Technical aspects of biportal video-assisted thoracoscopic S10 segmentectomy of the lung: fissureless posterior approach

General principles

As a rule we perform video-assisted thoracoscopic (VATS) anatomic segmentectomies through a biportal approach, including a 3–4 cm anterior utility incision and another 1.5 cm inferior port.

We utilize a 5 or 10 mm, 30 degree angled HD video-thoracoscope.

The surgeon and the assistant are usually positioned on the anterior (abdominal) side of the patient. The surgeon can change position and place himself cranially or caudally with respect to the assistant depending on the different steps of the operation.

Initially, the anterior utility incision is made and the wound is protected by a plastic soft tissue retractor (wound protector) kept in place by a ring in the chest cavity and one outside the skin (Alexis Retractor, Applied Medical USA). This incision is usually placed at the 4^th–5^th intercostal space between the tip of the scapula and the breast in the anterior axillary line.

A second 1.5 cm port is positioned more posteriorly at the level of the 7^th intercostal space just anterior to a straight line down from the tip of the scapula and is performed under endoscopic guidance using the thoracoscope through the utility incision made previously.

Specific technical steps (Figure 1)

Figure 1 Technical aspects of biportal video-assisted thoracoscopic S10 segmentectomy of the lung: fissureless posterior approach (1). Available online: http://www.asvide.com/article/view/25766

For the S10 segmentectomy, I prefer a posterior approach to the hilar structures of the segment as shown in the video. In this approach the camera is almost always kept in the inferior port, similar to what is done for lower lobectomies. This allows a more direct visualization of the inferior pulmonary vein (IPV) and the posterior aspect of the hilum. The entire posterior mediastinal pleura are opened. Station 7 lymphadenectomy is usually performed at this stage and often facilitate further dissection of the hilar structures of the lung. The hilar dissection is generally performed using a combination of thoracoscopic suction device, which also keeps the field dry during dissection, and a monopolar diathermy with a long shielded tip or an energy device.

The IPV is carefully dissected to expose its segmental branches. The most important point is to identify the superior segmental vein that must be preserved. Caudal to the superior segmental vein (V6), is the V10, which is dissected and divided using a vascular endoscopic stapler. Alternatively, if the size of the vessel is relatively small (<6 mm), vascular endoclips and energy device can be used to divide the vessel. This step of the operation is crucial as it allows the identification of the segmental bronchus, which lies immediately anterior to the vein (Figure 2, S10). Once identified, the B10 is carefully dissected, encircled and divided using endoscopic stapler passed usually from the utility incision (Figure 3, S10).

Figure 2 Division of segmental vein V10 (2). Available online: http://www.asvide.com/article/view/25767

Figure 3 Division of segmental bronchus B10 (3). Available online: http://www.asvide.com/article/view/25768

As shown in the video, the next step is the identification of the A10 segmental artery, which is situated in close proximity of the segmental bronchus usually in a more anterior and cranial position. The A10 is carefully dissected and divided using endoscopic vascular stapler. This step is facilitated by the partial fissureless division of the parenchyma between the superior and posterior segments using a tunnel technique (Figure 4, S10).

Figure 4 Division of segmental artery A10 (4). Available online: http://www.asvide.com/article/view/25769

The final step after the division of the segmental artery is the division of the intersegmental parenchymal plane. We usually identify the segmental plane re-inflating the lung and after clamping the segmental bronchus. However, especially for the basilar segments of the lower lobes this step is often challenging as the plane that needs division is tridimensional (i.e., pyramidal).

The intersegmental plane is divided successive application of endoscopic staplers along the inflation-deflation line. This step can be accomplished by alternating the camera from the utility incision to the inferior port. This will depend upon the angle of exposure and the most convenient point of entry for the endoscopic stapler.

The specimen is finally extracted from the chest in a protective bag (this can be achieved with or without prior removal of the wound protector). Finally a systematic lymph node dissection is performed.

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Visualized Surgery for the series “Uncommon Segmentectomies”. The article has undergone external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/jovs.2018.06.23). The series “Uncommon Segmentectomies” was commissioned by the editorial office without any funding or sponsorship. AB served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Journal of Visualized Surgery from Dec 2016 to Nov 2018. 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 studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for publication of this manuscript and any accompanying images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Brunelli A. Technical aspects of biportal video-assisted thoracoscopic S10 segmentectomy of the lung: fissureless posterior approach. Asvide 2018;5:605. Available online: http://www.asvide.com/article/view/25766
2. Brunelli A. Division of segmental vein V10. Asvide 2018;5:606. Available online: http://www.asvide.com/article/view/25767
3. Brunelli A. Division of segmental bronchus B10. Asvide 2018;5:607. Available online: http://www.asvide.com/article/view/25768
4. Brunelli A. Division of segmental artery A10. Asvide 2018;5:608. Available online: http://www.asvide.com/article/view/25769