Anatomy of inferior pulmonary vein should be clarified in lower lobectomy

doi:10.1016/S0003-4975(98)00999-0

The Annals of Thoracic Surgery

Volume 66, Issue 5, November 1998, Pages 1799-1800

https://doi.org/10.1016/S0003-4975(98)00999-0 Get rights and content

Abstract

We successfully performed surgery for carcinoma of the lung on 2 patients with the anatomic variation of the middle lobe vein draining to the right inferior pulmonary vein. This variation is surgically important because division of the right inferior pulmonary vein may result in blockage of middle lobe vein drainage in right lower lobectomy. Surgeons must always pay attention to this variation when performing the right lower lobectomy.

Section snippets

Patient 1

Computed tomography (CT) on a 37-year-old woman revealed a circular mass, and carcinoma of the middle lobe was diagnosed. The clinical stage of cT₁N₀M₀ indicated a surgical resection. A middle lobectomy and mediastinal lymph node dissection by R₂a was performed via right standard thoracotomy. First, the right superior PV was exposed, and the middle lobe vein was sought but not found. Next, the interlobular pulmonary artery was exposed and the two middle lobe arteries were ligated and divided.

Comment

Surgeons may divide the right inferior PV trunk without exposure of its tributaries when performing right lower lobectomy when the right inferior PV trunk is long enough to divide safely. However, this procedure causes blockage of venous return from the middle lobe vein in patients who have the anatomic variation of middle lobe vein drainage to the right inferior PV as was seen in our cases. The ligation of a PV that should be preserved can lead to severe lung edema, which may cause infection

References (2)

D.C. Sabiston
Neoplasm of the lung
H. Yamashita
Variations in the pulmonary segments and the bronchovascular trees

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Though sequence of vessels interruption remains controversial still identification of pulmonary structures deserves its importance as the presence of aberrant components might be an obstacle during operation if overlooked (Subotich et al., 2009). Moreover, division of pulmonary vessels that should be preserved during lobectomy can also lead to potentially life-threatening complications (Sugimoto et al., 1998). Variable pulmonary vessels are often associated with misinterpretation of a radiograph or computed tomography (CT) scan (Ghaye et al., 2001; Nakamura et al., 2009).
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Less common venous drainage abnormalities reported include a common ostium for the left and right inferior pulmonary veins,11,12 a lingular vein draining to the lower pulmonary vein,13 a lateral segment vein of the middle lobe draining to the inferior pulmonary vein, and a superior segment vein draining directly into the left atrium.4,14 Given the variability in the pulmonary venous drainage, some investigators have recommended routine formal preoperative venous system assessment with CT in all patients.15 Some investigators have reported on the utility of preoperative CT for surgical planning16 before thymectomy.
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Anatomical variations of the pulmonary vessels relevant to pulmonary surgery are of concern to thoracic surgeons. Among such variations, the right upper lobe vein posterior to the bronchus intermedius (UVPBI) has received little attention thus far.
Chest computed tomographic images and medical records of 725 patients were retrospectively reviewed. The frequency, drainage pattern, diameter, and associated anatomical characteristics of the UVPBI were assessed, and our right thoracotomy cases with the UVPBI were examined.
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Case ReportsAnatomy of inferior pulmonary vein should be clarified in lower lobectomy

Abstract

Section snippets

Patient 1

Comment

Neoplasm of the lung

Variations in the pulmonary segments and the bronchovascular trees

Case Reports
Anatomy of inferior pulmonary vein should be clarified in lower lobectomy