Thoracoscopic segmentectomy and lobectomy assisted by three-dimensional computed-tomography bronchography and angiography for the treatment of primary lung cancer

Figure 2 Presurgical confirmation of anatomical variations. Preoperative three-dimensional (3D) computed-tomography bronchography and angiography images can clearly and vividly display the targeted segmental structure and variations of vessels and bronchi. A: The bronchus of the right upper lobe is divided into the apical segmental bronchus (B¹), posterior segmental bronchus (B²), and anterior segmental bronchus (B³). The distance between the B³a and B³b of the anterior segmental bronchus is very great; B: The 3D image reveals the variations of the right upper-lobe artery: the A³a originates from the distal end of the A¹, while the enlarged A³b coexists with the proximal end of the A¹. Care should be taken to protect A¹ when dealing with the A³b during the surgery; C: The segmental and sub-segmental veins of the right upper lobe are labeled successively in the 3D image. There was no central vein, and the V² a flowed into the apex vein (V¹) through the upper pulmonary hilum; D: The 3D image reveals the variations of the B² and V² in the right upper lobe. The B² branched out separately, but the B¹ and B³ arose from a common stem. When the B¹ is resected, the surgeon often accidentally resects the B³ as well. Additionally, the right upper posterior pulmonary vein (V²) merged into the right inferior pulmonary vein (RIPV). When the surgeon deals with the right lower pulmonary vein, the V² could be mistakenly cut off altogether, leading to postoperative hemoptysis; E: The 3D image demonstrates the variation of the mediastinal lingual-segment artery (Med A⁴⁺⁵) in the left upper lobe. The A⁴b and A⁵ of the left upper lingual-segment artery originated from the upper pulmonary trunk, while the A⁴a originated from the interlobar-fissure artery separately. When left superior segmentectomy is performed, it is possible to cut off the A⁴b and A5 at the same time, resulting in decreased pulmonary blood flow to lingular-segment lung tissue and an imbalanced ventilation: Blood flow ratio.