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Uniportal Video-Assisted Thoracic Surgery Left Lower Posterobasal Anatomic Segmentectomy S10

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posted on 14.06.2022, 20:25 authored by Veronica Manolache, Natalia Motas, Mugurel Bosinceanu, Diego Gonzalez-Rivas

A segmentectomy is typically defined as a sublobar anatomic resection containing a segment—or a group of segments—by means of an individual approach to the artery, vein, and bronchus. This video presents a uniportal video-assisted thoracic surgery left lower posterobasal anatomic segmentectomy S10.

The incision is performed in the fifth intercostal space between the anterior and lateral axillary lines. This can be observed in the video above when the camera enters the thorax just above the interlobar fissure.

The dissection begins in the inferior mediastinum, with the section of the pulmonary ligament tooling an ultrasonic scalpel. The inferior pulmonary vein and its tributaries are exposed. Further dissection of the venous branches is performed with a forceps dissector, including identification of the V10 (the terminobasalis vein, also known as the inferior basal vein). The video displays the proximal ligation of the venous stump using a suture ligation and a vascular clip—a distal vascular clip. The division is performed using the ultrasonic scalpel.

The segmental bronchus B10 terminobasalis is identified by delicate dissection into the lung parenchyma posteriorly and cranially from the inferior vein. The dissection uses the ultrasound followed by the 90° dissecting forceps. Using the suction trick, the path behind the bronchus is prepared at the correct angle and preserved for passing the stapler. After closing the stapler on the bronchus, the lung is inflated by the anesthesiologist to verify the correct identification of the bronchus and delimit the intersegmental planes.

Further cranial dissection identifies the artery A10, terminobasalis. The artery is ligated with a proximally placed suture. Next a vascular clip is placed and cut with the ultrasonic scalpel.

Given that segment 10 is bronchovascular disconnected, the segment is now separated from the rest of the parenchyma (from segment 9 first and then from segment 6). The distinction is based on the previous inflation test using staplers. The distal stumps are kept distally from the stapling line to correctly resect the segment anatomically. For this purpose, the stapling line is prepared using a grasper for both compressing the lung parenchyma and more easily exposing both sides of the intersegmental limit.

This inferior approach is a different technique for basal segmentectomies. It is preferred because it avoids the fissure dissection, and it can be performed when the fissure is missing. Segment 10 is difficult to disconnect from its bronchovascular branches since it is the most distal part of the lung. The individual bronchial division is known in detail based on the preoperatory bronchoscopy. The potential common trunk B9-B10 is not accidentally resected.

The integrity of the bronchial stump and parenchyma suture lines are checked using saline and lung inflation.


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