Thoracoscopic right-S10 segmentectomy: Alternative posterior approach

Individual basal segmentectomies can be particularly challenging. The author has previously used an anterior approach when performing S10 segmentectomies. However, he finds that a posterior approach allows direct access to the vein and bronchus, which is further aided by dividing the posterior portion of the S6-S10 intersegmental plane. The trunk of the inferior pulmonary vein now becomes a convenient landmark because it hugs and delineates the segmental bronchus while it courses posteriorly. The author currently favors this approach for all S10 segmentectomies. Cross-sectional imaging and/or 3-dimensional reconstructions are essential in delineating anatomic relationships, in particular the relationship of the vein and its branches (which may vary) and the bronchus. They are also useful for locating the segmental artery, which typically lies just deep to the bronchus. Imaging is used both as a tool for preoperative planning and as a guide during operative dissection. Regardless of the approach, the S10 remains a difficult segmentectomy. Great care is required while dissecting and dividing delicate bronchovascular structures located deep within the operative field.