Thoracoscopic left upper division (S1/2/3) resection: alternative posterior approach

A minimally invasive pulmonary segmentectomy allows adequate oncological treatment in selected cases while preserving lung parenchyma and minimizing perioperative morbidity and length of hospital stay. Most lung segments may be resected as segmentectomies or as part of bisegmentectomies (as is the case for the lingula). In the author's experience, left upper division resection (S1, S2, S3 trisegmentectomy) may be challenging. Because the lingula and lingular structures need to be preserved, they may obstruct visualization and hamper the movement of the dissecting instruments. This has been the author's experience using an anterior approach. In contradistinction, a posterior approach allows direct access to the artery and arterial branches and greatly facilitates access to the segmental bronchus. Dissection of the bronchus proceeds from back to front, away from the artery. In addition, when we are isolating and encircling the bronchus, we have already freed the artery from the bronchus and it is safely out of the way. The advantages of a posterior approach are particularly apparent when pathological nodes between the bronchus and artery make the dissection tedious, as in the case presented. Regardless of the surgical approach, S1/S2/S3 trisegmentectomy remains a challenging procedure that requires great care in its execution.