The tips of uniportal thoracoscopic lateral and posterior basal (S9+10) segmentectomy

The appropriate lateral and posterior basal (S9+10) segmentectomy requires exposure and recognition of common basal pulmonary vein or artery branches located deeply in lung parenchyma. It is helpful for thoracic surgeons to know pulmonary vessels running direction information preoperatively to perform appropriate S9+10 segmentectomy, which is also applied to other complicated segmentectomy. Therefore, a 3-dimensional image of computed tomography angiography (3D-CTA) is performed for any patient who is having pulmonary segmentectomy in our institution. Several procedures were introduced to perform appropriate S9+10 segmentectomy in previous studies. Among them, unidirectional dissection is considered suitable for uniportal thoracoscopic S9+10 segmentectomy because the angle of dissection in uniportal approach has limitations although our team previously reported the efficacy of "intersegmental tunneling" method in S9+10 segmentectomy via multiportal approach. Additionally, we consider that selective inflation of target segment by jet-ventilation or intravenous indocyanine green injection might be better way to identify an intersegmental plane in uniportal thoracoscopic approach due to the limited working space although the best way to identify an intersegmental plane is controversial. In Japan, some institutions use electrocautery to divide the intersegmental plane. However, electrocautery cutting in intersegmental division might not be suitable for uniportal approach because electrocautery cutting requires countertraction which is difficult to perform in uniportal approach. Therefore, we usually use staplers to divide intersegmental plane in uniportal pulmonary segmentectomy. Finally, we show the video describing uniportal thoracoscopic S9+10 segmentectomy in our institution.