen is extracted by enlarging port B to 5 cm.
Fig. 5.23
Positioning and port placement
- 2.
The lower lobe is pushed to the apex of the thoracic cavity with ring forceps and held via port D. The inferior pulmonary ligament is divided using the L hook to the inferior base of the hilum and the station 9 lymph node packet removed (Fig. 5.24).
Fig. 5.24
Division of the inferior pulmonary ligament (white arrow), exposing station 9 nodes (black arrow)
- 3.
The lower lobe is then retracted anteriorly to expose the pleural reflection and aorta. The pleura is then divided from the inferior vein to the top of the pulmonary hilum with the L hook to expose the main bronchus, pulmonary artery and vagus nerve (Figs. 5.25 and 5.26).
Fig. 5.25
Division of the posterior hilar pleura (black arrow) to expose the pulmonary artery. The inferior pulmonary vein is visible (white arrow)
Fig. 5.26
The pulmonary artery (black arrow) is visible posteriorly once the pleura is completely divided
- 4.
Using cotton tipped dissectors and the L hook, the tissue between the superior aspect of the inferior vein and the inferior aspect of the main bronchus is opened to expose station 7. Commonly, a bronchial artery can be identified as station 7 is exposed (Fig. 5.27). All lymph nodes in the area are then removed and the area packed with hemostatic, absorbable gauze.
Fig. 5.27
Exposure of station 7 with visualization of a bronchial artery (black arrow) and hemostatic gauze (white arrow) placed previously during mediastinoscopy
Tips When performing mediastinoscopy at the same stage of a planned lung resection, leave hemostatic, absorbable gauze in the location of the nodes that were biopsied, especially 4L and 7. At the time of subsequent thoracoscopic mediastinal lymph node dissection, this will serve as a landmark to ensure you have identified the correct location of these nodal stations.
- 5.
Station 4L can be accessed just superior to the edge of the bronchus and the posterior aspect of the pulmonary artery. If a mediastinoscopy is performed pre-operatively with biopsy of station 4L, this remaining node dissection is greatly facilitated (Fig. 5.28).
Fig. 5.28
Exposure of station 4L (circle) with visualization of hemostatic gauze placed previously during mediastinoscopy
Tips Performing mediastinal lymph node sampling at the beginning of the operation allows time for pathologic analysis and facilitates dissection of vascular structures.
- 6.
The lung is then retracted posteriorly and inferiorly to expose the aortopulmonary window. The vagus is visualized passing vertically over the arch of the aorta, providing the posterior landmark for the recurrent laryngeal nerve, which must be avoided. Similarly, the phrenic nerve is identified anteriorly. Dissecting between these structures stations 5 and 6 nodal stations are exposed and removed (Fig. 5.29).
Fig. 5.29
Exposure of the AP window to expose stations 5 (white circle) and 6 black (circle). The phrenic nerve is preserved (white arrow)
Removing these lymph nodes at this point completes the mediastinal staging and also facilitates later exposure of the anterior arterial branches.
- 7.
Retracting the upper lobe anteriorly and away from the hilum, the posterior aspect of pulmonary artery is identified. Gentle blunt dissection and careful use of the L hook will expose the main artery and its apicoposterior and superior segmental branches (Fig. 5.30). At times, a small portion of the fissure may require division to access these vessels.
Fig. 5.30
Partial division of the fissure may be necessary to expose the apicoposterior (white arrows) lingular (black arrow) and superior segment (arrowhead) branches of the pulmonary artery, visualized posteriorly
- 8.
The apicoposterior branches to the upper lobe are then divided. Care is taken to identify and preserve the superior segmental artery of the lower lobe, which arises in close proximity to the posterior upper lobe branches (Fig. 5.31).
Fig. 5.31
After division of an apicoposterior branch, a lingular branch (black arrow), superior segment branch (white arrow) and an additional apicoposterior branch (arrowhead) are visible
- 9.
After division of the arterial branches, the next steps depend on the completeness of the fissure and/or ability to identify the interlobar pulmonary artery:
- A.
If the fissure is complete, it is opened with the L hook, though recently, we have found bipolar energy shears to be helpful here. The dissection is carried onward until the lingular branches are identified and confirmed by gentle forward traction on the lingular segment.
- B.
If the fissure is partially complete but the pulmonary artery is visible, the pleura will be opened atop of the artery. Once in the correct plane, the artery will be pushed away from the lung creating a tunnel toward the superior aspect of the fissure (Fig. 5.32). The fissure can then be completed with a stapler to expose the interlobar artery and the origin of the most proximal lingular branch (Fig. 5.33).
Fig. 5.32
Creation of a tunnel over the interlobar pulmonary artery (black arrow) in order to divide an incomplete fissure
Fig. 5.33
Division of an incomplete fissure using a stapler
- C.
If the fissure is incomplete and the interlobar artery not visible, the anterior hilar dissection is begun by dividing the pleural reflection from the inferior vein to the area of the superior hilar dissection. The superior pulmonary vein is visualized and defined through a combination of gentle blunt dissection with the suction and sharp dissection with cautery to expose the borders of the vein and its division into the apical branches superiorly and the lingular branches inferiorly. Removal of the lymph nodes between the superior and inferior veins anteriorly often opens up the space needed to identify the interlobar pulmonary artery and the distal lingular branch. From this space, completion of the fissure can be performed if necessary to identify these branches.
- A.
- 10.
Gentle traction on the lingula helps to delineate the lingular vein(s) clearly to preserve them (Fig. 5.34). The vascular stapler then divides the apical vein branch(es), further exposing the anterior arterial branches and the bronchus.
Fig. 5.34
Superior (black arrows) and inferior/lingular (white arrow) divisions of the superior pulmonary vein
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