Thoracoscopic electrocautery-based bidirectional S9-10 segmentectomy

Segmentectomies for the lateral basal segment (S9), posterior basal segment (S10), or both are considered most difficult anatomical segmentectomies (1). They are located deep in the lung parenchyma, far from the interlobar fissure. Besides, the intersegmental plane is cuboid-shaped, making it difficult to fold into a two-dimensional plane by stapler. To solve this problem, several different strategies were proposed. One is the “intersegmental tunnelling” method (2). It features by separating superior (S6) and basal segments first by constructing a tunnel between S6 and S10. This method could be helpful for sufficient dissection of A9/10 and B9/10; however, it results in complete separation of S6 and S8. Possible torsion of the remaining S6 after complete separation is a big concerning. Another strategy is posterior approach or pulmonary ligament (PL) approach, which tracks the anatomy from the pulmonary vein. This method has also its shortcomings: first, a good exposure of pulmonary artery and bronchus is difficult, sometimes resulting confusion. Besides, compared to conventional procedures from the interlobar fissure, this method carries a greater risk of incomplete lymph node dissection. To overcome the difficulties and to achieve satisfactory surgical outcomes, we herein report the thoracoscopic electrocautery-based bidirectional S9-10 segmentectomy.