[A new technical procedure for middle and lower lobe lobectomy]

Among combined pulmonary resections, one of the most difficult operations is right middle and lower lobe lobectomy because of the very intricate anatomical relations between the three pulmonary lobes. Technical difficulties during the first-stage approach to the pulmonary artery in the fissure are compounded by the presence of pathological processes (neoplasm, suppuration, etc.) which provoke adhesions between the pulmonary artery and the bronchus, with inevitable major risks. A new technique for middle and lower lobe lobectomy which avoids the frequent accidents during this operation is described. The first stage involves ligature and section of the inferior root of the superior pulmonary vein and liberation of the horizontal fissure. Opening of the horizontal fissure exposes the superior fissural vein, which is then displaced towards the upper lobe. This allows access to the pulmonary artery in the fissure, together with its branches to the lower and middle lobes, and the fissural arteries to the upper lobe. This procedure enables simple dissection and ligature of the pulmonary artery, as at this level it is not adherent to the intermediary part of the bronchus. The triangular ligament, inferior pulmonary vein, and intermediary bronchus are then ligatured and sectioned. The advantages of this method consist in the simplification of the dissection, ligature, and section of the pulmonary artery in the fissure, and the need to apply only one ligature if there are no anatomical variations (common dorsal fissural and inferior apical artery, or common ventral fissural and middle lobe artery).