RIGHT UPPER LOBECTOMY

The anatomy of the hilar structures of the right upper lobe is more complex than that of any other lobe, and
arterial anomalies are more common. In about 80% of individuals, the anterior segment of the right upper
lobe is partially or completely fused to the middle lobe, and a segmental dissection of this area is required.
The mediastinal pleura is incised around the hilum of the right lung, lateral to the superior vena cava,
inferior to the azygos vein, continuing posteriorly over the bronchus, anterior to the vagus nerve that is
visible subpleurally, to the level of the bronchus intermedius.

Anteriorly, the incision is carried to the level of the superior pulmonary vein, posterior to the phrenic nerve
( Fig. 27-1 A).

A pledget dissector is used to push the azygos vein superiorly, demonstrating the upper border of the right
main bronchus and the upper lobe bronchus originating from it.

Inferior to the azygocaval junction, a lymph node is found. Just below this lymph node is the upper border
of the pulmonary artery.

The areolar tissue overlying the pulmonary artery is dissected, and the superior arterial trunk is visualized.

This artery and its apical and anterior segmental branches are dissected.

The apical segmental vein crosses the anterior segmental artery, and it is often convenient to ligate and
divide this vein before dealing with the artery (see Fig. 27-1 B).

The superior arterial trunk is doubly tied with 0-0 silk; the apical and segmental branches are tied and then
divided.

If the segmental arteries are short, additional length may be obtained by dissecting with a right-angle
clamp into the pulmonary parenchyma overlying the branches, dividing the parenchyma with cautery.
Suture ligatures or clips are then applied, and the segmental arteries are divided.
After division of the superior trunk of the pulmonary artery, the common stem of the apical and anterior
segmental veins is dissected and divided. The interlobar trunk of the pulmonary artery lies directly beneath
the upper and middle stems of the superior pulmonary vein, and this dissection must be performed
cautiously.
The remaining arterial supply to the right upper lobe is the posterior ascending artery, present in 90% of
patients . Dissection of this artery can be the most formidable task in the procedure. Three approaches
have been described: an anterior approach, an approach through the oblique fissure, and a retrograde
approach.
The anterior approach requires prior division of the posterior and inferior venous tributaries of the middle
stem of the superior vein, which is closely applied to the anterior surface of the inferior trunk of the
pulmonary artery. Further dissection of the interlobar artery is required because the posterior segmental
artery arises from the anterior aspect of the interlobar artery just above the superior segmental artery.
Isolation of the right pulmonary artery may be required because laceration of the posterior ascending
artery or the interlobar artery from which it arises may occur during this dissection.
An approach to the posterior segmental artery through the oblique fissure is acceptable provided that the
oblique fissure is virtually complete. Otherwise, the artery is again

at risk for injury . The retrograde method for completion of the dissection is both safe and expeditious.

Fig. 27-1. A. Anterior aspect of the right hilum. Division of the apical segmental vein facilitates dissection
of the superior trunk of the pulmonary artery. B. The superior arterial trunk before ligation, The anterior, as
well as the apical, segmental vein has been divided to demonstrate the interlobar trunk of the pulmonary
artery.
Retrograde exposure of the posterior ascending artery proceeds as follows: Attention is directed to the
posterior aspect of the hilum. The vagus nerve is grasped with an Allis clamp and retracted, thus
demonstrating its branches to the right upper lobe. The branches are divided ( Fig. 27-2 A). Deep to the
vagal branches, the bronchial artery may be observed ; it is clipped and divided. The lower border of the
upper lobe bronchus is dissected. In the crotch between the upper lobe bronchus and the intermediate
bronchus is a constant lymph node. This node is dissected toward the specimen, clearing the inferior border
of the right upper lobe bronchus. It is not advisable to pass a clamp from the lower border of the right upper
lobe bronchus medially to encircle the bronchus because the posterior ascending artery may be lacerated.
Rather, scissor dissection of the medial surface of the bronchus is performed, sweeping areolar tissue and
nodes toward the specimen (see Fig. 27-2 B). The bronchus is not denuded of its fascia, which supplies the
vascularity required for healing. An index finger can then be inserted along the anterior aspect of the
bronchus to reach its lower border (see Fig. 27-2 C). A right-angle clamp may then be passed safely around
the right upper lobe bronchus. A Semb clamp is used to widen the peribronchial space, allowing for the
passage of a 4.8-mm stapling device. The bronchus is either stapled and divided or manually sutured. If
stapled, the staple line generally includes the bronchial artery to the right upper lobe. The cut edge of the
specimen side of the bronchus is grasped with an Allis clamp. Traction is placed on the Allis clamp, a toothed
bronchus clamp is applied, and the Allis clamp is removed. By turning the handle of the bronchus clamp
medially, thus elevating the cut bronchus, the fissure dissection is facilitated. With gentle medial traction on
the bronchus clamp, the areolar tissue and nodes are readily dissected off the interlobar pulmonary artery,
and the posterior ascending artery is identified, ligated, and divided ( Fig. 27-3 ). Occasionally, an
additional arterial branch to the anterior segment originates from the interlobar artery. Rarely, the
posterior segmental artery originates from the superior segmental artery.
Attention is next directed to the fissures, which may be managed by sharp dissection along the
intersegmental vein using partial inflation of the middle and lower lobes against the now airless upper lobe,
by stapled division, or by a combination of both methods ( Fig. 27-4 ). With the bronchus divided and the
posterior segmental artery transected, it is safe to pass a stapling device to divide the posterior aspect of
the oblique fissure. The minor fissure is similarly completed. We emphasize that attempts to divide fissures
without prior identification of the segmental arteries may lead to hemorrhage. Medial traction of the
bronchus clamp and further

dissection with the interlobar artery under direct vision lead immediately to the middle trunk of the superior
pulmonary vein and its posterior and inferior tributaries. At this point, the operator can appreciate the
intimate relationship of these branches to the inferior trunk of the pulmonary artery ( Fig. 27-5 A). The
common stem of the posterior and inferior veins is identified, and the site of insertion of the middle lobe
vein into the superior pulmonary vein is identified and preserved. The venous stem is doubly ligated, as are
the posterior and inferior veins, which are then divided. The stapling device generally is not useful for
managing the right superior pulmonary vein. The importance of minimizing air leak from the middle lobe
cannot be overemphasized. The intersegmental vein defines the proper plane of dissection.

Fig. 27-2. A. Posterior aspect of the right upper lobe hilum after division of the mediastinal pleura. Vagal
branches posterior to the bronchus are not yet divided. B. The right upper lobe bronchus is dissected. C.
Finger dissection separates the bronchus from the interlobar pulmonary artery.

Fig. 27-3. The bronchus has been stapled and divided. Medial traction on the specimen facilitates dissection
of the posterior ascending artery.


Fig. 27-4. The oblique fissure is completed by a sharp, and blunt dissection and is stapled where required.
After the specimen is removed, the pleural cavity is irrigated, and the bronchial closure is tested. The
inferior pulmonary ligament is divided, allowing rotation of the lower lobe to facilitate complete filling of the
pleural space. Because the fissure between the middle and lower lobes is generally complete, torsion of the
middle lobe is possible. To prevent such torsion, the edges of the partially expanded middle and lower lobes
are grasped with an Allis clamp, and a silk tie is used to approximate these edges along the course of the
fissure (see Fig. 27-5 B). A single application of a TA-30 stapling device accomplishes the same results, at
much greater cost.

Fig. 27-5. A. Retracting the lobe medially and stapling the minor fissure exposes the middle trunk of the
superior pulmonary vein. Note the relationship of this trunk to the underlying interlobar pulmonary artery.
The middle lobe vein has been identified and preserved. B. Edges of the middle and lower lobes are
approximated with silk ties to prevent middle lobe torsion.



MIDDLE LOBECTOMY
Middle lobectomy is not commonly performed as an isolated procedure. In years past, it was performed for
middle lobe syndrome. Incomplete fissure and hyperplastic or calcified lymph nodes, adherent to
segmental arteries and the middle lobe bronchus, made it a formidable procedure, generally requiring
proximal control of the right pulmonary artery.
Most often, middle lobectomy is performed in association with either upper or lower lobectomy for tumors
that cross fissures. Combined middle and lower lobectomy was often required for the treatment of
bronchiectasis.
If upper and middle lobes are resected, the bronchi are closed separately; for middle and lower lobectomy,
the bronchus intermedius is divided just distal to the right upper lobe bronchus. The major fissure is opened,
and the lower lobe is retracted posteriorly ( Fig. 27-6 A). By following the posterior edge of the middle lobe
as it joins the
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major fissure, and dissecting deep within the fissure, lymph nodes are noted, indicating the site of the
interlobar pulmonary artery. The artery is dissected proximally in the subadventitial plane, and the middle
lobe artery is identified ( Fig. 27-6 B). Generally, two middle lobe arteries exist; the first one identified
arises from the interlobar artery anteriorly, more or less opposite to the superior segmental artery arising
posteriorly. Further proximal dissection of the interlobar artery demonstrates a second, and rarely a third,
artery to the middle lobe. Occasionally, an anomalous branch of the middle artery to the upper lobe is
identified. After ligation and division of the middle lobe arteries, the table is rotated posteriorly, and the
anterior aspect of the hilum is dissected, isolating and ligating the middle lobe vein that enters the lower
portion of the superior pulmonary vein ( Fig. 27-7 ). After division of the middle lobe vein, the bronchus is
readily accessible ( Fig. 27-8 A). In difficult dissections, it may be more expeditious to divide the middle
lobe vein, isolate and divide the bronchus, and then ligate and divide the middle lobe arteries. Manual
suturing is generally easier than inserting a stapling device.

Fig. 27-6. A. Dissection of the oblique fissure at its junction with the horizontal fissure demonstrates the
interlobar pulmonary artery and its branches. One middle lobe artery is divided. B. Dissection of the oblique
fissure at its junction with the horizontal fissure demonstrates the interlobar pulmonary artery and its
branches. One middle lobe artery is divided.
The closed middle lobe bronchus is deep within the parenchyma, and disruption of this bronchial closure is
virtually unknown. The distal portion of the transected middle lobe bronchus is grasped with a bronchus
clamp. Using differential inflation and traction on the bronchus clamp, the fissure may then be completed
along the lines of the intersegmental veins, by a combination of sharp and blunt dissection and stapling (see
Fig. 27-8 B). After completion of the fissure and removal of the specimen, the raw surfaces of the upper
lobe are approximated to the lower lobe by several ties to help seal air leak.


RIGHT LOWER LOBECTOMY
The oblique fissure is opened while retracting the right upper and middle lobes anteriorly and the lower lobe
posteriorly. The interlobar pulmonary artery is deeply situated in the region where the oblique and
horizontal fissures meet ( Fig. 27-6 B). The temptation to staple and divide areas of fusion between the
posterior segment of the right upper lobe and the superior segment of the lower lobe before demonstrating
the interlobar pulmonary artery and its branches must be avoided. The visceral pleura overlying the
interlobar artery is opened, and the pulmonary artery is dissected. The middle lobe artery, originating from
the anteromedial surface of the interlobar artery, must be demonstrated. Directly opposite and
posterolaterally lies the superior segmental artery. Rarely, the posterior ascending artery to the upper lobe
originates from the superior segmental artery. Occasionally, the superior segment of the right lower lobe
has two branches. Often, it is best to isolate and divide the

basal arteries first, distal to the middle lobe and superior segmental arteries ( Fig. 27-9 ). The basal arteries
may have a short common trunk from which two branches originate: one supplying the anterior and medial
segments, and the other supplying the posterior and lateral segments. Occasionally, the four basal
segmental arteries originate separately distal to the middle lobe artery, and dissection into the lung
parenchyma is required to obtain adequate length for ligation and division. Attention is then directed to
securing the superior segmental artery, taking care to preserve the posterior segmental artery to the right
upper lobe.

Fig. 27-7. The anterior mediastinal pleura is incised. The middle lobe vein is isolated and divided.

Fig. 27-8. A. The middle lobe bronchus is identified. The line of bronchial transection is illustrated . B.
Traction on the specimen bronchus and differential inflation facilitate completion of the horizontal fissure.
C. Hilum after middle lobectomy.

Fig. 27-9. Arterial supply of the right lower lobe. The origin of the middle lobe artery is visualized. Stapling
the posterior portion of the oblique fissure facilitates the dissection of the superior segmental artery.
The lobe is retracted anteriorly and superiorly. The inferior pulmonary ligament is divided up to the lymph
node at the lower border of the inferior pulmonary vein ( Fig. 27-10 A). The posterior mediastinal pleura is
incised over the posterior surface of the inferior pulmonary vein, which is cleared of areolar tissue, and the
pleural incision is carried superiorly to above the level of the bronchus intermedius. The interval between
the lower border of the bronchus and the superior pulmonary vein is dissected. The anterior surface of the
inferior pulmonary vein is then cleared. With an index finger serving as a guide, the inferior pulmonary vein
is then isolated, using a Semb clamp (see Fig. 27-10 B). The interval between the lower lobe bronchus and
the inferior vein is widened so that a vascular stapler may be inserted to occlude the cardiac end of the vein.
The extrapericardial portion of the right inferior pulmonary vein is short. It is not advisable to ligate the vein
because the tie may spring off the fibrous pericardium. Rather than sacrifice length, application of a Sarot
clamp to the specimen side of the vein and cutting on the clamp ensure sufficient length of the vein to be
clamped and closed by a vascular suture or divided after application of a vascular stapler (see Fig. 27-10 C).
Alternatively, the superior and basilar segmental veins are ligated individually. The lower lobe bronchus is
then dissected. Because the middle lobe bronchus and the superior segmental bronchus originate from the
intermediate bronchus at almost the same level, it may be necessary to close the basal segmental bronchus
and the superior segmental bronchus separately to avoid obstructing the middle lobe bronchus. Usually, an
oblique application of the 4.8-mm stapling device does not occlude the middle lobe bronchus ( Fig. 27-11
A). It is advisable to apply the stapler, close it without firing, and then reaerate the right lung to ensure the
patency of the middle lobe bronchus. Although a similar anatomic situation exists with regard to left lower
lobe bronchus and the lingular bronchus, the risk for occluding the middle lobe bronchus is far greater than
that for occluding the lingular


bronchus. Alternatively, the lower lobe bronchus may be sutured as previously described.

Fig. 27-10. A. The lung is retracted anteriorly. B. The inferior pulmonary ligament is divided. ( continued )

Fig. 27-11. A. Oblique transection of the right lower lobe bronchus preserves patency of the middle lobe
bronchus. B. Oblique transection of the right lower lobe bronchus preserves patency of the middle lobe
bronchus.
LEFT UPPER LOBECTOMY
The most common anatomic variation encountered during left upper lobectomy is the number of segmental
arterial branches, which vary from three to eight. The procedure is straightforward, provided the apical and
anterior arteries are not injured during their isolation and division. To best accomplish this safely, proximal
control of the left pulmonary artery is recommended, and these proximal branches are the last to be
dissected and divided.
The left lung is retracted inferiorly, and the mediastinal pleura overlying the pulmonary artery is incised
( Fig. 27-12 A). After identification of the course of the phrenic nerve, the pleural incision is carried over the
medial portion of the superior pulmonary vein just lateral to the pericardium ( Fig. 27-12 B). Posteriorly, the
incision is made to a point below the level of the bronchus. The vagus nerve is visible subpleurally, marking
the posterior limit of the hilar dissection ( Fig. 27-13 ). Areolar tissue overlying the convex surface of the
pulmonary artery is cleared. The upper border of the left main bronchus is defined after division of vagal
branches. A pledget dissector is used to roll the pulmonary artery away from the left main bronchus.
Anteriorly, the interval between the pulmonary artery and the superior pulmonary vein is defined, and
again the pulmonary artery is rolled out of its sheath, allowing an index finger to encircle the artery ( Fig.
27-14 ). A Semb clamp may then be used to draw a Silastic vessel loop around the artery. The ends of the
loop are tied with a heavy silk suture, and the loop is allowed to lie in the chest, readily accessible in the
event of pulmonary artery injury.
The lung is retracted anteriorly, and the pulmonary artery is dissected into the oblique fissure ( Fig. 27-15
A). If necessary, the posterior part of the fissure is completed with clamps or a stapler with the pulmonary
artery visualized. The pulmonary artery is dissected over the middle point of its presenting surface as it
curves around the left upper lobe bronchus. As the fissure dissection proceeds, the posterior segmental
arteries are noted opposite the superior segmental artery (see Fig. 27-15 B). Further distal dissection
demonstrates one or two lingular arteries; the arterial dissection is complete when the basilar segmental
branches are identified. With the lower lobe retracted inferiorly and the upper lobe retracted superiorly, the
lingular branches are isolated and divided. The upper lobe is then rotated clockwise and the posterior
segmental branches are ligated and divided. Proceeding in this fashion, from the lingular arteries
proximally and rotating the lobe, makes each subsequent arterial isolation easier. The apical and anterior
branches arise from the convex surface of the pulmonary artery often as a short trunk, slightly anterior to
the middle point of the artery. These branches are the last to be divided ( Fig. 27-16 ). Ligation and division
of the apical segmental vein may enhance the visualization of the apical and anterior segmental arteries.
The now completely mobilized pulmonary artery is rolled away from the upper lobe bronchus and is
inspected for anomalous branches originating from its medial surface. This maneuver facilitates the later
transection of the bronchus.

Fig. 27-12. A, B. The mediastinal pleura is incised, and the pulmonary artery is dissected in the
subadventitial plane. The interval between the pulmonary artery and the superior pulmonary vein is
defined.

Fig. 27-13. Dissection of the posterior aspect of the left upper lobe hilum medial to the vagus nerve.
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The lobe is retracted posteriorly, and the anterior surface of the superior pulmonary vein is cleared of
areolar tissue. The posterior surface of the pulmonary vein is freed by carrying the dissection on the
anterior surface of the bronchus just external to the peribronchial connective tissue. Three or four branches
enter the superior pulmonary vein and are encircled with ligatures. The extrapericardial length of
pulmonary vein is often inadequate for safe ligation; therefore, it is an ideal place for the use of a vascular
stapler. In the absence of a stapling device, the branches are tied, a vascular clamp is applied proximally,
and the vein is divided and then closed with a vascular suture. It is often easier to divide the bronchus first.
To divide the bronchus at the appropriate level, the interval between the lingular bronchus and the lower
lobe bronchus is defined by rolling the pulmonary artery posteriorly, thus exposing the bifurcation of the left
main bronchus ( Fig. 27-17 A). The upper lobe bronchus is occluded with a stapling device. Differential
inflation ensures that the lower lobe bronchus is not compromised; the stapler is fired , and the bronchus
is transected with a Semb clamp positioned between the bronchus and the vein to protect the vein. After
closure of the bronchus, the specimen end of the bronchus is grasped with a bronchus clamp. Elevation of
the clamp exposes the deep surface of the superior pulmonary vein (see Fig. 27-17 B). The superior
pulmonary vein is then managed as previously described. The inferior pulmonary ligament is divided to
allow the left lower lobe to advance upward to better fill the thoracic cavity.
LEFT LOWER LOBECTOMY
Provided that the oblique fissure is complete, left lower lobectomy is the simplest of all to perform; vascular
anomalies are not commonly noted. The lung is retracted anteriorly, and the posterior mediastinal pleura is
incised from the level of the bronchus to the inferior pulmonary ligament, which should be divided at this
time. The upper lobe is retracted anteriorly and superiorly, and the lower lobe is moved posteriorly and
inferiorly, exposing the pulmonary artery in the fissure ( Fig. 27-18 A). It is best to commence dissection of
the pulmonary artery from its sheath at the posterior aspect of the fissure. If the fissure is obliterated by
adhesions, dissection of the posterior segment of the upper lobe from the superior segment of the lower
lobe is accomplished by pledget dissection of the interlobar pulmonary artery from the overlying
parenchyma as well as by the creation of a tunnel so that a stapling device or clamps may be inserted to
complete enough of the fissure to allow further exposure of the interlobar artery. The anteromedial portion
of the fissure is easily completed after bronchial closure. The superior segmental artery arises from the
posterolateral surface of the interlobar pulmonary artery at a slightly lower level than the posterior
segmental artery to the left upper lobe. Dissection of the interlobar artery along its midpoint is continued
to delineate the origin of the lingular arteries, which must not be sacrificed. The basal trunk is then
dissected, exposing the basal segmental branches. Occasionally, it is possible to double-ligate the basal
trunk distal to the lingular arteries and have one distal tie, but usually the basal branches must be ligated
separately to ensure adequate length of the proximal stump ( Fig. 27-18 B).

Fig. 27-14. A, B. The left pulmonary artery is dissected from the left main bronchus and is encircled with a
Silastic loop.

Fig. 27-15. A, B. The posterior portion of the fissure is completed by stapling, and the segmental arteries
are demonstrated.

Fig. 27-16. A, B. After division of the lingula and posterior segmental arteries, rotation of the lobe aids
dissection of the apical and anterior segmental arteries.

Fig. 27-17. A. The pulmonary artery is rolled away from the left upper bronchus. The site of bronchial
transection is indicated. B. The left upper lobe bronchus is stapled and divided. The superior pulmonary vein
is stapled and occluded distally by a Sarot clamp. C. Left upper lobe hilum after lobectomy.

Fig. 27-18. A. Oblique fissure is completed, and pulmonary artery branches are demonstrated. B. The
superior segmental artery is ligated. Basal arteries are ligated and divided after the lingula arterial branches
are demonstrated.

Fig. 27-19. A. The interval between the pulmonary vein and the lower lobe bronchus is defined. B. The
inferior pulmonary vein has been stapled. A Sarot clamp is applied to the specimen side before transection.

Fig. 27-20. A. Oblique transection of the bronchus prevents formation of a cul de sac. B. View of the hilum
after left lower lobectomy.
The inferior pulmonary vein is then cleared of areolar tissue, demonstrating its superior segmental and
basal tributaries, and the interval between the bronchus and the vein is defined ( Fig. 27-19 A). The
extrapericardial portion of the left inferior pulmonary vein is longer than the right; double proximal ligation
is acceptable. The preferred management, however, is stapling the cardiac end of the vein, or application
of a vascular clamp and suture. Additional length may be obtained by occluding the specimen side with a
Sarot or other nonslipping clamp (see Fig. 27-19 B).
The bronchus is cleared of areolar tissue, and the crotch below the upper lobe bronchus is dissected. The
stapling device is applied just distal to the upper lobe bronchus to avoid creating a cul de sac, or the
bronchus is closed manually as described previously ( Fig. 27-20 ).
ACKNOWLEDGMENT
The authors gratefully acknowledge the support of the Feldesman Fund for Thoracic Surgery at Montefiore
Medical Center.
REFERENCES
Blades B, Kent EM: Individual ligation technique for lower lobectomy. J Thorac Surg 10 :84, 1940.
Lewis RJ, Sisler GE, Caccavale RJ: Imaged thoracic lobectomy: should it be done? Ann Thorac Surg 54 :80,
1992.
McCaughan BC, et al: Chest wall invasion in carcinoma of the lung. J Thorac Cardiovasc Surg 89 :836, 1985.
Overholt RH, Langer L: The Technique of Pulmonary Resection. Springfield, IL: Charles C. Thomas, 1951.
Trastek VF, et al: En bloc (non-chest wall) resection for bronchogenic carcinoma with parietal fixation.
Factors affecting survival. J Thorac Cardiovasc Surg 87 :352, 1984.
Reading References
Edmunds JH Jr, Norwood WI, Low DW: Atlas of Cardiothoracic Surgery. Philadelphia: Lea & Febiger, 1990.
Waldhausen JA, Pierce WS (eds): Johnson's Surgery of the Chest. 5th Ed. Chicago: Year Book, 1985.