What are the operative steps for a left upper lobe trisegmentectomy (lung resection procedure)?

From the Guidelines

A left upper lobe trisegmentectomy is a complex surgical procedure that involves removing three segments of the left upper lobe of the lung while preserving the lingula, and its operative steps should be carefully planned and executed to minimize morbidity and mortality. The procedure begins with general anesthesia and single-lung ventilation using a double-lumen endotracheal tube 1.

Key Steps:

• A posterolateral thoracotomy incision is made, typically through the 4th or 5th intercostal space, to access the lung.
• The lung is retracted and the pulmonary ligament is divided to improve exposure, allowing the surgeon to identify and individually ligate the pulmonary arterial branches supplying the apical, posterior, and anterior segments of the left upper lobe, while preserving blood supply to the lingula.
• The bronchi to these three segments are identified, dissected, and divided, with care taken to preserve the lingular bronchus, as described in guidelines for lung cancer surgery 1.
• The pulmonary veins draining these segments are then ligated and divided, and the intersegmental planes are identified by temporarily inflating the lung and observing the demarcation line.
• The intersegmental planes are then divided using staplers or electrocautery, and hemostasis is achieved.
• An air leak test is performed, and chest tubes are placed before closing the thoracotomy in layers, to ensure a safe and effective procedure.

Preoperative Evaluation:

• Patients undergoing left upper lobe trisegmentectomy should undergo thorough preoperative evaluation, including pulmonary function tests, to assess their suitability for surgery 1.
• The guidelines recommend that patients with a post-bronchodilator FEV1 >1.5 liters can undergo lobectomy, including left upper lobe trisegmentectomy, without further respiratory function tests, unless there is evidence of interstitial lung disease or unexpected disability due to shortness of breath 1.
• The estimated postoperative FEV1 and TLCO should be calculated to assess the risk of surgery, and patients with estimated postoperative FEV1 >40% predicted and estimated postoperative TLCO >40% predicted are considered average risk 1.

From the Research

Operative Steps for Left Upper Lobe Trisegmentectomy

The operative steps for left upper lobe trisegmentectomy involve a video-assisted thoracic surgery (VATS) approach, which is a minimally invasive technique used to remove the affected lung tissue while preserving the lingula [ 2 ]. The procedure typically involves:

• Resection of the left upper lobe with preservation of the lingula, which is the anatomic equivalent of a right upper lobectomy with preservation of the right middle lobe [ 2 ]
• Use of the Harmonic scalpel for dissection, which minimizes blood loss and speeds up patient recovery [ 3 ]
• VATS segmentectomy, which is associated with safe and feasible procedures [ 3 ]

Comparison with Other Surgical Procedures

Left upper lobe trisegmentectomy has been compared with other surgical procedures, such as left upper lobectomy, in terms of survival outcomes and morbidity. Studies have shown that:

• VATS trisegmentectomy and lobectomy provide equivalent survivals for stage IA and IB lung cancer [ 4 ]
• Trisegmentectomy can be performed by VATS with no greater morbidity and mortality than with VATS lobectomy [ 4 ]
• Lingulectomy and trisegmentectomy lead to similar oncological outcomes compared to left upper lobectomy for T1 and T2 N0 NSCLC [ 5 ]