Illustrated Anatomical Segmentectomy for Lung Cancer

Illustrated Anatomical Segmentectomy for Lung Cancer (Paperback)

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More and more SLRs are now performed by a thoracoscopic, a video-assisted or a robotically-assisted approach. Although surgeons are performing pulmonary segmentectomies for years, they need a better understanding of anatomy when using a closed chest approach, because vision is more limited and they cannot stretch and expose the parenchyma and broncho-vascular elements. In this article, we will describe most of the significant anatomical variations we have encountered during a consecutive series of full thoracoscopic segmentectomies, either at surgery or preoperatively by studying the 3-dimensional 3D modelisation.

In other words, there are only variations.

Illustrated Anatomical Segmentectomy for Lung Cancer

Although surgeons are performing pulmonary segmentectomies for years, they need a better understanding of anatomy when using a closed chest approach, because the vision is more limited and they cannot stretch and expose the parenchyma and broncho-vascular elements as they used to do with hands inside the chest cavity.

Throughout this article, we will describe most of the anatomical variations we have encountered during a consecutive series of full thoracoscopic segmentectomies, either at surgery—with systematic shooting of anatomical features—or preoperatively by studying the 3-dimensional 3D modelisation 1 , 2. This underlines the need for a thorough preparation of these procedures with use of 3D reconstructions, whose benefit has been stressed by many authors 3 - 9.

By reading this paper and looking at the figures, those of the younger surgeons or those just embarking in this surgery will realize that even segmentectomies taken to be straightforward, e. Most data reported in this paper have been borrowed to this atlas. In this article, we will describe only significant anatomical features of most common sublobar resections SLR and only those which have surgical consequences. As it enters the parenchyma, the upper lobe bronchus triplicates into three segmental bronchi: They arise from the truncus anterior TA and from the PA in the fissure, also named arterial truncus intermedius ascending arteries.

The TA duplicates into two branches: The posterior segment is supplied by the ascending A 2 Asc.

A 2 that originates within the fissure from the posterior aspect of the pulmonary artery, opposite the middle lobe artery. It ascends to S 2 and lies posteriorly to the lobar bronchus. In most patients, there is only one artery, while there are none or two in some patients. When there are two ascending A 2 , the most anterior one must not be mistaken for an anterior ascending branch A 3 which supplies the anterior segment Figure 2. Thoracoscopic dissection demonstrating two ascending arteries within the fissure. A 3 ; B as dissection is continued, it becomes clear that this artery is for S 3.

A 2 s, stump of Asc. A 2 ; B, upper lobe bronchus. It usually runs along the bronchus.

When present, the recurrent A 2 can be at risk during dissection of B 1 or B 2. In most cases, the segmental veins of the upper lobe are the two upper tributaries of the upper lobe vein: I V 1 is the uppermost branch and is found in the hilum of the upper lobe. It gives a large posterior branch for V 2 and small tributaries for V 3.

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A small vein V 2t draining S 2 frequently cross the posterior aspect of the ascending A 2 Figure 3 and must be severed before dissecting this artery V 2t crossing the posterior aspect of Asc. A 3D reconstruction; B thoracoscopic view. B 3 is the anterior branch of the upper bronchus. Lymph nodes are frequently found at the origin of B 3.

Even for benign conditions, removal of these nodes is required for an optimal disclosure of B 3 root. A 3 is the lowermost branch of the TA. An ascending A 3 is present in some patients, raising close to the ascending A 2 and recognizable by its anterior direction. In some cases, there are two ascending arteries in the fissure. The posterior one Asc. A 2 for segment 2 and the anterior one Asc. A 3 for segment 3 Figure 4.

The latter must not be confused with a middle lobe artery which must always be identified before any ligation or clipping of an ascending artery. There are two types of veins: I a large V3 that is the lowermost branch of the central vein and II 1 or 2 small ascending veins branching from the central vein that are easily recognized as they come directly from the anterior segment.

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The superior segmental bronchus originates opposite or slightly above the middle lobe bronchus. It lies posteriorly to the segmental artery and separates into two main branches, rarely into 3. B 6 is single in most patients but can seldom be double. The superior segment of the right lower lobe is supplied by an artery A 6 which originates within the fissure at the same level than the basal trunk. It is usually single, but can be double Figure 5 and even triple.

In some patients, the superior segmental artery originates from the ascending artery of the upper lobe A 2 , or from the basal trunk 12 Figure 6. The vein to the superior segment is the uppermost and smaller segmental tributary V 6 of the inferior pulmonary vein IPV. The origin of the common basal trunk is found in the fissure 1 to 2 cm beyond the origin of B 6. The basilar bronchial trunk usually separates in three branches: Usual pattern of right basilar bronchi, with a common trunk for B 9 and B The arterial supply of the basal segments is the termination of the pulmonary artery after the birth of A 6.

It can also separate into 3 to 4 segmental branches. Two different pattern of the arteries to the basilar segments. A middle lobe artery can arise from the basilar trunk, sometimes at a low level Figure 9. Example of a middle lobe artery arising from the basilar arterial trunk and that could be damaged if dissection of the basilar arteries is insufficient. In some patients, there is only one common venous trunk or, on the contrary, a multiramified vein.

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In most cases, the two basilar veins receive tributaries from adjacent segments. The superior vein V 6 must be clearly identified before stapling these two trunks. The middle lobe vein can join the IPV Figure Conversely, the basilar vein can drain into the middle lobe vein. Basilar vein and middle lobe vein draining together in the inferior pulmonary vein.

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As, stump of the basilar arterial trunk; Bas. Bs, stump of the basilar bronchial trunk; IBVs, stump of the inferior basal vein. These three segmental bronchi have a short course that can make their identification and dissection difficult. However, when dissected in the fissure, the lingular bronchus is usually not visible if the lingular artery has not been divided.

Only its origin is usually seen. There are two different supplies to the let upper lobe: The TA is often broad and short. The posterior arteries originate in the fissure and distribute themselves over the curve of the pulmonary artery Figure Their number varies from 1 to 5, but most often from 2 to 3. Multiple arterial stumps arrowheads after control of all arteries to segments 1, 2 and 3 of the left upper lobe. Dissecting around the bronchus should be done smoothly.

A 3D modelisation; B thoracoscopic view after division of the bronchial trunk B The superior pulmonary vein has usually three major tributaries Figure 13A. The middle branch V 3 drains S 3 and the lowermost branch drains the lingula. It can be preferable to preserve the inferior branch of V 3. In some cases, it is almost impossible to determine if the adjacent vein to the lingular one comes from the lingula or from S 3. It seems prudent to preserve this vein, especially if the lingular vein is small.

The left superior pulmonary vein.

Nomori Hiroaki, Okada Morihito. Illustrated Anatomical Segmentectomy for Lung Cancer

The lingular bronchus originates from the bifurcation of the upper lobe bronchus and has a short course before it enters the parenchyma. In rare cases, the lingular bronchus can rise from the basilar bronchial trunk. The main supply to the lingula comes from the lingular trunk, which is the most anterior branch of the posterior segmental arteries. It originates from the anterior aspect of the pulmonary artery within the fissure and splits into two segmental branches.

Its presence should be suspected when the usual lingular artery is tiny or absent. However, having 2 of these arteries with a normal diameter is not unusual. Common trunk between the lingular arteries and A 3. An artery to the basilar trunk or to A 8 can rise from A 4. This underlines the need for an extensive dissection of the lingular artery.

Acknowledgements

If this variation is encountered, the branches of the lingular artery must be controlled separately. The lingular vein is the lowermost tributary of the superior pulmonary vein. However, in some patients, there are multiple radiating venous branches. In these cases, it is safer to divide only the lowermost branch. Once the lingula will become mobile thanks to the arterial and bronchial division, the venous drainage will become more apparent. A lingular vein can drain into the IPV Figure Venous drainage of the lingula into the inferior pulmonary vein arrow.

IPV, inferior pulmonary vein. While wedge resection is a simple procedure, it has a higher risk of local recurrence of cancer than a lobectomy. On the other hand, segmentectomy is a well known curative surgery for small lung cancers. However, it is difficult to perform accurately because of its anatomical complexity, which makes surgeons hesitant to use it. To better illustrate an accurate anatomical segmentectomy, the text shows details of anatomy during segmentectomy.

This can involve up to 25 patterns, each of which is shown in roughly 10 illustrations.

This worthy objective is achieved with a high level of detail and accuracy by the authors. The book is written for clinicians at all levels involved in the diagnosis and treatment of patients with lung cancer. The stylized illustrations are descriptive and clear. This is an excellent resource for the field of lung cancer and thoracic surgery. Part I General Statement. Chapter 1 Nomenclature of Segments. Chapter 2 General Knock of Segmentectomy.

Chapter 3 Segmentectomy of the Right Upper Lobe.

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