Ma Qianli, Liu Deruo
Department of Thoracic Surgery, China Japan Friendship Hospital, Beijing 100029, China.
J Vis Surg. 2016 Mar 14;2:46. doi: 10.21037/jovs.2016.02.14. eCollection 2016.
Video-assisted thoracic surgery (VATS) is commonly used for posterior, superior and lingular segmentectomy. Segmental resections involving the left upper lobe are the following: upper division (S1+2 and S3) (lingular sparing lobectomy), apicoposterior segmentectomy (S1 + S2), and lingulectomy (S4 + S5). Lingular sparing lobectomy is still a challenge for more technical demanding and more anatomic variations, especially when facing calcified lymph nodes.
A 73 years old woman was admitted for founding a ground glass opacity (GGO) during the screening test (1.0 cm × 1.0 cm). Her pulmonary function result was forced expiratory volume in 1 second (FEV): 1.51 L (54.7% predicted). She was a non-smoker, with negative bronchoscopy findings. She received general anesthesia with double-lumen endotracheal intubation and right lung ventilation. Right lateral decubitus position was chosen. The first 1.5-cm incision was selected in the 8 intercostal space in the midaxillary line, and was used for the camera. A 4-cm long incision was made in the 4 intercostal space in the preaxillary line. A third 1.5-cm incision was performed in the 9 intercostal space in the postaxillary line for assistant. Pulmonary ligament and the entire left hilum were mobilized. The superior pulmonary vein has usually three major tributaries. The superior branch drains the apicoposterior segments and frequently blocks the access to the apicoposterior arteries. The middle branch drains the anterior segment, and the lowermost branch drains the lingula. The lingular vein must be preserved. The apicoposterior and anterior segment vein was transected with a vascular stapler. Anterior pulmonary artery and anterior bronchus were then divided and stapled. The upper lobe bronchus splits immediately into the lingular bronchus and a common stem. All these segmental bronchi have short course and a calcified lymph node located between the apicoposterior pulmonary artery and apicoposterior bronchus. These situations make the dissection and identification very difficult. Following many failure attempts of trying take the calcified lymph node out. Staple the left apicoposterior pulmonary artery together with the apicoposterior bronchi is completed. And left upper division (S1+2 and S3) was taken out after stapling lung tissue above the level of lingular segment with a 60-mm green linear stapler. Mediastinal lymph nodes of level 9, 7, 4L and 5 were cleared afterwards.
Pathology was confirmed with adenocarcinoma (ancinar component dominant). There were no complications and the patient was discharged 6 days postoperatively.
Staple the left apicoposterior pulmonary artery together with the apicoposterior bronchi is a safe and feasible way when facing the difficult dissection of the calcified lymph nodes during segmentectomy.
电视辅助胸腔镜手术（VATS）常用于后段、上段和舌段切除术。涉及左上叶的节段性切除包括：上叶（S1+2和S3）（保留舌叶的肺叶切除术）、尖后段切除术（S1+S2）和舌叶切除术（S4+S5）。保留舌叶的肺叶切除术在技术要求更高且解剖变异更多时仍是一项挑战，尤其是面对钙化淋巴结时。
一名73岁女性在筛查时发现磨玻璃影（GGO）（1.0 cm×1.0 cm）入院。她的肺功能结果为第1秒用力呼气量（FEV）：1.51 L（预测值的54.7%）。她不吸烟，支气管镜检查结果为阴性。她接受双腔气管插管全身麻醉和右肺通气。选择右侧卧位。在腋中线第8肋间选择第一个1.5 cm切口用于放置摄像头。在腋前线第4肋间做一个4 cm长的切口。在腋后线第9肋间做第三个1.5 cm切口用于助手操作。游离肺韧带和整个左肺门。肺上静脉通常有三条主要分支。上支引流尖后段，常阻碍进入尖后动脉。中间支引流前段，最下支引流舌叶。必须保留舌叶静脉。用血管吻合器切断尖后段和前段静脉。然后分别切断并吻合前肺动脉和前支气管。左上叶支气管立即分为舌叶支气管和一个共同干。所有这些节段性支气管行程短，且在尖后肺动脉和尖后支气管之间有一个钙化淋巴结。这些情况使得解剖和识别非常困难。多次尝试取出钙化淋巴结失败后。将左尖后肺动脉与尖后支气管一起吻合完成。然后用60 mm绿色直线吻合器在舌段水平以上吻合肺组织后切除左上叶（S1+2和S3）。随后清扫第9、7、4L和5组纵隔淋巴结。
病理确诊为腺癌（以腺泡成分占主导）。无并发症，患者术后6天出院。
在节段切除术中面对钙化淋巴结的困难解剖时，将左尖后肺动脉与尖后支气管一起吻合是一种安全可行的方法。
