VATS Lung Middle Lobectomy With Bloc Anatomical Subsegmentectomy S3b

I report a case of VATS middle lobectomy with en bloc sub Segmentectomy S3b. This intervention was performed for a suspicious lesion localized in the horizontal fissure and we plan to perform an anatomical lung sparing resection: middle lobectomy plus upper lobe anterior medial subsegment S3b.
We start by opening the mediastinal pleura using harmonic device taking care of the phrenic nerve. We isolate the middle vein branch and staple it. Then we move to the fissure to identify the pulmonary artery in order to open the anterior part of the oblique fissure with stapler.
Please note that we never grasp the remaining lung and we always use rolled gaz to expose.
I strongly recommend the use of curved tip in routine for safe procedure.
Then we remove the station 11 lymph node to easily staple the bronchus and the pulmonary artery for the middle lobe.
Lifting up the middle lobe, we see the central vein. We remove lymph nodes for good exposure. We dissect the central vein and its branche V3b and cut it. We carry on the dissection of the subsegmental structures. We open the pleura and identify the branche V1 in order to preserve it.
We dissect the bronchus for S3 and we isolate the branche B3b. Behind this stump we finish by taking the arterial branche A3b with a clip and energy section.
To delimit the intersegmental plane with use ICG and fluorescent camera. In green appears the vascularized tissues whereas the futur specimen doesn’t flash.
We clearly identify the plane and we mark the limits with electrocoagulation before the washout of the ICG.
Last part consists to cut the parenchyma. We use stapler taking care of carrying out the broncho-vascular stumps and also the cauterized marks of the parenchyma to perform a complete anatomical resection.
Here is the final aspect with all the stumps and the specimen with the lesion marked with a string for the pathologist.