VATS All Folks: Minimally Invasive Surgery in the Left Lower Lobe

by Brie Eteson, Digital Surgery
LLL Superior Segmentectomy

We are introducing you to our second video-assisted thoracoscopic surgery (VATS) simulation, and this time we’re focusing on Left Lower Lobe Superior Segmentectomy. You can also view our previous post on Right Upper Lobectomy to learn about another VATS procedure. Video-assisted thoracic surgery is a minimally invasive procedure. A thoracoscope is inserted through a small incision between the ribs, which enables the surgeon to see the entire chest cavity without having to open up the chest or spread the ribs.1 Minimally invasive surgery, unlike open thoracotomy, is shown to result in fewer major complications, a shorter recovery time, and reduced length of hospitalization.2,3,4

Depending on the diagnosis, a segmentectomy can be performed for the treatment of lung cancer. This surgical procedure involves the removal of a lung segment and is particularly successful in cases of early-stage lung cancer.5 This simulation depicts a left lower lobe superior segmentectomy. Unlike lobectomies, segmentectomies preserve the pulmonary parenchyma. This is beneficial to the patient’s physiological state, with less than 1% mortality rate when they have good baseline pulmonary function.6

A Little Lung Anatomy to Kick Things Off

There are two pleural membranes in lung anatomy: parietal and visceral. The parietal pleura lines the inner wall of the thoracic cavity, the visceral pleura lines the surfaces of the lung parenchyma. The space between the two pleural membranes is called the pleural cavity.

Follow the breakdown of the Key Phases of a Segmentectomy below, or head straight to our app to see the full simulation, authored by Mark W. Onaitis, MD, to test your knowledge of this VATS procedure.

The patient is prepped and draped to expose the left side of the body, whilst the right lung is selectively ventilated. Landmarks are identified for several small incision sites. The first of these is at the 7th intercostal space, on the midaxillary line, just above the diaphragm. This is for the Camera Port. Another aligns with the scapular angle, at the adequate intercostal space for the Posterior Assistant Port. A final mark is made for the Utility Port, at the 4th or 5th intercostal space, just anterior to the camera port. The port sites are all blocked with local anesthetic prior to the incisions.

A thoracoscope is inserted through the camera port into the chest cavity. It is used to help identify the utility port site under direct vision. Once the intercostal space has been identified, the incision is made on the anterior axillary line, and a wound protector is inserted. Finally, the posterior port site is identified and incised, and thoracoscopic ring forceps are inserted.

Camera port insertion with 30° thoracoscope

Utility port incision under direct vision

Isolation and dissection of lymph nodes

Identification of the oblique (major) fissure

The lung cavity is inspected and Adhesions Dissected, if present, using electrosurgical shears. Once the Tumor and Oblique Fissure are Identified, the left lower lobe (LLL) is retracted superiorly to identify the Inferior Pulmonary Ligament. This can be divided up to the level of the inferior pulmonary vein.

Station 9 Lymph Nodes are identified, isolated and dissected, then removed from the chest cavity via the utility port. As the LLL superior segment is located posteriorly, the posterior Hilum is Dissected after the LLL is retracted anteriorly. Any station 10 lymph nodes encountered are removed.

The lung is retracted posteriorly to identify the upper and lower lobe bronchi, and the peribronchial lymph nodes. The Station 11L or “Sump” Lymph Nodes are found between the upper and lower bronchi. These lymph nodes are dissected and removed through the utility port.

The oblique (major) fissure is divided by a stapler until the interlobar pulmonary artery is reached, which is then bluntly dissected to achieve clear visualization of the LLL superior segment. This completes the Oblique Fissure Dissection.

The Pulmonary Artery is Bluntly Dissected at the LLL superior segment, and a stapler is used to transect the artery. The staple line should be checked for hemostasis and that the transection is adequate. Station 12 Lymph Nodes are dissected through the oblique fissure. 

The superior segmental Pulmonary Vein is isolated and stapled to transect the vein. As previously, the staple line is checked for hemostasis and adequacy of transection. This process is repeated with the superior Segmental Bronchus.

The superior segment is identified and isolated by retracting the lower lobe posteriorly. The divided hilar structures should be in the specimen. Afterwards, a stapler is used to transect the fissure. The LLL Superior Segment is Removed from the chest, through the wound protector, via the utility port.

After removal of the LLL superior segment, the left upper lobe is retracted posteriorly to locate and dissect out the Station 5 and 6 Lymph Nodes. These are also removed via the utility port.

The LLL is retracted anteriorly to expose the Station 7 Lymph Nodes in the subcarinal space, before dissecting and removing them.

Segment removal

Superior segment of the left lower lobe

Application of topical skin adhesive over the incision sites

Paravertebral Block is injected into the chest around intercostal spaces 2 to 9. The camera is removed and reinserted into the utility port. From there, it can be used to inspect the insertion and placement of the Chest Tube into the original camera port.

The remaining lung is reinflated, and the camera and wound protector are removed from the utility port.

The chest tube is secured to the skin with a suture, and dressing is applied. All Port Sites are Closed appropriately with sutures, and topical skin adhesive is applied to the sites.

This procedure involves many complicated and intricate objectives that are briefly outlined in this blog. For a more in-depth demonstration, featuring both animation and surgical video, go to the Touch Surgery™ app.

Launch in App

or scan the QR code below.

How to cite this simulation: Onaitis MW. Thoracic VATS LLL Superior Segmentectomy. Touch Surgery Simulations. Published Jul. 21, 2021.


1. American Lung Association. Minimally Invasive Thoracic Surgery. American Lung Association. Updated Jun. 29, 2020. Accessed Jun. 14, 2021.

2. O’Sullivan KE, Kreaden US, Hebert AE, Eaton D, Redmond KC. A systematic review and meta-analysis of robotic versus open and video-assisted thoracoscopic surgery approaches for lobectomy. Interact Cardiovasc Thorac Surg. 2019;28(4):526-34.

3. Montagne F, Bottet B, Sarsam M, et al. Robotic versus open and video-assisted thoracoscopic surgery approaches for lobectomy. Mini-invasive Surg. 2020;4(17).

4. Ma J, Li X, Zhao S, Wang J, Zhang W, Sun G. Robot-assisted thoracic surgery versus video-assisted thoracic surgery for lung lobectomy or segmentectomy in patients with non-small cell lung cancer: a meta-analysis. BMC cancer. 2021;21(1):1-6.

5. Lynne Eldridge. Lobectomy Complications and Prognosis. Very Well Health Website. Updated Nov. 5, 2020. Accessed May. 5, 2021.

6. Bhimji S. What are the mortality rates for lung segmentectomy and limited pulmonary resection (wedge resection)? Medscape Website. Updated Feb. 22, 2021. Accessed Aug. 2, 2021.

7. Yang CF J, D’Amico T. Chapter 32: Segmentectomy and Lesser Pulmonary Resections. In: Rocco G, LoCicero J, eds. Shields General Thoracic Surgery. Baltimore, MD: Williams and Wilkins; 2018:947-970.

8. Hwang Y, Kang C, Kim H, Jeon J, Park I, Kim Y. Comparison of thoracoscopic segmentectomy and thoracoscopic lobectomy on the patients with non-small cell lung cancer: a propensity score matching study. Eur J Cardiothorac Sur. 2014;48(2):273-278.

9. Mendogni P, Tosi D, Rosso L, et al. VATS segmentectomy: an underused option? J Vis Surg. 2017;3(136).

10. Shah RD, D’Amico TA. Modern impact of video assisted thoracic surgery. J Thorac Dis. 2014;6(Suppl 6):S631-S636.

11. Silvestri GA, Gonzalez AV, Jantz MA. Methods for staging non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143(5 Suppl):e211S-e250S.