Technique of Thoracoscopic Segmentectomy

Positioning and port placement. Patients are placed in the lateral decubitus position. Our technique uses two incisions—one at the 7th or 8th intercostal space along the posterior axillary line, the other at the 5th or 6th intercostal space anteriorly.

Instrumentation. The optimal profile for instruments used in minimally invasive thoracic surgery is long and curved. Sample instruments here include Harken clamps, a Scanlon clamp, long curved empty sponge-stick, and Scanlon scissors.

Branches of left superior pulmonary vein. From an anterior view, the upper lobe branches (dissected out with the Harken clamp) of the LSPV are dissected out and ligated. AO = aorta; LIPV = left inferior pulmonary vein; LSPV = left superior pulmonary vein.

Left upper lobe bronchial anatomy. The segmental bronchus of the left upper lobe is exposed (above Scanlon clamp) and the superior division bronchus is stapled. AO = aorta; LPA = left pulmonary artery; LSPV = left superior pulmonary vein.

Anterior and apicoposterior arteries of left upper lobe. The anterior and apicoposterior branches of the LPA are dissected out and stapled, sparing the lingular branch of the pulmonary artery. LPA = left pulmonary artery; LSPV = left superior pulmonary vein; UL = upper lobe.

Lingular branch of left pulmonary vein. The lingular branch of the LSPV is approached anteriorly, exposed (above Scanlon clamp), and ligated. AO = aorta; LPA = left pulmonary artery; LSPV = left superior pulmonary vein.

Left upper lobe lingular bronchial anatomy. Upon stapling of the vein, the bronchial anatomy is exposed, revealing the superior division and lingular division segmental bronchi. The lingular bronchus is then stapled. LIPV = left inferior pulmonary vein; LPA = left pulmonary artery; LSPV = left superior pulmonary vein.

Posterior view of inferior pulmonary vein. In a superior segmentectomy, the pulmonary vein is approached posteriorly. The superior segmental branch (under Scanlon clamp) of the LIPV is dissected and stapled. LIPV = left inferior pulmonary vein.

Posterior view of superior segment bronchus of left lower lobe. The superior segmental bronchus is exposed and stapled, sparing the basilar bronchi.

Posterior view of superior segmental artery. The superior segmental branch of the pulmonary artery is also approached and stapled posteriorly. LIPV = left inferior pulmonary vein; LLL = left lower lobe.

Anterior view of basilar branch of right lower pulmonary vein. From an anterior view, the basilar branches of the inferior pulmonary vein are dissected and stapled. RIPV = right inferior pulmonary vein; RPA = right pulmonary artery; RSPV = right superior pulmonary vein; SVC = superior pulmonary vein.

Right basilar arterial trunk. The basilar branch of pulmonary artery is approached through the oblique fissure and stapled. RLL = right lower lobe; RML = right middle lobe; RUL = right upper lobe.

Right basilar bronchus. The basilar segmental bronchus is dissected from an anterior approach and stapled.