Intravascular Stapling Technique for Interlobar Fissure Division in the Left Lower Lobectomy

Abstract

Introduction: Prolonged air leak is the most common complication after pulmonary resection. This occurs more frequently in patients with incomplete interlobar fissure, chronic obstructive pulmonary disease, or emphysema. Interlobar lymphadenopathy can make interlobar fissure division difficult.

Surgical technique: Several techniques of interlobar fissure division have been documented. The interlobar fissure is routinely divided using a stapler during pulmonary lobectomy. Normally, a stapler is used extravascularly. Here, we present a patient who successfully underwent interlobar fissure division wherein the jaw of the stapler passed through the interlobar pulmonary artery between A6 and A8 branches during resection of a lung squamous cell carcinoma in the left lower lobe with an interlobar lymphadenopathy.

Conclusion: Interlobar fissure division inserting a jaw of stapler into pulmonary artery is easy and useful option for left lower lobectomy. This technique is especially useful for a patient with an interlobar lymphadenopathy.

Keywords: interlobar fissure division; left lower lobectomy; lymphadenopathy; pulmonary artery; stapling.

Fig. 1. Preoperative chest computed tomography scan shows a 3.1 cm squamous cell carcinoma in the lateral basal segment (S⁹) of the left lower lobe with an interlobar lymphadenopathy, and both superior and inferior lingular arteries descending between the upper pulmonary vein and bronchus from the left main pulmonary artery.

Fig. 2. Intraoperative view of interlobar fissure division. (A) Cutting a peripheral resection stump of the interlobar pulmonary artery. (B) Inserting forceps into the interlobar pulmonary artery stump. (C) Passing the jaw of the stapler through the interlobar pulmonary artery following a Penrose drain guide. (D) The remaining posterior wall of the interlobar pulmonary artery.

Video legend (The video is available online) Intraoperative video from transection of the pulmonary artery to interlobar lymph node dissection. The pulmonary artery was also transected using a vascular stapler between A¹⁺²c branch and A⁶a branch. Cutting a peripheral resection stump of the interlobar pulmonary artery. Inserting forceps into the interlobar pulmonary artery stump. Passing the jaw of the stapler through the interlobar pulmonary artery following a Penrose drain guide. Dissecting the interlobar fissure including the anterior wall of the interlobar pulmonary artery between A⁶ and A⁸ branches. The interlobar lymph node dissection after cutting remaining posterior wall of the interlobar pulmonary artery.