Video-assisted thoracic surgery experience of calcified lymph nodes for lingular sparing lobectomy

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 (FEV₁): 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^th intercostal space in the midaxillary line, and was used for the camera. A 4-cm long incision was made in the 4^th intercostal space in the preaxillary line. A third 1.5-cm incision was performed in the 9^th 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.