Coman C
Poumon Coeur. 1982;38(4):227-31.
Among combined pulmonary resections, one of the most difficult operations is right middle and lower lobe lobectomy because of the very intricate anatomical relations between the three pulmonary lobes. Technical difficulties during the first-stage approach to the pulmonary artery in the fissure are compounded by the presence of pathological processes (neoplasm, suppuration, etc.) which provoke adhesions between the pulmonary artery and the bronchus, with inevitable major risks. A new technique for middle and lower lobe lobectomy which avoids the frequent accidents during this operation is described. The first stage involves ligature and section of the inferior root of the superior pulmonary vein and liberation of the horizontal fissure. Opening of the horizontal fissure exposes the superior fissural vein, which is then displaced towards the upper lobe. This allows access to the pulmonary artery in the fissure, together with its branches to the lower and middle lobes, and the fissural arteries to the upper lobe. This procedure enables simple dissection and ligature of the pulmonary artery, as at this level it is not adherent to the intermediary part of the bronchus. The triangular ligament, inferior pulmonary vein, and intermediary bronchus are then ligatured and sectioned. The advantages of this method consist in the simplification of the dissection, ligature, and section of the pulmonary artery in the fissure, and the need to apply only one ligature if there are no anatomical variations (common dorsal fissural and inferior apical artery, or common ventral fissural and middle lobe artery).
在联合肺切除术中，最困难的手术之一是右中、下叶肺叶切除术，因为这三个肺叶之间的解剖关系非常复杂。在第一阶段处理裂沟内肺动脉时的技术困难，因病理过程（肿瘤、化脓等）导致肺动脉与支气管之间粘连而更加复杂，存在不可避免的重大风险。本文描述了一种新的中、下叶肺叶切除技术，可避免该手术中频繁出现的意外情况。第一阶段包括结扎和切断上肺静脉下根以及游离水平裂沟。打开水平裂沟可暴露上裂沟静脉，然后将其向上叶移位。这样就可以接近裂沟内的肺动脉及其到下叶和中叶的分支，以及到上叶的裂沟动脉。此操作能使肺动脉的解剖和结扎变得简单，因为在此层面肺动脉不与支气管中间部分粘连。然后结扎并切断三角韧带、下肺静脉和中间支气管。该方法的优点在于简化了裂沟内肺动脉的解剖、结扎和切断操作，并且如果没有解剖变异（常见的背侧裂沟动脉和下尖动脉，或常见的腹侧裂沟动脉和中叶动脉），只需进行一次结扎。
