Uniportal VATS Left Upper Lobectomy: Report of Two Cases with a Variant Interlobar Pulmonary Artery

The left upper lobectomy is considered by many surgeons to be the most difficult lobectomy performed using minimally invasive VATS approaches. Part of this difficulty is due to the frequent variability of the vascular anatomy of this region, especially when the interlobar fissure is incomplete or missing.

In some cases of left upper lobectomies, in addition to the possible variations of the arterial and venous branches to the upper lobe itself, the arterial branches to the left lower lobe can emerge in an abnormally proximal/high position from the interlobar pulmonary artery, outside the fissure plane. In situations where the fissure is complete and visualization of the vessels is easy, this evaluation tends to be simple and immediate, thus providing the proper preservation of the anomalous arterial branches to the left lower lobe. However, when the fissure is incomplete or absent, visualization of arterial branches over the interlobar fissure may be difficult or even impossible. In those cases where the "fissureless technique" needs to be employed, the approach must be even more cautious in order to avoid bleeding and/or inadvertent ligation of arterial branches (variants or not) to the left lower lobe.

This video examines the example of two similar operations performed in a hospital in Spain and a hospital in Brazil, using the same uniportal VATS technique. The purpose of this video is to demonstrate how the approach by uniportal VATS offers a direct view of the hilum, giving a clear and safe view of the fissure from its anterior and most inferior aspect. This is based on specific anatomic landmarks, initially from the space between the superior and inferior pulmonary veins, then the left main bronchus division, and then the interlobar pulmonary artery and surrounding lung parenchyma.