胸腔鏡下後外側・後下葉（S9+10）区域切除における修正後方アプローチ：A9+10およびB9+10に対する手技

A lateral and posterior basal (S9 + 10) segmentectomy via the posterior approach is a helpful procedure that can be used for patients with incomplete lobulation. It has another benefit in that the procedure can be performed with minimal dissection of visceral pleurae in patients who may have multiple operations in the ipsilateral side of the lung. However, the difficulty associated with this procedure lies in encircling or dividing A9 + 10 and B9 + 10 in the narrow surgical field of the hilum. Therefore, we now introduce a modified posterior approach to facilitate encircling and dividing A9 + 10 and B9 + 10.

First, V9 + 10 is divided in the hilum; V7 is also divided in the right-side surgery. Second, the entire intersegmental plane between the superior (S6) and S9 + 10 segments (S6/S9 + 10) is divided along with V6b + c and its extension line. After that, B9 + 10 and A9 + 10 can be divided in the good surgical field of the hilum. Finally, the intersegmental plane between the anterior basal (S8) and S9 + 10 is divided after identifying it by using indocyanine green fluorescence imaging; the intersegmental plane between the medial basal (S7) and S9 + 10 segments is also identified and divided in the right-side surgery.

When we perform a thoracoscopic S9 + 10 segmentectomy via the posterior approach, dividing the entire S6/S9 + 10 along the run of V6b + c before encircling or dividing A9 + 10 and B9 + 10 ensures a good surgical field for the structures.