be performed. On the left side, an apical or basal segmentectomy may again be performed for the lower lobe.

Overall, segmentectomy is most often done for the superior segments of the lower lobes. The next most common segmentectomy is the lingulectomy. These will now be discussed.

For the superior segmentectomy of either side, first the arterial and venous supplies of the superior segment are taken. This includes careful dissection to avoid injury to the right middle lobe artery on the right and the lingular artery on the left within the fissure. Likewise, the right middle lobe vein and the left lingular vein need to be carefully identified to avoid injury to the left and right superior pulmonary vein. After the vessels are taken, the superior segmental bronchus is clamped, being careful to avoid the right middle lobe orifice or the left upper lobe orifice. With the superior segmental bronchus clamped, the lung is inflated. The noninflated portion of the lung represents the superior segment which is then staple resected with a GIA or TA instrument.

A similar overall procedure is carried out when performing a basal segmentec-tomy on either side, except that the superior segmental vessels and bronchus are preserved and it is the basal segmental vessels and bronchus that are taken. Similarly, the basal segmental bronchus is clamped and when inflating, it is the basal area that will remain noninflated; it is this that is staple resected.

For a lingular segmental resection, the lingular artery is controlled in the fissure. The lingular vein is then taken. Finally, the lingular bronchus is clamped, the lung inflated and that portion of the lung not inflating (corresponding to the lingula) is staple resected.

Generally, segmentectomy is an inferior cancer operation to a lobectomy, although a segmentectomy is more anatomic and therefore a superior operation to a wedge resection for neoplasia. Nonetheless, wedge resections and segmentecto-mies have definite roles in patients who have limited pulmonary reserve and in whom a lobectomy would not be safe because of poor predicted postoperative pulmonary functions.

Sleeve Resection

A sleeve resection is a localized resection of a bronchial orifice with a bronchoplasty or reimplantation of the distal bronchial segment to the proximal bronchial segment. This is shown in Figures 12.11 and 12.12a-c. Those lesions which are amenable to sleeve resection are a tumor in the orifice of the right upper lobe bronchus; a tumor at the orifice of the middle lobe bronchus; a tumor at the orifice of the left upper lobe bronchus or at the orifice of the left lower lobe bronchus. The most common indication for a sleeve resection is a carcinoid tumor at the orifice of the right upper lobe bronchus. In this case, a right upper lobectomy can be performed with resection of the orifice of the right upper lobe and the distal portion of the right mainstem bronchus, as well as the proximal portion of the bronchus intermedius. The bronchus intermedius is then anastomosed to the right mainstem bronchus as a bronchoplasty. The advantage is that the right middle and right lower lobes are preserved. More malignant tumors at the origin of the right upper lobe bronchial orifice may likewise undergo bronchoplasty. Without a bronchoplasty sleeve resection procedure, a pneumonectomy would be required for such a lesion. The technical details of a right upper lobe sleeve resection will be described.

A right 4th to 5th intercostal space posterolateral thoracotomy is performed and assessment is made for resectability, i.e. critical search for mediastinal nodes, interlobar nodes or diffuse metastases, all of which would preclude a sleeve resec-

Fig 12.11. Tumor locations for which sleeve resections are technically feasible.

Sleeve Resection Bronchus Intermedius

Right main stem bronchus

Posterior ascending artery
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