Surgical technique for minimally invasive segmentectomies of the right lung: anatomic rationale for a posterior approach

Introduction

Segmentectomies have emerged as an important technique for the treatment of early-stage lung cancer and lung cancer in otherwise fragile or physiologically compromised patients. However, minimally invasive segmentectomies remain complex procedures that in many cases may be more challenging than lobectomies because of complex anatomical relationships between delicate bronchovascular structures (1,2). Surgical approaches, thoracoscopic (multiport, uniportal) and robotic, have not been standardized and continue to evolve.

Most surgical approaches involve an anterior approach and either some dissection within the fissures to identify the pulmonary artery and its branches (3) or the division of fissures from the front to the back just to reach the target segment’s bronchovascular structures (4-8). This approach may work well for segments whose hila are readily accessible anteriorly, such as segments S3, S7, and S8. However, the hila of other segments (specifically S2, S6, S10, and often S1) are located posteriorly and access is not straightforward (4-8). In addition, more extensive dissection and division of the fissures may potentiate air leaks, and may increase technical difficulty in case further resections are required in the future. As a result, a posterior approach may be particularly well suited for cases with dense fissures.

This paper describes a posterior operative approach to segments S1,2,6,10; it presents key technical points, and adds some nuances and reflections borne out of the author’s experience. The guiding principles underlying this approach include direct access to bronchovascular structures, targeted dissection with minimal disruption of tissue planes, avoidance of dissection within fissures, and sufficient versatility to adapt resections to unexpected intraoperative findings. These principles aim to simplify the surgical procedure, minimize surgical tissue trauma, minimize air leaks, and preserve tissue planes in case further resections are required in the future (2,4). This article is presented in accordance with the SUPER reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0011/rc).

Preoperative preparations and requirements

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Verbal informed consent was obtained from the patients for the publication of this study, accompanying images, and the videos. The patients’ identities have been fully anonymized, and no personally identifiable information is disclosed in this study.

Posterior bronchovascular anatomy

Figures 1,2 illustrate the general anatomy of the right lung hilum and bronchovascular structures relevant to segments S1, S2, S6, and S10. S2, S6, and S10 and their respective hila are located posteriorly, and from an anterior viewing position, they are hidden by the fissures as well as intervening bronchovascular structures that must be preserved (9-12). However, as shown in figure 2, from a posterior viewing position, these segmental hilar structures are essentially subpleural and directly accessible. S1 is somewhat of an exception, as it is located at the apex of the operative field and as such may be accessed from the front or the back, each approach having its advantages and drawbacks (3,13,14). These will be considered specifically in a separate section devoted to S1.

Figure 1 Segments S1, S2, S6, and S10 of the right lung may be resected using a posterior approach. Access to the bronchovascular structures at the root of the segmental hila may be more direct than when using a more conventional anterior approach. S, segment.

Figure 2 The hila of segments S1, S2, S6, and S10 are located posteriorly. The corresponding bronchovascular structures are illustrated from a posterior view. A posterior approach may thus allow a direct approach to these structures while minimizing dissection and disruption of tissue planes. A, artery; B, bronchus; IPV, inferior pulmonary vein; RMB, right mainstem bronchus; S, segment; V, vein.

Camera and trocar positioning

The patient is under general anesthesia and one-lung ventilation using a double lumen endotracheal tube. The patient is positioned in a lateral decubitus position and the table is flexed in order to widen intercostal spaces, which improves access and freedom of movement of the instruments. Camera and trocar positioning are generic to all the posterior approaches described herein. Figure 3 illustrates camera and trocar positioning for a posterior approach. Conventional video-assisted thoracic surgery (VATS) approaches usually utilize a rigid 30 degree scope positioned inferiorly and anteriorly to the border of the latissimus dorsi. Although it is possible to view the posterior aspect of the lung hilum from this point, positioning the camera somewhat posterior to the border of the latissimus dorsi may help with optimal visualization of the posterior hilum (9,10).

Figure 3 A minimally invasive posterior approach for S1, S2, S6, and S10 segmentectomies uses the following operative port positions: the camera is positioned in the 7th intercostal space, somewhat behind the border of the latissimus dorsi; the surgeon uses ports in the 3d and 6th intercostal spaces posteriorly; a port located anteriorly in the 6th intercostal space is used by the assistant mainly for retraction. Reused with permission from AME Publishing Company (15). S, segment.

In conventional VATS approaches, the main working incision is positioned below the axilla, usually in the third intercostal space (4). However, the axilla and arm impose a limit on how high this incision can be positioned, as well as on the surgeon’s range of motion. In contradistinction, a posterior approach utilizes a trocar which can be positioned quite high behind the scapula, with very little anatomic restriction, and potentially facilitating access to the apex. The main operative trocar is positioned posteriorly, two or three intercostal spaces below, and is used for most of the dissection and stapling (9-12). Proper positioning of this trocar is key in order to obtain an optimal working angle: too high will result in tangential alignment and inadequate triangulation of operating instruments; too low may result in limitation of the range of motion and fulcrum effects at the intercostal space potentially injuring intercostal tissues and the intercostal nerve (Figure 3) (15). A 4th and final port is positioned inferiorly and anteriorly, and is used mainly for retraction by the assistant (9-12,15).

Retraction

The objective of retraction is to bring relevant bronchovascular structures into full view of the camera and make them directly accessible to the operating instruments. Proper retraction requires full mobilization of the lung, which includes the division of any adhesions as well as complete division of the inferior pulmonary ligament. The lung is then retracted anteriorly, and, very importantly, rotated counterclockwise, as will be illustrated in Videos 1-4 (14). To allow for a successful posterior approach, retraction needs to allow access to the three following anatomic landmarks/spaces:

• The upper border of the superior lobe bronchus and apex of the hilum.
• The bronchial bifurcation (lesser carina).
• The space between the S6 segmental vein and common basal veins.

Successful retraction is active and purposeful, and will require some time and effort: optimal exposure will ensure a smooth procedure, whereas suboptimal exposure will often result in a procedure that may be tedious and frustrating (14). In some patients the posterior hilar structures are initially masked by the parenchyma that needs to be mobilized off the hilum to reveal the bronchi.

Step-by-step description

The following sections consider specific segmentectomies individually. Each segmentectomy is conceptualized in terms of a dissection space containing relevant structures. Parenchymal division is guided by named anatomic landmarks and generally follows bronchovascular dissection. Additional measures to outline intersegmental planes (differential insufflation, indocyanine green) may be helpful but are not described in detail here. All procedures were performed by the author (G.R.) in a tertiary care hospital (Hôpital Maisonneuve-Rosemont, Montreal, Qc, Canada). Standard cross-sectional imaging (rather than 3D reconstructions) is used throughout to illustrate the surgical anatomy, as it is practical and readily available to all surgical teams.

All resected specimens are assessed by frozen section to confirm adequate margins (at least 2 cm or the tumor diameter). Peribronchial lymph nodes, including segmental nodes, are systematically dissected; frozen section is used to confirm the absence of lymph node metastases. The posterior approach may possibly facilitate segmental lymph node dissection, as the access to the bronchi using this technique is felt by the author to be easier and more direct. However, there is no difference with other approaches as to mediastinal lymph node dissection.

S2 segmentectomy (Video 1)

The dissection space for S2 segmentectomy consists of an inverted triangle delineated by the upper lobe bronchus, bronchus intermedius and the parenchymal border (Figures 2,4). This space is cleared of lymphatic tissue to access the posterior segmental artery A2 beneath the parenchyma (4,15).

Figure 4 The posterior surgical approach for segmentectomies S2, S6, S10, and S1. A schematic illustration of segmental anatomy is provided, as well as key intraoperative views and corresponding cross-sectional anatomy as seen on preoperative imaging. (A) The limits of the S2 segment and associated bronchovascular structures are illustrated (segmental bronchus B2; segmental artery A2; segmental vein V2). V2 generally separates into 3 subsegmental branches designated V2a, b, and c, respectively. In addition, there is often a recurrent A2 artery (asterisk) originating from the apical segment artery. (B) The dissection space for S2 segmentectomy is conceptualized as an inverted triangle, outlined by the upper lobe bronchus (B2), the bronchus intermedius, and the lung parenchyma. The minor carina forms the apex of this triangle, while the parenchyma forms the base. The segmental artery (A2) and vein (V2) will be found coursing through this space. A, artery; B, bronchus; S, segment; V, vein.

The A2 artery may have an individual origin from the interlobar artery but a frequent variant is a common trunk with the superior segment artery A6 which can complicate dissection (1). One should be wary of this variant during preoperative planning as well as during the course of the operation. Video 1 illustrates this variant. Once the posterior segment artery is identified, dissection is carried forward along the artery, beneath the fissure. This will allow one to divide the posterior aspect of the fissure while keeping the anvil of the stapler above the artery. There are two caveats to consider when positioning the stapler: (I) although it is possible to divide the posterior aspect of the fissure before identification of the artery, this may result in inadvertent trauma to the artery or the staple line deploying in close proximity to the artery making subsequent dissection tedious; (II) a feature specific to the posterior approach is that V2 courses just deep to the artery; it is important to avoid encroaching on the vein when positioning the stapler; this issue is considered further in the section “Tips and pearls” (12,15).

After the artery is uncovered by dividing the fissure, it is readily dissected and divided. Division of the artery will allow access to the segmental bronchus (12,15). The parenchyma is retracted upward (toward 12 o’clock) and gradually teased off the upper lobe bronchus as the dissection proceeds distally. Gradually, the origin of B2 will be revealed. The V2 segmental vein typically courses in the angle between B2 and B3, obscuring B3 and then disappearing behind B2 (1,14). When isolating B2, one must be wary not only of the V2 vein that courses just behind, but also of the presence of a potential recurrent artery coming around the apex toward S2, deep to the field of view (Figures 4,5) (1).

Figure 5 During S2 segmentectomy, dividing the segmental artery A2 and bronchus B2 will fully reveal the segmental vein V2. Although somewhat controversial, V2 may be dissected and divided, or incorporated into the intersegmental staple line. A, artery; S, segment; V, vein.

Dividing the bronchus will allow access to the segmental vein V2 and its branches. The management of the vein and subsegmental venous branches is controversial. The author divides the segmental vein, but it is also possible to include the vein in the parenchymal staple line, and some have also advocated preserving subsegmental branches V2a and V2c to insure the preservation of venous drainage (Figure 4) (15). However, the presence of collateral pulmonary venous drainage as well as the bronchial circulation make this point moot.

Once bronchovascular structures as well as the fissure have been divided, the S2-S3 and S2-S1 intersegmental planes are divided in usual fashion. If there is a recurrent artery, it may be either included in the parenchymal staple line or dissected out individually (1,15).

S6 segmentectomy (Video 2)

The dissection space is located between the inferior pulmonary vein and the origin of the bronchus intermedius at the minor carina (Figures 2,6,7). This space partially encompasses the dissection space described for S2 segmentectomy, that contains A2 and A6 (see also Figures 2,4) (4). The segmental vein V6 is found at the superior border of the inferior pulmonary vein (Figure 2) (1,11). As dissection is carried distally toward the parenchyma along the inferior pulmonary vein, the origin of V6 is gradually revealed. V6 is usually well individualized and dissection is usually straightforward. Dividing the V6 segmental vein will allow access to the basal bronchus distal to B6 (Figure 7). The lower border of B6 is approached from this direction, while the superior border of B6 is approached from the direction of the bronchus intermedius. Vertical traction on the parenchyma will help expose the origin of B6 which will then point to 12 o’clock and lie at approximately a right angle to the bronchus intermedius. Dividing the posterior-most portion of the S6–S10 intersegmental plane may help facilitate access to B6 (11).

Figure 6 The posterior surgical approach for segmentectomies S2, S6, S10, and S1. A schematic illustration of segmental anatomy is provided, as well as key intraoperative views and corresponding cross-sectional anatomy as seen on preoperative imaging. (A) The limits of the S6 segment and associated bronchovascular structures are illustrated (segmental bronchus B6; segmental artery A6; segmental vein V6). (B) The dissection space for S6 segmentectomy extends from the inferior pulmonary vein to the origin of the bronchus intermedius. It contains segmental bronchovascular structures. The bifurcation of B6 and the basal bronchus (BB) may be seen. A, artery; B, bronchus; S, segment; V, vein.

Figure 7 During S6 segmentectomy, dividing the segmental vein V6 and segmental bronchus B6 will allow access to the segmental artery A6. As B6 and A6 lie in close proximity, great care is required when encircling and dividing B6. The basal artery and origin of A6 may be readily appreciated during dissection. A, artery; B, bronchus; S, segment; V, vein.

The course of the arteries closely mirrors that of the bronchi. The segmental artery A6 takes off vertically from the interlobar artery deep to and parallel to the segmental bronchus B6 (1), while the basal artery continues its path distally, parallel and deep to the common basal segment bronchus (1). Fatty and lymphatic tissue are reflected from B6 toward the parenchyma, clearing the origin of B6 which can now be isolated using a right angle clamp, hugging the bronchus to avoid A6 coursing directly behind. As the bronchus is divided, traction on the parenchyma should be minimized to avoid injury to the artery as the bronchus is “released”.

Dividing the bronchus allows access to the segmental artery A6 as well as the basal artery, coursing at a right angle to A6 (Figure 7). Dissection is carried anteriorly above and across the basal artery, toward the middle lobe. At this point, the posterior portion of the S6–S10 intersegmental plane may be safely divided, while keeping the anvil of the stapler above the basal artery. Dividing the intersegmental plane allows more comfortable access to A6, which can now be dissected and divided. How much of the intersegmental plane should be divided before addressing B6 and A6 is partly a matter of personal preference and partly dictated by local findings, as long as one can insure adequate exposure and atraumatic handling of tissues. Dividing A6 will allow access to the interlobar artery; the plane along the interlobar artery can be followed proximally until the confluence of the horizontal and oblique fissures, at the very root of S6 (see Figure 6).

In the author’s experience, two potentially troublesome anatomic variations are (I) a proximal bifurcation of B6 or A6 into two subsegmental branches and (II) a common origin of A2 and A6 from the interlobar artery. Not recognizing these variations may lead to misidentification or injury.

The upper portion of the oblique fissure between S6 and S2 can now be divided while keeping the anvil of the stapler above the interlobar artery. Parenchymal division is carried up to the middle lobe to complete the segmentectomy.

S10 segmentectomy (Video 3)

The dissection space is in the shape of an inverted triangle delineated by V6, the common basal vein, and the parenchymal border (Figures 2,8). Isolating and encircling V6 with a suture and then retracting it cephalad will help open up this space, which contains the basal segment bronchus (5,8,10).

Figure 8 The posterior surgical approach for segmentectomies S2, S6, S10, and S1. A schematic illustration of segmental anatomy is provided, as well as key intraoperative views and corresponding cross-sectional anatomy as seen on preoperative imaging. (A) The limits of the S10 segment and associated bronchovascular structures are illustrated (segmental bronchus B10; segmental artery A10). The segmental vein V10 is generally not dissected out individually. (B) The dissection space for S10 segmentectomy is conceptualized as an inverted triangle delineated by the segmental vein V6, the common basal vein, and the parenchymal border. The apex of the triangle is formed by the confluence of the veins, while the parenchyma forms the base. The segmental artery A10, as well as segmental bronchi B10 and B9 will be found coursing through this space. A, artery; B, bronchus; S, segment; V, vein.

The parenchyma is gradually mobilized off the bronchial wall, away from the hilum. As the bronchial borders become more clearly visible, the posterior portion of the S10-S6 intersegmental plane may be divided with an endoscopic stapler. This “bronchial plane” now consists of the B10 segmental bronchus, the B9 segmental bronchus, and the B7 segmental bronchus which, at this point, are not yet individually recognized (Figures 8,9). V10 usually continues the superior portion of the common basal vein, and, as it courses toward the depth of the operative field, it often hugs and loops around the B10 bronchus (10). This is readily appreciated on cross sectional imaging and 3D reconstructions, which makes the vein a useful landmark for identifying B10 (see Figure 10 and Video 3). The inferior border of B10 is therefore gradually delineated by carrying the dissection distally along the upper border of the common basal vein, in continuity with V10. One must be careful not to avulse any tiny venous branches form the larger venous trunks in the process. An advanced bipolar device is ideal for this portion of the procedure.

Figure 9 During S10 segmentectomy, dividing the segmental bronchus B10 will reveal the segmental artery A10. As the space is constrained and as segmental bronchovascular structures are delicate, great care is required when encircling and dividing B10. A, artery; B, bronchus; V, vein.

Figure 10 The posterior surgical approach for segmentectomies S2, S6, S10, and S1. A schematic illustration of segmental anatomy is provided, as well as key intraoperative views and corresponding cross-sectional anatomy as seen on preoperative imaging. (A) Cross sectional imaging shows the general configuration of S10 segment bronchovascular structures. (B) A magnified view illustrates the plane of dissection for S10 segmentectomy. Using a posterior approach, the segmental vein V10 usually comes off the common basal vein and courses deep into the operative field, as it “hugs” and loops around the B10 segmental bronchus. Carrying the dissection along the common basal vein in continuity with V10 is a useful way of confidently reaching the B10 bronchus. The segmental artery, A10, courses just deep to the bronchus. A, artery; B, bronchus; S, segment; V, vein.

Once the borders of B10 are clearly outlined, the bronchus may be dissected and isolated with a right angle clamp. As the segmental bronchi are thin, and as the segmental artery A10 courses immediately behind the segmental bronchus, great care is required during this manoeuvre (5,8,10). In some cases, A10 can be identified just cephalad and deep to the segmental bronchus before the bronchus has been divided. One should be careful not to advance the stapler deep to the bronchus when initially dividing the posterior portion of the intersegmental plane, in order to avoid injuring the artery.

When the bronchus is divided, one gains access to the segmental artery (Figure 9). Dissection is carried proximally along the artery beneath the parenchyma. In theory this plane runs all the way to the lower lobe artery, but dissection need not go further than the S10-S6 intersegmental border. The intersegmental plane can now be divided above the artery with the endoscopic stapler. This will fully expose the artery, which may now be completely dissected and isolated. The segmental artery is small and flimsy and great care should be taken during dissection and division.

Once the artery is divided, the remaining intersegmental plane S10-S9/S10-S7 may be divided. The intersegmental plane may be tricky, as it has a fairly complex 3-dimensional configuration (5,8,10). Some work and patience may be required. As a general principle, one alternates between S10-S9 and S10-S7 staple lines which are begun peripherally and gradually converge toward the segmental hilum. They merge into a single staple line below the hilum, as the bronchovascular stumps are retracted into the specimen. Parenchymal division is continued while pointing the stapler toward the apex of the S10-S6 staple line, at which point the segmentectomy is complete (Figures 1,8; Video 3).

S1 segmentectomy (Video 4)

The S1 segment is a special case. The apical location makes this segment tricky to reach both from an anterior and a posterior approach (3,13,14). Both approaches have certain advantages and drawbacks, and individual anatomy may inform the approach that is eventually chosen in a specific patient.

From an anterior approach, delicate vascular structures that need to be preserved (superior pulmonary vein, anterior segment artery), may be in the way, hinder identification and exposure of the apical artery and apical bronchus, and may be vulnerable to injury. On the other hand, a posterior approach may offer direct access to the apical bronchus and artery, but the disadvantage is that vascular structures are deeper in the surgical field, and so access may be more difficult; in the case of a recurrent A2 originating from A1, the recurrent artery may be difficult to identify intraoperatively; exposure of the apical vein V1b may also be challenging (9,14). In addition, variations in bronchial anatomy are frequent, requiring careful surgical planning and intraoperative orientation (1,16).

The dissection space is located at the apex of the hilum (Figures 11,12). Dissection is carried around the apical border of the upper lobe bronchus and along the arch of the azygos vein toward the front of the hilum. Optimal exposure requires careful retraction and active adjustments of the camera. During this manoeuvre it is important to be wary of the apical artery as well as the phrenic nerve, which should be positively identified in all cases. The edge of A1 will usually be reached during this portion of the procedure. The parenchyma is gradually teased off the upper lobe bronchus as the dissection proceeds distally. Gradually, the origin of B1 will be revealed. B1 is then carefully isolated using a right angle clamp, being mindful that the apical artery courses immediately behind. As the segmental bronchus is divided, it is important to minimize upward traction on the parenchyma in order to avoid injury to the segmental artery as the bronchus is “released” (3,9,14).

Figure 11 The posterior surgical approach for segmentectomies S2, S6, S10, and S1. A schematic illustration of segmental anatomy is provided, as well as key intraoperative views and corresponding cross-sectional anatomy as seen on preoperative imaging. (A) The limits of the S1 segment and associated bronchovascular structures are illustrated (segmental bronchus B1; segmental artery A1; segmental veins V1a, V1b). (B) The dissection space for S1 segmentectomy is located at the apex of the hilum. It extends from the minor carina to the arch of the azygos vein at the apex of the hilum, and extends distally toward the parenchyma. A, artery; B, bronchus; pn, phrenic nerve; S, segment; SVC, superior vena cava; V, vein.

Figure 12 The posterior surgical approach for segmentectomies S2, S6, S10, and S1. A schematic illustration of segmental anatomy is provided, as well as key intraoperative views and corresponding cross-sectional anatomy as seen on preoperative imaging. (A) In a posterior approach to S1 segmentectomy, the segmental bronchus B1 is usually dissected and divided first. As the segmental artery A1 courses just deep to and in close proximity to B1, great care is required when encircling and dividing B1. A recurrent S2 segmental artery (rec) may become visible at this point; any significant recurrent A2 should be preserved. (B) When B1 and A1 have been divided, the segmental vein V1b may often be visible. It is usually included in the parenchymal staple line that divides the intersegmental plane, rather than being dissected and divided individually. A, artery; B, bronchus; S, segment; SVC, superior vena cava; V, vein.

Dividing the bronchus will provide direct access to the apical artery which courses parallel to and just deep to the bronchus (Figure 12). Care is taken to identify and preserve any significant recurrent branch coursing to S2, which will also have been identified on preoperative imaging (1,16).

Once the segmental artery is divided, the intersegmental plane S1/S2-S1/S3 is divided from back to front. The author has found that as opposed to an anterior approach, a posterior approach allows better visualization and easier retraction of the bronchovascular stumps during parenchymal division, as they are located posteriorly. The segmental vein V1b lies deep within the operative field and is typically divided en bloc with the parenchyma.

Postoperative considerations and tasks

The author began using posterior approaches for segmentectomies in 2015, and published a learning curve for minimally invasive segmentectomies in 2022 (17); competency for all segmentectomies was achieved after 32 cases, while the overall complication rate was 13.6%. Most of these (88.9%) were Clavien-Dindo 1/2, with an even distribution throughout the learning curve (17). Conversion to open thoracotomy occurred in 1.5% of cases. After learning curve completion, mean OR time was 128.59±32.42 min; median duration of chest tube drainage was 1 day (interquartile range 1 day); median length of stay was 2 days (interquartile range 3.75 days) (17).

Tips and pearls

It is important to remember that segmental bronchovascular structures may be small and delicate. Arteries may be divided using either staplers or energy devices, depending on local conditions and personal preference. As illustrated, veins (as well as some arteries, such as a recurrent A2) may often be included in parenchymal staple lines. As spaces are often restricted and angles narrow, the author frequently uses a small red rubber catheter as an atraumatic guide for the anvil of the stapler. In addition, sutures looped around bronchi are useful for retraction, and including such a loop in the distal bronchial staple line provides a useful handle for manoeuvring the distal bronchial stump during parenchymal transection.

Regardless of approach, bronchovascular segmental structures may be challenging to identify. In the author’s opinion, the best way to insure proper anatomic identification is a thorough review of preoperative imaging, careful preoperative planning, and intraoperative review of cross sectional imaging, as needed. 3D reconstructions may be helpful as well. Anatomic variations are frequent; these should be recognized, and the operative approach adapted accordingly. Flexibility and versatility seem preferable to a one-size-fits-all approach.

Discussion

S2 and S6

The approaches to S2 and S6 share some common features, as in each case the dissection space comprises the angle at the origin of the bronchus intermedius. In addition, A2 and A6 are both located near one another along the interlobar artery, and sometimes share a common origin (1). In the case of S2, an anterior approach or one that involves dissection through the fissure may facilitate the identification of the central vein and V2 (4,15); when performing a posterior approach, care must be used when stapling the posterior portion of the fissure in order to avoid encroaching on V2. Thus V2 may sometimes need to be dissected early on during dissection and before division of the posterior portion of the fissure (S2-S6 plane). It is useful to recognize the relationship between A2 and V2; with the help of preoperative imaging and with care and patience, V2 may be safely identified from a posterior approach (15,16).

In both S2 and S6 resections, if required for oncologic or technical reasons, a corresponding upper or lower lobectomy may be completed through the same (posterior) approach. The key is following vascular planes all the way to the anterior aspect of the hilum, while gradually dividing the overlying fissures (the posterior/central vein in the case of S2, and the basal artery in the case of S6).

S10

S10 is in general a more difficult segmentectomy, because bronchovascular structures are located deeper within a restricted space (5,8). Nevertheless, the posterior approach does seem advantageous given that approaching S10 using a conventional approach involves dissection within the fissure and may be extremely challenging because of intervening anatomic structures that obstruct access (specifically the hila of S7 and S8) (5,8). Precisely identifying the S10-S6 intersegmental plane using a posterior approach is not straightforward, as the technique described involves dividing the parenchyma first in order to gain adequate access to bronchovascular structures (5,8,10,18). This precludes the use of differential insufflation or intravascular contrast agents as methods of intersegmental plane delineation, but this may not be formally necessary (18). The author uses the underlying bronchovascular structures as a guide, recognizing that absolutely precise delineation would require alternative methods. In theory, dissection may be carried proximally along the segmental artery A10 all the way to the lower lobe artery. Dividing the parenchyma overlying the artery could thus allow access to the hilar structures of the lower lobe and allow one to extend an S10 resection to bordering segments, if required (S6, S9, or the common basal segment).

S1

S1 is a special case. In the author’s experience, neither an anterior nor a posterior approach is ideal for every case. The apex is the most difficult area to reach and expose properly, and this is where the bronchovascular structures at the root of S1 are located. The advantages of a posterior approach are unimpeded, direct access to segmental hilar structures, but this is contingent on individual anatomy (Figure 13) (3,14). In some cases, this approach may be tedious because vascular structures anterior to the bronchus may be hidden from view. In particular, from this vantage point the segmental vein V1b lies deep within the operative field. The author suggests carefully reviewing preoperative imaging in order to decide on the optimal operative approach. Nevertheless, familiarity with a posterior approach to S1 will facilitate extending an S2 resection to include S1 and vice-versa, if required.

Figure 13 The posterior surgical approach for segmentectomies S2, S6, S10, and S1. A schematic illustration of segmental anatomy is provided, as well as key intraoperative views and corresponding cross-sectional anatomy as seen on preoperative imaging. (A) Cross sectional imaging shows the general configuration of S1 segment bronchovascular structures. (B) A magnified view illustrates the plane of dissection for S1 segmentectomy. Using a posterior approach, the upper lobe bronchus is the first structure to be encountered. As it is followed distally, the B1-B2 bronchial bifurcation will be identified. The segmental artery A1 lies deep to the corresponding bronchus. From the posterior approach, V1b is located far from the operator; it is usually incorporated into the intersegmental staple line rather than being individually dissected and divided. V2b is usually not encountered from the posterior approach and is also included in the parenchymal staple line. A, artery; B, bronchus; S, segment; V, vein.

Conclusions

This paper outlines an anatomic and technical rationale for a posterior approach in the resection of segments S1,2,6,10. The guiding principles underlying this approach include direct access to bronchovascular structures, maximal sparing of tissue planes, and sufficient versatility to adapt resections to unexpected intraoperative findings. Approaches and techniques for segmentectomies continue to evolve, promoting development toward continued improvement and refining of technique.

Acknowledgments

The author acknowledges the contribution of Kathy Hernandez, Christopher Desalliers, and Sylvain Durocher (DERI, Service des techniques audiovisuelles, CIUSSS de l’Est-de-l’Île-de-Montréal) for the production of the artwork, figures, and videos, as well as their support for this project and utmost professionalism. The author also wishes to acknowledge Mr. Kris Leblanc (Pointe-Claire, Qc, Canada) for providing the audio narration for the surgical videos.

Footnote

Reporting Checklist: The author has completed the SUPER reporting checklist. Available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0011/rc

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0011/prf

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2026-0011/coif). G.R. reports receiving a grant for graduate students/research from TranMedTech (Montreal, Canada); speaker fees from Johnson and Johnson; and payment from a medico-legal case (McCarthy-Tetrault, Montreal, Canada). The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Declaration of Helsinki and its subsequent amendments. Verbal informed consent was obtained from the patients for the publication of this study, accompanying images, and the videos. The patients’ identities have been fully anonymized, and no personally identifiable information is disclosed in this study.

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