Identifying the intersegmental line using a concave portion during upper lobe apical segmentectomies

The hilum approach of intersegmental division along the intersegmental vein is difficult in the case with central vein type during upper lobe apical segmentectomy. We aimed to explore the possibilities of the simple intersegmental division used the concave portion of the apical pleura with computed tomography images.

We evaluated computed tomography images of patients who underwent anatomical lung resection between June 2020 and April 2024. The upper pulmonary vein branching pattern was categorized into apical, apico-central and central vein types. We evaluated whether the peripheral points of intersegmental veins (left V1 + 2a or right V1b) could be identified, on which portions (anterior-convex, concave and apical-convex) within the apical pleura in each branching pattern, using three-dimensional computed tomography images.

The peripheral points of the intersegmental veins of 175 subjected patients were concentrated in the anterior-convex, concave and apical-convex portions. In the left lung, the peripheral points were significantly concentrated in the concave (n = 106, 60.9%) and the anterior-convex portion of the right lung (n = 115, 67.2%). By contrast, the peripheral points were significantly identified in the concave portion of the central vein type (n = 9, 100%) in the left lung for each branching pattern of the upper pulmonary vein. There was no similar tendency in the right lung.

Peripheral intersegmental points obtained from the intersegmental veins were concentrated in the three portions constituting the concave portion of the apical pleura and especially in the concave portion of the left lung, suggesting that they can serve as convenient intersegmental line markers during upper segmentectomy.