Surgical technique for minimally invasive segmentectomies of the right lung: anatomic rationale for a posterior approach.

Segmentectomies are potentially more complex than lobectomy because of gradually more complex anatomic relationships between more delicate bronchovascular structures. Operative approaches include thoracoscopic (multiport, uniportal), and robotic. The details of surgical technique continue to evolve, especially for so-called "atypical" or "complex" segmentectomies. In theory, most segments are amenable to individual resection or may be resected as a portion of bisegmentectomies (e.g. lingular resection). Most surgical approaches involve an anterior approach and at least some dissection within the fissures to identify the pulmonary artery and its branches. This approach may work well for segments whose bronchovascular hila are readily accessible anteriorly, such as segments S3, S7, and S8. However, the hila of other segments, specifically S2, S6, S10, and often S1 are located posteriorly and complex dissection is required through an anterior approach just to reach their hila. The posterior approach aims to simplify the surgical procedure, minimize surgical tissue trauma and preserve tissue planes. This may help minimize air leaks, decrease postoperative complications and length of stay, and facilitate future surgical resections in the case of metachronous lesions. This paper describes the anatomic rationale and step-by step technique for a posterior approach for right-sided segmentectomies S1,2,6,10.