Anatomical variations and pitfalls to know during thoracoscopic segmentectomies

Dominique Gossot, Agathe Seguin-Givelet, Dominique Gossot, Agathe Seguin-Givelet

Abstract

The rate of sublobar resection (SLR) for early-stage non-small cell lung carcinoma (NSCLC) is increasing, mainly because of a growing rate of early-stage lung carcinomas and ground-glass opacities. More and more SLRs are now performed by a thoracoscopic, a video-assisted or a robotically-assisted approach. Although surgeons are performing pulmonary segmentectomies for years, they need a better understanding of anatomy when using a closed chest approach, because vision is more limited and they cannot stretch and expose the parenchyma and broncho-vascular elements. In this article, we will describe most of the significant anatomical variations we have encountered during a consecutive series of 390 full thoracoscopic segmentectomies, either at surgery or preoperatively by studying the 3-dimensional (3D) modelisation.

Keywords: Sublobar resection (SLR); anatomy; lung cancer; segmentectomy.

Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Independent bronchi as seen on 3D reconstruction (A) and at thoracoscopy (B), (C) shows common B1+2 and independent B3.
Figure 2
Figure 2
Thoracoscopic dissection demonstrating two ascending arteries within the fissure. (A) The most anterior artery (indicated by “?”) could be a second Asc.A2 or an Asc.A3; (B) as dissection is continued, it becomes clear that this artery is for S3. Asc.A2s, stump of Asc.A2; B, upper lobe bronchus.
Figure 3
Figure 3
V2t crossing the posterior aspect of Asc.A2. (A) 3D reconstruction; (B) thoracoscopic view.
Figure 4
Figure 4
3D reconstruction demonstrating two ascending arteries from the main pulmonary artery, one for S2 and one for S3.
Figure 5
Figure 5
Double A6 artery.
Figure 6
Figure 6
Common origin of A6 and A2.
Figure 7
Figure 7
Usual pattern of right basilar bronchi, with a common trunk for B9 and B10.
Figure 8
Figure 8
Two different pattern of the arteries to the basilar segments. (A) Four independent branches to each of the segments; (B) A9+10 and one A8 with lacking A7.
Figure 9
Figure 9
Example of a middle lobe artery arising from the basilar arterial trunk and that could be damaged if dissection of the basilar arteries is insufficient.
Figure 10
Figure 10
Basilar vein and middle lobe vein draining together in the inferior pulmonary vein. Bas.As, stump of the basilar arterial trunk; Bas.Bs, stump of the basilar bronchial trunk; IBVs, stump of the inferior basal vein.
Figure 11
Figure 11
Multiple arterial stumps (arrowheads) after control of all arteries to segments 1, 2 and 3 of the left upper lobe.
Figure 12
Figure 12
Mediastinal lingular artery. (A) 3D modelisation; (B) thoracoscopic view after division of the bronchial trunk B1-3. LUL, left upper lobe; LLL, left upper lobe; TA, truncus anterior.
Figure 13
Figure 13
The left superior pulmonary vein. (A) Usual pattern with three main branches; (B) tiny lingular vein at risk of torsion and/or thrombosis.
Figure 14
Figure 14
Common trunk between the lingular arteries and A3. LUL, left upper lobe; LLL, left upper lobe.
Figure 15
Figure 15
Venous drainage of the lingula into the inferior pulmonary vein (arrow). IPV, inferior pulmonary vein.
Figure 16
Figure 16
Exposure and dissection of B6. Note that the bronchus can be at some distance from the artery. LN, lymph nodes; A6s, stump of A6; PA, pulmonary artery.
Figure 17
Figure 17
A6 artery, in its most common pattern. (A) Early bifurcation in two branches; (B) double A6 artery (3D reconstruction); (C) double A6 artery (thoracoscopic view).
Figure 18
Figure 18
Common rise of A6and A10.
Figure 19
Figure 19
Bifurcation of the V6 vein: upper tributary for S6 and lower tributary for the basilar segments (white arrow). SPV, superior pulmonary vein; IPV, inferior pulmonary vein; SBV, superior basal vein; IBV, inferior basilar vein.
Figure 20
Figure 20
Lingular artery originating from the basilar arterial trunk. LUL, left upper lobe.
Figure 21
Figure 21
Lingular vein joining the inferior pulmonary vein. Bas.As, stump of the basilar arterial trunk; Bas.Bs, stump of the basilar bronchial trunk; IPV, inferior pulmonary vein.
Figure 22
Figure 22
Common bronchial B8 and B9 trunk and common arterial A8 and A9 trunk. (A) 3D modelisation; (B) thoracoscopic view after clipping of A8. A8s, stump of A8.
Figure 23
Figure 23
Arteries to left segment S8: common pattern.

Source: PubMed

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