Oblique Fissure Research Articles

Early radiologic and bronchoscopic changes after bronchial thermoplasty in patients with severe asthma.

Bronchial thermoplasty (BT) is a treatment to reduce the airway smooth muscle mass by delivering radiofrequency thermal energy to the airways. BT is used in patients with severe asthma. The present study reported on cases of pneumothorax directly after BT and retrospectively analyzed early radiologic and bronchoscopic modifications after BT. The clinical data and radiologic and bronchoscopic findings of 12 patients with severe asthma who were subjected to BT between July 2014 and October 2017 were analyzed. A total of 33 chest radiographs were collected within 18-24 h after BT. Radiological abnormalities were observed in 32 radiographs as atelectasis (53.1%), peribronchial consolidations (84.4%), pleural effusion (18.8%), effusion in oblique fissures (3.1%), pleural thickening (6.3%) and pneumothorax (3.1%). Of note, one patient suffered pneumothorax after the third BT session and underwent chest drain insertion, followed by mechanical ventilation at the intensive care unit and multiple bronchoscopic interventions, which revealed extensive phlegm plugs. A total of six patients with worsened symptoms and lobar atelectasis also required bronchoscopic intervention, which revealed that phlegm plugs occluded the bronchus in the treated lobe. No bronchoscopic intervention was required in the remaining five patients. During 16-30 days of follow-up, 95.7% of the findings on chest radiography were resolved. To the best of our knowledge, the present study reported the first case of pneumothorax following BT. Early radiologic modifications such as atelectasis and peribronchial consolidations appear common after BT. However, whether bronchoscopic intervention is required for atelectasis following BT warrants further investigation. Of note, BT should be audited and recorded in detail to ideally contribute to a framework of clinical trials to improve risk-benefit evaluations and the selection of patients likely to benefit from treatment.

RIGHT MIDDLE LOBE TORSION IN THE SETTING OF ABERRANT BRONCHIAL ANATOMY

SESSION TITLE: Medical Student/Resident Cardiothoracic Surgery Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Pulmonary torsion (PT) is defined as twisting of the entire lung or lobe around its bronchovascular pedicle. This disorder most commonly involves the right middle lobe (RML) following right upper lobe (RUL) lobectomy. The objective of this report is to describe a case of RML torsion following RUL lobectomy, in the setting of aberrant bronchial anatomy, which potentially led to this problem. CASE PRESENTATION: A 61-year-old African American woman with a RUL nodule, suspected to be cancerous, presented for RUL lobectomy. Flexible bronchoscopy revealed a right mainstem bronchus (RMB), which ended in a trifurcation of the upper, middle, and lower lobe bronchi. During thoracotomy, the inferior pulmonary ligament (IPL) was divided and RUL lobectomy was completed. Her major and minor fissures were noted to be partially complete and she had a short pedicle to the RML. As her risk of developing RML torsion was deemed to be low, no prophylactic fixation was done. Pathology confirmed the nodule to be a T1a N0M0 stage I adenocarcinoma. Post-operatively she complained of chest pain and hemoptysis. CT scan of the chest showed opacification of the right upper hemithorax, and RML torsion was suspected. Subsequent bronchoscopy showed that the RML bronchi were extrinsically compressed. Thoracoscopy demonstrated that the RML was torsed and engorged with venous blood (Figure 1). A thoracotomy and RML lobectomy were performed. Final pathology showed ischemic necrosis and hemorrhage. DISCUSSION: Ordinarily, the RMB gives rise to the RUL bronchus and the bronchus intermedius, which then bifurcates into the RML and right lower lobe (RLL) bronchi. The bronchus intermedius was absent in this patient and, instead, the RMB ended in a trifurcation of the RUL, RML, and RLL bronchi. The risk of RML torsion increases with division of the IPL in patients with complete pulmonary fissures and a lack of parenchymal bridges between the lobes prior to surgery. These factors increase the mobility of the RML, while the presence of a long pedicle predisposes to additional rotation along the bronchovascular pedicle.(1-3) This patient, despite lacking these risk factors, still developed RML torsion after RUL lobectomy. We speculate that the aberrantly located RUL takeoff, once resected, increased the range of rotational motion of the RML relative to the RLL, resulting in torsion of the RML. CONCLUSIONS: In patients at risk for RML torsion after RUL lobectomy, incomplete severing of the IPL and prophylactic inter-lobar fixation (or fixation to the thoracic wall or cardiac fat pad) are suggested. (2,3) Such measures may need to be considered in patients with a trifurcate RMB. Reference #1: Felson B. Lung torsion: Radiographic findings in 9 cases. Thoracic Radiology 1987 March; 162(3): 631-8. Reference #2: Moser E, Proto A. Lung torsion: Case report and literature review. Thoracic Radiology 1987 March; 162(3): 639-43. Reference #3: Kanemitsu S, Tenaka K, Suzuki H et al. Pulmonary torsion following right upper lobectomy. Ann Thorac Cardiovasc Surg 2006; 12: 417-9. DISCLOSURES: No relevant relationships by Batool Abuhalimeh, source=Web Response No relevant relationships by Joseph Lahorra, source=Web Response No relevant relationships by Tanya Marshall, source=Web Response No relevant relationships by Sanjiv Tewari, source=Web Response

AN UNUSUAL PRESENTATION OF ENDOBRONCHIAL ASPERGILLOMA

SESSION TITLE: Medical Student/Resident Chest Infections Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Endobronchial aspergilloma (EBA) is a rare manifestation of pulmonary Aspergillosis characterized by growth of an Aspergillus species as a space-occupying lesion into the bronchial lumen. This can be an isolated manifestation of aspergillus, or occurs in association with parenchymal aspergilloma, allergic broncho-pulmonary aspergillosis, or necrotizing forms of pulmonary aspergillus.1 The clinical presentation of EBA is quite diverse, ranging from an asymptomatic state to dyspnea, cough, hemoptysis and weight loss. In most cases, EBA is found incidentally when patients undergo bronchoscopy for evaluation of other pulmonary symptoms. EBA can mimic endobronchial cancer or carcinoid due to similar clinical and radiographic presentation.1 CASE PRESENTATION: A 46-years-old female was admitted to hospital for surgical fixation of hip fracture after a fall. She also had exertional dyspnea with non-productive cough for past six months. She denied hemoptysis, chest pain, fever, chills and night sweats. Her past medical history included recurrent pneumonia, type I diabetes, end stage renal disease on hemodialysis, and right heart failure. Laboratory evaluations were unremarkable. Chest x-ray showed right upper lobe opacity superior to minor fissure. Computerized tomography (CT) scan of the chest (Figure 1) revealed right upper lobe consolidation with partial occlusion of the right upper lobe bronchus. A diagnostic bronchoscopy was performed to confirm the etiology. It demonstrated complete endobronchial obstruction of the anterior segment of the right upper lobe with cobblestone appearing white material. A biopsy demonstrated pseudohyphae (Figure 2). Polymerase chain reaction (PCR) of material was diagnostic of Aspergillus species. A final diagnosis of EBA was made and the patient was treated with antifungal (Voriconazole) therapy for 6 weeks with subsequent resolution of her symptoms. DISCUSSION: Aspergillus spp. have been associated with a wide spectrum of lung disorders, especially in immunosuppressed patients. Our patient had multiple comorbidities, but did not have typical risk factors for opportunistic infection, resulting in a low index of suspicion for invasive fungal disease. The diagnosis of EBA is challenging on cross-sectional imaging. Bronchoscopy with biopsy is mandatory to confirm the diagnosis of EBA.2 The morphology of fungal form found in our case was atypical for aspergillus, which required further confirmation with PCR testing. Medical management with antifungal therapy may be effective, however, a surgical approach is recommended in patients with massive hemoptysis and adequate lung reserve.3 CONCLUSIONS: A high index of suspicion is required for diagnosing EBA. Bronchoscopic evaluation of endobronchial masses, followed by histologic examination is critical in establishing a diagnosis of EBA. Early medical management with antifungal therapy may hasten resolution of infection. Reference #1: Huang D, Li B, Chu H, et al. Endobronchial aspergilloma: A case report and literature review. Exp Ther Med 2017;14(1):547-54. doi: 10.3892/etm.2017.4540 [published Online First: 2017/06/01] Reference #2: Ma JE, Yun EY, Kim YE, et al. Endobronchial aspergilloma: report of 10 cases and literature review. Yonsei Med J 2011;52(5):787-92. doi: 10.3349/ymj.2011.52.5.787 [published Online First: 2011/07/26] Reference #3: Pohl C, Jugheli L, Haraka F, et al. Pulmonary aspergilloma: a treatment challenge in sub-Saharan Africa. PLoS Negl Trop Dis 2013;7(10):e2352. doi: 10.1371/journal.pntd.0002352 [published Online First: 2013/11/10] DISCLOSURES: No relevant relationships by Yumna Gulzar, source=Web Response No relevant relationships by Richa Purohit, source=Web Response No relevant relationships by stephen Selinger, source=Web Response No relevant relationships by Muhammad Yousaf, source=Web Response

Thoracoscopic S4a subsegmentectomy combined with wedge resections for treatment of metastatic tumors located at the intersection of the major and minor fissures.

Thoracoscopic S4a subsegmentectomy combined with wedge resections for treatment of metastatic tumors located at the intersection of the major and minor fissures.

Are textbook lungs really normal? A cadaveric study on the anatomical and clinical importance of variations in the major lung fissures, and the incomplete right horizontal fissure.

The lungs have three main fissures: the right oblique fissure (ROF), right horizontal fissure (RHF), and left oblique fissure (LOF). These can be complete, incomplete or absent; quantifying the degree of completeness of these fissures is novel. Standard textbooks often refer to the fissures as complete, but awareness of variation is essential in thoracic surgery. Fissures in 81 pairs of cadaveric lungs were classified. Oblique fissures were measured from lung hila posteriorly to the lung hila anteriorly; and the RHF measured from the ROF to the anteromedial lung edge. The degree of completeness of fissures was expressed as a percentage of the total projected length were they to be complete. The frequency and location of accessory fissures was noted. LOF were complete in 66/81 (81.5%), incomplete in 13/81 (16.0%) and absent in 2/81 (2.47%); ROF were complete in 52/81 (64.2%), incomplete in 29/81 (35.8%) and never absent; RHF were more variable, complete in 18/81 (22.2%), incomplete in 54/81 (66.7%) and absent in 9/81 (11.1%). LOF and ROF were on average 97.1% and 91.6% complete, respectively, being deficient posteriorly at the lung hila. The RHF on average 69.4% complete, being deficient anteromedially. There were accessory fissures in 10 left and 19 right lungs. This study provides a projection of the anatomy thoracic surgeons may encounter at operation, in particular the variable RHF. This knowledge is essential for optimal outcomes in both benign and oncological procedures influenced by the fissures.

Types of pulmonary fissures and its surgical implications: A cadaveric study

Being the essential organs of respiration, pair of lungs are situated on either side of the mediastinum. Each lung is divided into lobes by the fissures. These fissures allow for proper expansion of lungs and on the other hand fissures may have a role in restricting infection to a particular lobe. Fissures may be complete, incomplete or absent.To study the variations in the fissures of lung, compare the results with the available data and to discuss the surgical importance of this study. 37 pairs of lungs (37 right and 37 left) from formalin fixed cadavers were observed and classified into different grades of fissures ( as per Craig and Walker criteria). Presence of accessory fissures was noted.Out of the 37 right lungs, 3 showed absence of horizontal fissure and the same fissure was incomplete in right sided 17 lungs. Among the left lungs, 9 had incomplete oblique fissure. Accessory fissure were found in 2 right and 1 left lungs.The current study showed that right lung may be without horizontal fissure or fissures may be incomplete. Thus, a light on these variations by the cardiothoracic surgeons will help in better planning of surgeries like lobectomy. Knowledge about the fissures will aid in arriving at better diagnosis for the clinicians and radiologists.

Complete Absence of Oblique Fissure in the Left Lung: A case report on anatomic variation

Classically, development of respiratory tissues in humans displays segmentation which produces a left lung with two lobes, separated by the oblique fissure. The bilobar left lung is smaller than the right lung as a standard, allowing space for the heart. However, absence of oblique fissure in the left lung, as is discussed in this abstract, is anomalous. 24 pairs of lungs obtained from routine dissection of adult formalin fixed cadavers used for first‐year regional anatomy course at Oakland University William Beaumont School of Medicine were used in this study. There was a total of 13 female and 11 male and cadavers with an average age of 80 years. The lungs were observed for presence or absence of fissures and lobes. We report a case of absent oblique fissure in the left lung in a 56‐year‐old female cadaver. While hypoplasia of the left lung is apparent, her right lung displayed standard trilobar development. Although no other cadavers within this cohort displayed similar lobar hypoplasia of the lung, our team did find that the left lung from a 74‐year‐old female cadaver was notably small. Developmental lung anomalies in adults are rare, and our findings contribute to prevalence reports of left lung hypoplasia. Recognition of variation in bronchopulmonary fissures may be useful in clinical settings, i.e., in localization of pulmonary lesions, surgical planning, planning for other invasive respiratory procedures, and interpretation of radiographs or computed tomography scans.

Nontyphoid Salmonella Empyema in a Patient with Type 2 Diabetes Mellitus.

Pleuropulmonary infections caused by nontyphoid Salmonella (NTS) are rare, but may develop in immunocompromised hosts. We report the case of a 56-year-old male with uncontrolled diabetes mellitus presenting with a multiloculated empyema due to NTS involving the left oblique pulmonary fissure.

A Study on Morphological Variations of Fissures and Lobes of Human Lungs with its Clinical Significance

Background: Fissures of lungs facilitate the movement of lobes which helps in expansion of lungs during breathing. The fissures may be complete, incomplete or absence. Sometime the accessory fissures may also present. Awareness of variations is essential during segmental resections as well as during radiological interpretation of lungs. Hence, the present study was aimed to study the morphological variations in fissures and lobes.
 Material and Methods: This study was consisted of sixty nine human lungs with irrespective of sex which were available in the department of anatomy of various medical colleges. All lung specimens were carefully observed and recorded for the presence of any variations in fissures and lobes.
 Results: The present study revealed that the absence of horizontal fissure was observed in 7.89%, while no specimen showed absence of oblique fissure on both sides. 35.48% of left lungs had incomplete oblique fissure compared to 28.95% of the right lungs. In addition, 22.58% of right lungs and 23.68% of left lungs showed presence of accessory fissure and lobes. From above, the incomplete and absent horizontal fissure was the most common abnormalities observed in this study. The accessory fissures were more common in lower lobe of right lung whereas in left lungs it was more common in upper lobe.
 Conclusion: The present study showed the wide range of variations in fissures and lobes of lungs. The knowledge of variations in morphology of lungs would be helpful for clinical diagnosis and pulmonary surgical procedures.

Very rare and serious complication of central line insertion

Very rare and serious complication of central line insertion - IJCA- Print ISSN No: - 2394-4781 Online ISSN No:- 2394-4994 Article DOI No:- 10.18231/j.ijca.2019.121, Indian Journal of Clinical Anaesthesia-Indian J Clin Anaesth

Variations in pulmonary fissural anatomy: a medicolegal autopsy study of 256 cases.

We aimed to document the anatomical variations of pulmonary fissures found during routine forensic autopsies. A total of 256 pairs of lungs were investigated. Presence of any variant and accessory fissures was noted. Seventy-seven percent of the lungs had anatomical variations. In about 2/3 of the cases, oblique fissures were incomplete on both sides. The horizontal fissure was incomplete in 68.4%, and absent in 4.3% of the lungs. Twelve left lungs (4.7%) had a horizontal fissure. Accessory fissures were observed in 35 lungs (13.7%). Azygos lobe variations were detected in 1.7% of the lungs. A superior accessory fissure was present in 6.2% and 2% of right and left lungs, respectively. This and previous similar studies demonstrate the existence of several different anatomical fissural variations in the lungs. Clinicians, radiologists and surgeons should keep these in mind to better evaluate and treat their patients.

IBS26.03 Surgical Technique of Pleurectomy/Decortication

IBS26.03 Surgical Technique of Pleurectomy/Decortication

Variations in the Morphology of Human Lungs and its Clinical Implications

Objective To observe variations in the fissures, in the lobes, and in the hilar pattern of lungs and correlate these findings with clinical implications. Materials and Methods The present study was performed on random lung specimens available in the Department of Anatomy. A total of 96 lungs (47 right and 49 left) were studied for variations in the fissures and lobes, and 92 lungs (45 right and 47 left) for variations in the hilar pattern. Results Among the right-sided lungs, 70% presented incomplete horizontal fissure, 15% with absence of the horizontal fissure, and 51% with incomplete oblique fissure. Accessory fissures were also seen, but incomplete, and accounted for 17% of the total number of right lungs.Among the left-sided lungs, 62% presented incomplete oblique fissures, and 4% with absence of the oblique fissure. Accessory fissures accounted for 6% of the total number of left lungs.Regarding hilar pattern variations, 11% of the right-sided lungs showed > 2 bronchi, 69% showed > 2 pulmonary veins, and 37% showed > 1 pulmonary artery.Among the left-sided lungs, 57% showed > 1 bronchi, 21% showed > 2 pulmonary veins, and 17% showed > 1 pulmonary artery. Conclusion The field of pulmonary surgery is now highly advanced, with well-developed radiological and endoscopic techniques. Hence, a proper understanding and knowledge of these morphological variations of lung fissures and of the hilar pattern would be advantageous for surgeons, as well as for radiologists.

Abstract 2908: Mesothelioma phylogeny reveal MTAP as a solitary clonal deletion, exposing vulnerability to the PRMT5 perturbagen, quinacrine

Abstract Background: Malignant Pleural Mesothelioma (MPM) remains an incurable cancer that is caused by asbestos, and for which there is a paucity of effective therapy. Stratified medicine for MPM is in its infancy. We hypothesized that deciphering the phylogenetic architecture of mesothelioma would yield a census of recurrent clonal homozygous copy number losses as potential therapeutic vulnerabilities. Methods and Results: We prospectively enrolled 125 patients with MPM undergoing radical pleurectomy decortication, into the MEDUSA (Mesothelioma Evolution: DrUgging Somatic Alterations) study. Multi-region whole exome sequencing was conducted on 106 tumours from 20 patients (Medusa20 cohort). Up to 5 consistent regions were sampled: apex, pericardium, anterior/ posterior costophrenic angles, and the oblique fissure. For each patient, matching whole blood DNA was also whole exome sequenced to allow identification of tumour- specific somatic variations. Somatic copy number alterations (SCNAs) in each tumour region were called using SEQUENZA. We inferred phylogeny for each patient’s tumour using the SCNA calls by maximum parsimony (TUMULT), which revealed branched evolution in all MPMs. The total number of SCNAs ranged from 78 to 380 across the cohort with biphasic MPMs exhibiting a significantly larger total and clonal SCNA burden compared to epithelioid MPMs (p=0.024) . Only 9p21 which harbours CDKNA and methylthioadenosine phosphorylase (MTAP), exhibited clonal homozygous loss in 3 patients (15%). Clonal heterozygous loss was seen in 2 patients (10%). A further 5 patients showed with evidence of parallel evolution involving MTAP loss in distant MPM regions (25%), with one patient's MPM having late homozygous deletion in a single branch (5%). MTAP loss was validated by array based SCNA analysis and was found to be negatively prognostic in an independent cohort. Protein arginine methyltransferase 5 (PRMT5) has been recently identified as a vulnerability in MTAP deleted cancer. We found that siRNA silencing of PRMT5, caused MTAP selective loss of clonogenicity with proliferative arrest. Utilizing the connectivity map, quinacrine was validated as a PRMT5 perturbagen, which suppressed c-jun-dependent PRMT5 expression without inhibiting its methyltransferase activity. Quinacrine phenocopied PRMT5 siRNA, reducing global symmetrical arginine dimethylation of histone H4 (H4R3me2S). Finally, exogenous wild-type PRMT5 rescued quinacrine-mediated cell arrest in MTAP-negative cells, an effect not seen using the PMRT5 E444Q methyltransferase dead mutant. Conclusion: MTAP deletion is a clonal homozygous event in mesothelioma, with potential as a therapeutically tractable Achilles heel, via PRMT5 silencing using a repurposed small molecule, quinacrine. Citation Format: Sara Busacca, Lee Brannan, Apostolos Nakas, Annabel Sharkey, Chiara Riganti, David Waller, Cathy Richards, Iris Salaroglio, Vladan Milosevic, Peter Wells-Jordan, Alan Dawson, Michael Sheaff, John LeQuesne, Aarti Gaba, Robert Hastings, Luke Martinson, Jin-Li Lo, Amrita Bajaj, Paul Boutros, Tom John, Bibhusal Thapa, Gareth Wilson, Jacqui Shaw, Charles Swanton, Frank Dudbridge, Edward Hollox, Dean A. Fennell. Mesothelioma phylogeny reveal MTAP as a solitary clonal deletion, exposing vulnerability to the PRMT5 perturbagen, quinacrine [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr 2908.

An Efficient Method for the Detection of Oblique Fissures from Computed Tomography images of Lungs.

Detection of a pulmonary fissure in lungs is difficult due to its anatomical changeability among humans and it is essential in the clinical environment for accurate localizing and treating the lung abnormalities on a lobe level in human lungs. In this work, an algorithmic approach is proposed to detect the lung oblique fissures from lung computed tomography (CT) images. In the preprocessing module of our approach, the lung structures are enhanced using morphological operation and lung images are de-noised using Wiener filter. In the second module, lung regions are segmented using techniques, namely, thresholding and background subtraction. In the third module of our algorithm, initially, fissure regions are segmented using the active contour model, then by applying the rule based approach on the fissure regions, the oblique fissures are segmented. The proposed algorithm has been tested on 50 images collected from Lung Image Database Consortium (LIDC) and 30 images obtained from Early Lung Cancer Action Program (ELCAP).

Visual and Automated CT Measurements of Lung Volume Loss in Idiopathic Pulmonary Fibrosis.

OBJECTIVE. The purpose of this study is to establish the relationship between CT markers of lung volume and pulmonary function test (PFT) parameters of lung volume in idiopathic pulmonary fibrosis (IPF). MATERIALS AND METHODS. The relationships between PFT-derived parameters of lung volume (forced vital capacity [FVC] and total lung capacity [TLC]) and both CT-derived automated lung volume and manually derived surrogate measurements of lung volume on CT were evaluated in 273 patients (212 men and 61 women; median age, 67 years) with a multidisciplinary diagnosis of IPF. All patients underwent unenhanced volumetric high-resolution CT of the thorax. Automated lung volume was extracted using commercially available software. Three manual CT surrogate measurements of lung volume previously tested in the setting of radiation-induced lung fibrosis were evaluated by two raters. These measurements were lung height, aortosternal distance, and oblique fissure retraction distance. Fibrosis extent on CT was scored by two observers. Correlation coefficients and multivariable regression analyses were performed to assess the relationship between CT measurements and percentage of predicted FVC (hereafter referred to as "percentage FVC") and TLC. Interobserver agreement for CT markers was evaluated on the basis of the intraclass correlation coefficient. RESULTS. There was a strong correlation between CT-derived automated lung volume and TLC (rP = 0.92; p < 0.0005). There was excellent interobserver agreement for all manual CT measurements (intraclass correlation coefficient, 0.82-0.96). There were significant correlations between manual CT measurements and percentage FVC. Lung height had the strongest relationship with percentage FVC (rP = 0.44; p < 0.0005). In multivariable analysis, the CT measurements were independent determinants of lung volumes, after adjustment for fibrosis and emphysema (R2 = 0.48; p < 0.0005 and p < 0.003, respectively). Lung height had the most significant impact on the fit against lung volumes. CONCLUSION. Automated and manual CT measurements of lung volume are significantly related to PFT-derived parameters of lung volume, independent of fibrosis and emphysema.

Cadaveric Study of Lung Anatomy: A Surgical Overview

Background: Thorough knowledge of variations in lung anatomy is of prime significance during surgical procedures of lungs. Arrangement of structures in lung hilum act as a guide in performing such procedures. Normal pattern of arrangement of hilar structures in right lung is eparterial bronchus, pulmonary artery, hyparterial bronchus and pulmonary veins from above downwards. In left lung it is pulmonary artery, principal bronchus and pulmonary vein from above downwards. Arrangement of hilar structures from anterior to posterior in both lungs is pulmonary vein, pulmonary artery and principal bronchus.&#x0D; Aim: To report variations in hilar anatomy (arrangement and number) of lungs.&#x0D; Methods and Material: 75 adult formalin fixed cadaveric lungs from department of Anatomy AIIMS New Delhi were observed for variations in lobar anatomy. Arrangement of pulmonary hilar structures observed and variations recorded.&#x0D; Results: Among 75 adult lung specimens observed, 36 were right and rest left lung. Normal pattern of arrangement of hilar structures was seen in 22 right and 23 left lungs. Rest of the lung specimens (14 Right and 16 Left) showed variations in hilar anatomy. Some of them showed alterations in sequence of arrangement of pulmonary artery, pulmonary veins, bronchus and others in number of these structures. Seven right lung specimens showed only 2 lobes with an oblique fissure dividing them and one left lung showed 3 lobes.&#x0D; Conclusion: Alterations in pattern of arrangement of structures in lung hilum are quite frequent. A compromise in knowledge of such variations will result in inadvertent intraoperative complications.

Thoracoscopic anterior segmentectomy of the right upper lobe (S3)

S 3 segmentectomy is a challenging procedure for three reasons: the anatomy of vascular elements is complex, the segment is comprised between S 1 and the middle lobe, and the minor fissure is most often fused. The key for accessing the bronchovascular pedicle is two-fold: (I) achieving a sufficient exposure of the bronchial trifurcation and (II) opening of the minor fissure between S 3 and the middle lobe. Once done, this maneuver helps exposing the vessels and greatly eases the procedure.

This video shows a case of left pulmonary artery injury when dividing the oblique fissure

This video shows a case of left pulmonary artery injury when dividing the oblique fissure

Video-assisted thoracic surgery double sleeve bilobectomy of right upper and middle lobes.

The evidence on the advantages of minimally invasive approach, represented by video-assisted thoracic surgery (VATS), in surgical treatment of both benign and malignant pulmonary diseases is mountain. Currently, VATS major pulmonary resection is routinely performed in many centers worldwide for patients with non-small cell lung cancer. However, hilar tumor invasion requiring bronchial sleeve or bronchovascular double sleeve lobectomy is generally considered as a contraindication of VATS (1). Even though the VATS bronchial sleeve lobectomy was reported more than one decade ago (2), VATS bronchovascular double sleeve lobectomy remained blank until our first report in 2014 (3). In recent years, a few high-volume centers have tried to perform such operations through the VATS approach (4-7). The results of VATS double sleeve lobectomy in our center were summarized recently (7). Most of the previous reported cases were the operations on the left side. Here we focused on the description of technical aspects of this challenging operation with a more detailed video which depicted a case of VATS bronchovascular double sleeve right upper and middle bilobectomy (Figure 1). Open in a separate window Figure 1 The video depicts a three-portal VATS bronchovascular double sleeve right upper and middle bilobectomy (8). The operation was carried out with the “Hollow-out” process. Lymph nodes and nearby soft tissues of the right hilum and mediastinum were firstly removed to hollow out the main structures of the hilum. The superior pulmonary vein and truncus anterior were transected one by one, followed by clamping the proximal PA using a releasable Bulldog clamp. The anterior part of the oblique fissure was incised, followed by transecting the middle lobe vein and bronchus. The common basal artery was mobilized and clamped with another Bulldog. Bronchial and arterial reconstruction was accomplished using running stiches after removing the diseased lobes. VATS, video-assisted thoracic surgery. Available online: http://www.asvide.com/article/view/26249