Thoracoscopic posterior approach for an S6 left lower lobe segmentectomy in a patient with an incomplete fissure: A case report

Thoracoscopic superior-segment (S6) segmentectomy is a simple procedure. However, it is applicable only when an interlobar fissure approach is applied, which can sometimes be challenging in cases with a fused interlobar fissure. Herein, we discuss our experience in performing thoracoscopic left S6 segmentectomy in a pediatric patient with congenital pulmonary airway malformation (CPAM) involving a fused interlobar fissure. A 5-year-old girl was prenatally diagnosed with a cystic mass in her left thorax and suspected to have a congenital pulmonary airway malformation. No postnatal respiratory symptoms were observed; elective surgery was performed after reaching the age when differential lung ventilation became feasible. Multiportal complete thoracoscopic surgery was performed under general anesthesia. A large cyst was identified in S6, and the interlobar fissure was fused; thus, we performed a fissure-last S6 segmentectomy using a posterior approach. We first manipulated the vein by retracting the lower lobe anteriorly thus enabling us to identify the segmental veins (V6), and subsequently divide V6a and V6c. We divided segmental arterial branches and separated the intersegmental plane between the S6 and basal segment along V6b using staplers. Lastly, the fused interlobar fissure was divided using a stapler. No postoperative leakage was observed, and the chest tube was removed on the evening of the day of surgery. Pathological examination revealed CPAM type 1 with no malignant findings. The patient survived and is living without any complications 16 months postoperatively. The fissure-last method may be an alternative treatment for patients with incomplete interlobar fissures.