Right upper lobe

Abstract

The right upper lobectomy is a difficult endoscopic procedure. Difficulties are from several orders. The operative field is large, and the scope has to switch from the anterior to the posterior mediastinum and from the apex to the diaphragm. In addition, the following difficulties may be faced:

• • The major fissure is frequently fused and sometimes crossed by posterior venous branches from the superior vein.

• • Lymph nodes are frequently present at the level of the upper bronchus and can lead to oozing or troublesome hemorrhage during dissection.

• • The superior vein and the truncus anterior may be close to each other, so their dissection can be tough. In some cases, it is more advisable to dissect partly from the front and partly from the back. This may require to divide the lobar bronchus first.

• • Identifying the interlobar plane between the right upper lobe and the middle lobe can take time.

• • Finally, once the upper lobectomy has been completed, securing the middle lobe to the lower lobe is not that simple, because of the lack of global view that makes the proper positioning of the middle lobe sometimes difficult, especially when the latter is fully mobile. Two different approaches can be used: (1) a classic anterior approach in which the truncus arteriosus and the superior pulmonary vein are controlled first and (2) a posterior approach in which the bronchus is divided first. If necessary, these two approaches can be combined.