Uniportal VATS Segment-3 resection right with ICG

Incision of approximately 4 cm in length in the area of the anterior axillary line at the upper edge of the 5th rib to access the 4th intercostal space above. As a guide, an imaginary line from the tip of the scapula to the nipple is often helpful here. Transection of the subcutis on the rib with the monopolar knife. Subsequently, stepwise preparation of the intercostal muscles with the monopolar knife. The pleura is opened bluntly with fingers. Palpation of the thoracic wall for adhesions and insertion of a wound protection film.

First, the exploration of the situs and palpation of the lung is performed. If the nodule described in the imaging can be reliably palpated and no further findings (such as pleural carcinomatosis) are observed, marking the tumor with a suture or sterile pen during the subsequent parenchymal resection is very helpful to ensure an adequate safety margin.

In the case presented here, a very clear anatomy of the lung hilum is already evident before dissection. Initially, the pleural covering is incised. Care must be taken to preserve the phrenic nerve. Subsequently, the preparation of the upper pulmonary vein is predominantly blunt. In the case of planned segmental resection, it is not circumferentially dissected free but followed peripherally until the branching into individual branches is clearly recognizable. Accurate assignment of the venous branches to the segments is often only reliably possible later in the operation, so dissection is performed at a later stage.

The fissure between the upper and middle lobes is at most suggested. Initially, stepwise dissection with the ultrasonic scissors is performed until the interlobar part of the pulmonary artery is exposed. An intersegmental vein, clearly extending from the middle lobe vein into segment 3, is circumferentially dissected.

• Note:

The parenchyma of the middle lobe remaining in situ must later be visceralized by suturing to prevent a persistent parenchymal fistula postoperatively. In this process, the lung parenchyma is sutured in such a way that the resection site is covered with lung tissue and intact visceral pleura. (See step 14)

The previously circularly dissected intersegmental vein can then be transected using the ultrasonic shears while placing titanium clips. The remaining parenchymal bridge underneath is also resected. Care must be taken to preserve the middle lobe vein and the pars interlobaris of the pulmonary artery.

Subsequently, the pars interlobaris of the pulmonary artery is further dissected. It is crucial to clearly expose the artery along the fissure of the lobe to prevent injury to the branches or even the main trunk during the later parenchymal resection. An accessory narrow-caliber branch leading into the 3rd segment can be transected using titanium clips and an ultrasonic scalpel.

After the preparation of the fissure, the preparation and identification of the venous drainage of the 3rd segment can now be continued. Here, it becomes apparent that the segment vein V3 (inferior vein) does not drain into the superior pulmonary vein with a common trunk, but rather the subsegmental veins V3a and V3b individually enter the superior pulmonary vein. These are circumferentially prepared separately and then resected with the application of titanium clips.

• Note:

The segmental resection can be complicated by anatomical variations of both venous and arterial vascular supply. It is important here to perform subtle and incremental preparation to recognize and safely manage these variations.