Lobectomy

Anatomy and Physiology

Pulmonary Surgical Anatomy

Pulmonary surgical anatomy encompasses a complex subdivision of anatomical structures involved in a lobectomy, which can be segmented into lung parenchyma, vascular system, and bronchial division. Classic pulmonary anatomy nomenclature has become simplified with the advent of 3D computed tomography (CT) anatomy for VATS segmentectomy.[9]

Lung Parenchymal Division 

The lung parenchyma is the functional tissue of the lung, and its segmentary divisions use the "S" prefix.[9] These divisions include: 

• Right Lung Parenchymal Division 
  • Right upper lobe: Posterior segment (S2), apical segment (S1), and anterior segment S3
  • Right middle lobe: Lateral segment (S4) and medial segment (S5)
  • Right lower lobe: Superior segment (S6), medial basal segment (S7), anterior basal segment (S8), lateral basal segment (S9), and posterior basal segment (S10) [9][10]
• Left Lung Parenchymal Division 
  • Left upper lobe: Apicoposterior segment (S1+2) and anterior segment (S3)
  • Left upper lobe Lingular division: superior segment (S4) and inferior segment (S5)
  • Left lower lobe: Superior segment (S6), anteromedial basal segment (S7+8), lateral basal segment (S9), and posterior basal segment (S10) [9][10]

Bronchial Topographic Anatomy And Segmentary Division

These divisions are as follows: 

• Right Main Bronchus 
  • The right main bronchus anatomy divides into 3 segments: the right upper bronchus, the bronchus intermedius, and the lower lobe bronchus. The right main bronchus gives rise to several key branches. The right upper lobe bronchus measures approximately 1.2 to 1.5 cm in length. Distal to this, the bronchus intermedius extends for about 2 cm before dividing into the middle lobe bronchus anteriorly and the superior segmental bronchus posteriorly. The lower lobe bronchus continues distally to form the lower basal bronchi.[11][12] 
  • The right bronchial segmental divisions use the "B" prefix with B1–B10 terminology, as seen with the same previous lung segmentary "S" names.[9][10] These include:
    • Right upper lobe bronchus
      • The right upper lobe bronchus is segmented when entering the lung parenchyma. The most common presentation is a common trunk for B1+2 and a single B3. Another segmentary presentation is an independent branch for each B1, B2, and B3.[9][10]
    • Right bronchus intermedius
      • The right bronchus intermedius feeds the middle lobe bronchus, which becomes segmented when entering the parenchyma. Most presentations (90%) have a common trunk: B4+5. In some cases, B4 and B5 are separated branches.
      • The right superior segmental bronchus arises from the intermedius bronchus as a single B6 branch. Another presentation is a double B6 branch.[9][10]
    • Right lower lobe bronchus
      • The lower lobe bronchus is a common basal trunk that forms 3 bronchial branches (when entering the parenchyma): B7+8, B9, and B10. Other anatomic bronchial variants are; 8% is B7, B8+9, and B10 presentation, and 6% have B7, B8, B9, and B10 separated branches presentation.[9][10]
• Left Main Bronchus 
  • The left side is simpler than the main right bronchus and consists of a main left bronchus that is 4 to 6 cm long and forms the upper lobe and lower lobe bronchi. The bronchial segmentary division consists of the upper lobe and lower lobe bronchi. The bronchial division uses the "B" prefix with B1-B10 nomenclature, as with the same previous segmentary names; B7 in some literature does not exist or has the name B7+8.[9][11][12]
    • Upper lobe bronchus
      • This bronchus bifurcates and forms a common trunk for B1+2, B3, and a lingular bronchus for B4+5.[9][10] 
    • Lower lobe bronchus
      • This bronchus bifurcates giving B6 and common basal trunk giving B8 and B9+10 (80%); in other cases, B8+7, B9, and B10 are isolated branches (16%).[9][10]

Vascular Topographic Anatomy And Segmentary Division

The lungs' vascular supply consists of 2 systems: the bronchial and pulmonary vascular (arterial and venous) systems.[11][12]

• Arterial bronchial supply
  • The arterial bronchial supply is a high-pressure system with low capacitance, designed for bronchi irrigation. This system runs posteriorly to the airways and progressively segments to irrigate the lobar and segmental bronchi. Characteristics of the topographic anatomy of the bronchial vascular system depend on the irrigation of each main bronchus. The most common configuration is 1 right and 2 left bronchial arteries. In surgical terms, this 1 to 2 arterial arrangement makes the right main bronchus more susceptible to ischemia.[10][11][12] 
  • The right bronchus artery emerges from the intercostal arteries (2–3 cm distal to the left subclavian artery).
  • The 2 left bronchial arteries emerge from the descending aorta (anterolateral).[9][10] 
  • Anatomical variants include: 
    • One right bronchial artery (from the intercostal) and 1 left bronchial artery (from the aorta).
    • Two right bronchial arteries (1 from the intercostal and 1 from the aorta) and 2 left bronchial arteries (from the aorta)
    • Two right bronchial arteries (1 from the intercostal and 1 from the aorta) and 1 left bronchial artery (from the aorta) [11][12]
• Venous bronchial system
  • Proximal right and left bronchial veins drain into the pulmonary veins. Segmental and subsegmental right bronchial veins drain into the azygos vein. Segmental and subsegmental left bronchial veins drain into the hemiazygos vein.[10][11][12]
• Pulmonary vascular system
  • The pulmonary vascular system consists of a main pulmonary artery and 1 superior and 1 inferior pulmonary vein (left and right), which are progressively segmented to give vascular supply for the lobar, segmental, and subsegmental lung.[10][11][12]
• Pulmonary artery system
  • The pulmonary arterial circulation is a low-pressure system with high capacitance for gas exchange, which supplies the main irrigation to the airways (75%–90%) at the level of the lobar and segmental bronchi. Before this level exists, a rich anastomosis interconnection network with bronchial arterial circulation. The topographic-anatomical configuration of the pulmonary arterial system is characterized by the main pulmonary artery (pulmonary trunk), which emerges from the right ventricle. The pulmonary trunk below the aortic arch divides into the right and left pulmonary arteries.[10][11][12]
  • Right pulmonary artery topographic anatomy
    • The right pulmonary artery highlights are: the intrapericardial portion (over three-fourths of its length is within the pericardium, runs below the carina behind the ascending aorta and superior vena cava), and the extrapericardial portion (runs anterior and inferior to the right main bronchus).
    • For topographic surgical anatomy comprehension, the central running of the extrapericardial right pulmonary artery is divided. Each division subsequently forms important branches for lobar and segmental irrigation. Extrapericardial right pulmonary artery division refers to the right pulmonary artery and the right interlobar artery (located between the fissure). The right pulmonary artery (first extrapericardial portion) irrigates the right upper lobe. The right interlobar artery (inferior to bronchus intermedius and anterior to superior pulmonary vein) irrigates S2 (in some cases), the middle lobe, and the inferior lobe.[10][11][12]
  • Right pulmonary artery segmentary division
    • The right pulmonary artery segmental anatomy uses "A" prefix nomenclature with the same previous bronchi segmentary names.[9][10] 
      • Right upper lobe arterial irrigation:
        • The extrapericardial right artery forms 2 segmental branches: the anterior truncus for A1+3 and the A2 separated branch (In literature, A2 is commonly named the " ascending posterior artery ", Asc.A2). The S2 arterial supply is the key point of interest from a right upper lobectomy standpoint.
        • In 10% of cases, the main A2 irrigation could emerge from the interlobar artery (posterior surface and opposite to the middle lobe artery) or the inferior lobe artery (common trunk with A6 or the arterial basal trunk). S2 could have double irrigation with a recurrent A2 (Rec.A2, 72% of cases) from anterior truncus or only have irrigation from anterior truncus trifurcation (A1+2+3).[9][10] 
      • Right middle lobe arterial irrigation: The middle lobe is irrigated by the middle lobe artery, which emerges from the interlobar pulmonary artery. The middle lobe artery leads to a common trunk A4+5. Anatomical variation can present as A4 and A5 isolated branches from the interlobar pulmonary artery.[9][10] 
      • Right lower lobe arterial irrigation: The right lower lobe is irrigated by the superior segmental artery (A6), which emerges from the interlobar artery (opposite to the middle lobe artery), and the arterial basal trunk artery that forks in A7+8 and A8+9, from a right lower lobectomy standpoint. S6 has a single A6 branch (sometimes it can be double or triple) that arises from the interlobar pulmonary artery. Common anatomic variations include A6 sharing a common trunk with A2 or arising from the arterial basal trunk. The arterial basal trunk divides into 2 terminal trunks, A7 and A8, and A9 and A10. From a segmentectomy standpoint, it highlights that anatomic variations are as follows: A9+10 and A8 have separate trunks from the common basal trunk (90%), while A7 lacks (16%).[9][10] 
  • Left pulmonary artery topographic anatomy
    • The intrapericardial portion of the left pulmonary artery runs below the aortic arch (aortopulmonary window). A long extrapericardial portion that exits the pericardium at the ligamentum arteriosum level runs above and behind the left main bronchus (arc three-fourths of the left main bronchus circumference). The extrapericardial left pulmonary artery divides, forming the branches for the left superior lobe, lingular lobe, and lower lobe.[10][11][12] 
  • Left pulmonary artery segmentary division
    • The left arterial segmental anatomy uses "A" prefix nomenclature with the same previous bronchi segmentary names.[9][10] 
      • Left upper lobe arterial irrigation
        • The left pulmonary artery forms diverse configurations of arterial branches for each upper lobe segment. The most common anatomic pattern is the truncus anterior artery, the posterior arteries, and the lingual artery. The truncus anterior artery bifurcates into 2 branches: a common branch (A1+2) and an isolated A3 branch. The posterior arteries supply irrigation to the apical-posterior lung segment; the number of posterior arteries can range from 1 to 5. Still, the most common pattern is 2 to 3. These posterior arteries emerge from the left pulmonary artery interlobar segment at the posterior surface and are opposite to the lingular artery.[9][10] The lingular artery arises from the anterior aspect of the left pulmonary artery within the fissure, and is considered, in diverse literature, the last branch of the posterior arteries; however, this artery actually rises from the anterior aspect. This artery has also been considered an individual branch with distinct anatomic variants for lobectomy purposes. In 80% of cases, the lingular artery is a common trunk A4+5. In 26% of cases, A4 and A5 are raised as separate branches. The truncus anterior artery branches off an occult artery named the mediastinal lingular artery for the lingula (suspect when lingular artery is tiny or absent), A4 could send arteries to the basilar trunk (inferior lung irrigation) or for S8, and the A4 artery could share a common trunk with A3.[9][10] 
      • Left lower lobe arterial anatomy
        • The interlobar segment of the left pulmonary artery gives the superior segmental artery (A6) and the basal trunk artery. The A6 superior segment artery is a single branch (diverges into 2 or 3 branches for S6 and rises in the posterior aspect of the left interlobar pulmonary artery). In 80% of cases, it is doubled; in 18% of cases, it is tripled, and in 2% of cases, it is quadrupled.
        • Anatomic variants include the posterior branch (A2) that can arise close to A6 or have a common trunk with A6. The basal trunk diverges into 2 main arterial trunks, A8 and A9+10.
        • Anatomic variants of the basal irrigation include the basal segments, which can be irrigated by A8, A9, and A10 isolated branches, and a lingular artery that can arise from the basal trunk.[9][10]
• Pulmonary venous system
  • The pulmonary venous system flows through 4 pulmonary veins that drain into the left atrium. Pulmonary veins enter the mediastinum anterior and below the pulmonary artery. The pulmonary veins' topographic arrangement is 1 superior and 1 inferior pulmonary vein for each lung (4 pulmonary veins).[10][11][12]
  • Right pulmonary veins topographic anatomy
    • The superior pulmonary vein drains the right upper and middle lobes, while the inferior pulmonary vein drains the lower lobe. The superior pulmonary vein is the most anterior structure at the hilum, and the inferior vein is the most inferior structure.[10][11][12] 
      • Right superior pulmonary vein segmentary division
        • The right superior pulmonary vein has 3 branches: the upper root that gives V1, the central vein that gives V2+3, and the middle lobe vein V4+5.[9][10] These branches have specific anatomic configurations for surgery purposes. V1 is the uppermost branch, the most anterior and superior vessel, and it is in the upper lobe anterior hilum. The central vein is within the fissure, forming a long V2 branch and short V3 tributaries. The central vein sometimes forms a V2 that runs posterior to Asc.A2. The middle lobe vein is the most inferior branch of the superior pulmonary vein; it can present as a common trunk for V4+5 or as V4 and V5 isolated branches. The middle lobe vein can arise from the right inferior pulmonary vein.[9][10]
      • Right inferior pulmonary vein segmentary division
        • The right inferior pulmonary vein has 3 principal branches: the superior segment vein V6, the inferior basilar vein V9+10, and the superior basilar vein V7+8.
        • Anatomic variants include the following: the 2 basilar veins could have a common trunk, and the basilar veins can present as isolated intercommunicating branches.[9][10]
  • Left pulmonary veins topographic anatomy
    • The superior pulmonary vein drains the left upper lobe, and the inferior pulmonary vein drains the lower lobe. The superior pulmonary vein is the most anterior structure at the hilum, and the inferior vein is the most inferior structure. The superior and inferior pulmonary veins could share a large or short common trunk that drains into the left atrium in 25% of cases.[11]
      • Left superior pulmonary vein segmentary division
        • The left superior pulmonary vein has 3 principal branches: the superior, middle, and inferior (lingular).[9][10] The superior vein forms V1+2. The middle vein forms V3; in some cases, the superior and middle veins may share a common trunk. The lingular vein is the lowermost branch of the left superior pulmonary vein that forms V4+V5.
        • The anatomic variants include the left superior pulmonary vein, which can present as multiple radiating branches; in this case, the lingular vein is considered the most inferior branch. The lingular vein can arise from the left inferior pulmonary vein.[9][10]
      • Left inferior pulmonary vein segmentary division
        • The left inferior pulmonary vein has 3 principal branches: the superior segment vein V6, the inferior basal vein, and the superior basal vein.[9][10] The superior segment vein gives the V6 branch. The inferior basilar vein forms a common trunk V9+10. The superior basilar vein forms V8.
        • Anatomic variants include the superior basal vein having a V8 (anterior branch) and V9 isolated branches. The inferior basal vein can drain S8, and the left lower lobe can drain by a V6 and a common basal vein.[9][10]

Indications

Pulmonary lobectomy—the surgical removal of an entire lobe of the lung—is indicated for both malignant and select benign conditions when complete resection is feasible and the patient has sufficient pulmonary reserve. Careful multidisciplinary assessment of pulmonary function, including forced expiratory volume in 1 second (FEV₁) and diffusion capacity of carbon monoxide (DLCO), cardiopulmonary status, and comorbidities, is essential to ensure postoperative lung function will meet physiologic demands.

Malignant Conditions

Lobectomy is the standard surgical approach for stages I and II NSCLC; it offers superior local control and long-term survival compared with sublobar resections when negative margins and systematic lymph node dissection are achieved.[13] Because lung cancer most often involves the right upper lobe, right upper lobectomy is the most common procedure. Other, less common neoplastic indications include mucoepidermoid tumors, adenoid cystic tumors, and primary pulmonary sarcomas. Selected patients with isolated pulmonary metastases may also benefit from lobectomy when control of the primary malignancy is achieved.

Benign Conditions

These can be infectious or noninfectious: 

• Infectious
  • Chronic infectious processes not controlled with medical therapy may require surgical resection. Tuberculosis remains the most common global indication for lobectomy. Although antitubercular antibiotics are the primary treatment, selected patients with localized disease or complications such as large cavitary lesions or localized bronchiectasis may undergo lobectomy after optimal medical therapy. These patients carry a high postoperative morbidity and mortality risk and require close follow-up.[14]
• Noninfectious
  • Developmental anomalies such as congenital bronchial atresia, pulmonary sequestration, bronchogenic cyst, and congenital cystic adenomatoid malformation may necessitate lobectomy when symptomatic or complicated.[15][16] Massive hemoptysis, from causes such as aspergilloma, cavitary lesions, arteriovenous malformation, or bronchiectasis, can be controlled definitively with lobectomy when less invasive measures fail. In trauma, lobectomy may be required for hilar vascular or bronchial injuries, though associated mortality can be as high as 40%.[17]

In all cases, lobectomy should be considered only after weighing operative risks—including bleeding, bronchopleural fistula, and loss of pulmonary reserve—against the anticipated benefits. A multidisciplinary team involving thoracic surgeons, pulmonologists, oncologists, anesthesiologists, and critical care specialists is key to optimizing patient selection, perioperative safety, and long-term outcomes.

Contraindications

The success of lobectomy is closely tied to careful patient selection and thorough preoperative physiologic assessment. Evaluating pulmonary function is critical to determine whether the patient can tolerate the loss of an entire lobe. Patients with a FEV1 less than 800 mL or a DLCO  less than 40% are considered high risk and are generally better served with sublobar resection (eg, segmentectomy or wedge resection) or nonoperative therapies such as stereotactic body radiation.

Lobectomy should also be avoided in patients with recent myocardial infarction or severe cardiovascular disease, given the elevated risk of perioperative morbidity and mortality. In addition, VATS lobectomy is typically not recommended when the tumor exceeds 6 cm, as larger lesions present significant technical challenges and may necessitate conversion to an open thoracotomy. Careful multidisciplinary evaluation—including thoracic surgery, pulmonology, cardiology, and anesthesia—ensures appropriate risk stratification and selection of the safest and most effective therapeutic approach.

Equipment

For conventional open lobectomy, a rib retractor remains the primary instrument to expose the thoracic cavity adequately. Long instruments are essential to access the hilar structures, and appropriate vascular instrumentation must be readily available because of the risk of major vessel injury. The lung parenchyma and hilar structures can be transected using a surgical stapler or a sharp incision with hand-sewn repair techniques.[7][18] Essential equipment includes a rib spreader, scapula retractor, and periosteal elevator to facilitate safe exposure and dissection.[7]

For VATS lobectomy, the instrumentation differs from that used in conventional endoscopic surgery.[7][18] Core equipment includes a video system with a 10 mm 30-degree video-thoracoscope, high-intensity light source, and energy dissection devices such as an ultrasonic dissector-coagulator or bipolar electrocautery devices. Long, curved VATS instruments with double articulation, vascular clips, and curved-tipped endoscopic staplers are required for safe hilar dissection and vessel control. Additional essential items include a plastic endobag for specimen retrieval, wound protectors for the utility port, and 10 mm trocars.[7]

Robotic VATS lobectomy requires further specialized equipment and system integration.[6] The robotic surgical system (eg, da Vinci platform) comprises a surgeon console, patient-side cart, and robotic arms. A high-definition 3D endoscope provides enhanced visualization of thoracic anatomy. Access is obtained via trocars and robotic ports designed for secure and stable instrument passage. Dedicated robotic instruments, including Maryland bipolar forceps, Cadiere forceps, vessel sealers, and curved scissors, allow precise dissection and vessel control. Endoscopic stapling devices compatible with the robotic platform safely divide the pulmonary artery, vein, and bronchus.[6]

Personnel

Personnel needs depend on the etiology and previous medical management. Lung disease care commonly involves pulmonology, infectious disease, internal medicine, oncology, and thoracic surgery departments. Lobectomy surgery staff includes an anesthesiologist, thoracic surgeon, assisting surgeon, and scrub nurse competent in thoracic surgical procedures.[18][19] Postoperative management in thoracic surgery uses an intensive care unit because cardiopulmonary complications require active, life-supporting treatments. Patients must be transferred to the general thoracic ward when they remain stable for a few hours.[20]

Preparation

Preoperative Evaluation

The preoperative evaluation begins with confirmation of the suspected diagnosis and a comprehensive assessment of patient-specific risk factors. Key considerations include personal factors such as smoking history and preexisting comorbidities, performance status, complete clinical examination, blood tests, imaging, bronchoscopy, and thorough cardiac risk evaluation.[4] For patients with lung cancer, a formal preoperative staging protocol is mandatory, incorporating positron emission tomography–computed tomography and invasive mediastinal staging to define disease extent accurately.[4] A structured preoperative assessment is essential once a definitive diagnosis and surgical indication for lobectomy are established.

Several professional societies—including the American College of Chest Physicians (ACCP), British Thoracic Society, and European Respiratory Society/European Society of Thoracic Surgery (ERS/ESTS)—have proposed guidelines for preoperative risk stratification, focusing on mortality risk and respiratory function.[4]

• Mortality risk
  • Validated tools include the Thoracoscore, ESTS model, Veterans Affairs (VA) model, and ACS-NSQIP (American College of Surgeons National Surgical Quality Improvement Program) scales, all recommended for predicting mortality and morbidity in thoracic surgery patients.[21][22][23][24]
• Respiratory function
  • Evaluation relies on spirometry, DLCO, ventilation/perfusion (V/Q) scintigraphy, cardiopulmonary exercise testing, low-technology exercise tests, and arterial blood gas analysis. This assessment determines whether the patient can tolerate the planned lung resection. ERS/ESTS and ACCP guidelines provide detailed algorithms. The British Thoracic Society recommends an absolute preoperative FEV1 of at least 1.5 L. In contrast, the ACCP advises a predicted postoperative DLCO or FEV1 >60% of normal in patients without high cardiac risk before proceeding with lobectomy.[4]

Anesthetic Considerations

Effective lung isolation is critical for safe hilar dissection. Double-lumen endotracheal tubes and bronchial blockers remain the standard of care for anatomic lung resections.[25] More recently, awake VATS has been performed in carefully selected patients undergoing major pulmonary resection.[26] Regional or local anesthesia as an adjunct to general anesthesia during VATS lobectomy has been associated with reduced hospital stay.[27]

Technique or Treatment

Over time, the technical aspects of lobectomy have changed. The surgeon can perform the surgical approach by conventional open surgery, VATS, or robotics. Different methodologies exist for dissecting hilar structures. The most important aspects focus on the hilum approach (anterior or posterior mediastinum) and the hilum dissection sequence (anterior or posterior), emphasizing the performance of an isolated dissection and division of the hilar structures (vein, artery, and bronchus). The patient should be in the lateral decubitus position for open and VATS lobectomy.[3][7][18]

Conventional Open Lobectomy

Posterolateral thoracotomy is the conventional open approach. The use of this approach has been decreasing over time; however, it remains preferred under complex conditions, both in lung cancer and benign disease. Complex conditions include centrally located tumors, tumors greater than 6 cm, endobronchial tumors, thick adhesions due to inflammatory processes, and complex congenital lung malformations. The hilum approach and dissection sequence depend on the surgeon's preference (posterior to anterior, anterior to posterior). For hilar division and repair, staplers or hand-sewn techniques are the choices.[3][18]

VATS Lobectomy

The Cancer and Leukemia Group B (CALGB) provides the most widely accepted definition of a VATS lobectomy. The key criterion is the use of an anterior utility port incision no longer than 8 cm, performed without rib spreading.[18][28] Proposals exist for different minimally invasive approaches. Duke, Copenhagen, and uniportal VATS are the most common minimally invasive techniques. The common denominators among these techniques are an anterior utility port incision, an anterior surgeon's position (patient's abdomen), an anterior hilum approach (anterior mediastinum), and an anterior-to-posterior hilum dissection sequence. The anterior utility port is a 5 cm-long incision in the fourth or fifth intercostal space between the anterior and middle axillary lines. This step is constant in the 5 types of lobectomy (right superior, right middle, right lower, left superior, left lower lobectomies).[3][18][29] 

Differences between the Duke, Copenhagen, and uniportal VATS techniques are:

• The Duke approach has 2 incisions, the utility port and the camera port; the latter is a 5 to 10 mm counter-incision adjacent to the posterior vertex of the utility port incision in the same intercostal space.[29] 
• The Copenhagen technique is a 3-portal approach: the anterior utility port incision, the camera port incision 1 cm located at the top of the diaphragm in the axillary anterior line, and a 1.5 cm working port incision located at the same level as the camera port, straight down the line from the scapula.[18] 
• A uniportal VATS has only the anterior utility port incision.[30]

Robotic Lobectomy

Robotic lobectomy has emerged as an important evolution in minimally invasive thoracic surgery, offering several advantages beyond those of conventional VATS. One of the most notable distinctions lies in visualization. Robotic systems employ a high-definition, 3D camera, providing depth perception and magnification that surpass the 2-dimensional (2D) view typically available with VATS. This enhanced visualization allows for improved fine vascular and bronchial structure identification and more meticulous lymph node dissection.[6][31]

Hilum Approach, Dissection Sequence, and Fissure Technique

The cornerstone of lobectomy is the individual dissection of the vein, arteries, and airway for the lobe. Currently, the most popular is the anterior approach (anterior mediastinum). The dissection sequence is anterior to posterior in a single direction.[18][32] During the surgery, the fissureless technique involves dividing the pulmonary fissures with direct stapling over the visceral pleura.[33] The fissure-last technique involves opening the fissure late in surgery to expose arterial structures.[34] If the fissure is opened first in surgery, it is called the fissure-first technique (tunnel technique). The fissure-first technique merits consideration when the hilum dissection is complicated, and the vascular and bronchial structures' plane dissections are challenging to identify; however, the fissure-less technique has been the recommended approach due to the minor risk of postoperative air leak.[33][35][36] 

Lobectomy Technical Aspects

This describes the Copenhagen anterior approach for VATS lobectomy, 1 of several proposed minimally invasive surgical techniques. Notably, in the uniportal VATS technique, the sequence of vascular dissection differs at certain steps compared with multiportal approaches. In both techniques, division of the hilar structures is typically accomplished using endoscopic staplers and vascular clips.[18][37] The techniques are described below: 

• Right upper lobectomy: hilar approach
  • Begin by opening the mediastinal pleura over the anterior hilum, using the azygos vein as the key anatomical landmark. The dissection and division of hilar structures should proceed anterior to posterior in a single direction as follows: first the superior portion of the pulmonary vein (including the superior and central veins), followed by the anterior truncus of the pulmonary artery, the anterior part of the minor fissure, the ascending posterior artery and any remaining arterial branches to the upper lobe, the upper lobe bronchus, and finally the posterior part of the fissure.
  • Key pitfalls include difficulty in accurately identifying the lower portion of the upper pulmonary vein, distinguishing the ascending posterior artery from the middle lobe artery (which becomes visible after division of the anterior part of the fissure), and recognizing anatomical variants, particularly in the course of the ascending posterior artery.[18][38] 
  • In the uniportal VATS technique, the anterior truncus of the pulmonary artery is the first hilum structure transected.[39]
• Right middle lobectomy: hilar approach
  • Open the mediastinal pleura over the anterior hilum at the level of the pulmonary veins. Dissect and divide the hilar structures anterior to posterior in a single direction in the following sequence: first the middle lobe vein, then the anterior part of the major fissure, the middle lobe bronchus, the middle lobe artery, and finally the remaining fissures.
  • Important pitfalls include accurately identifying venous and arterial anatomical variants, which may alter the expected course of the middle lobe vein or artery and increase the risk of inadvertent injury.[18][38] 
  • In the uniportal VATS technique, the middle lobe artery is transected before the middle lobe bronchus (beneath the middle lobe artery).[40][41]
• Right lower lobectomy: hilar approach
  • Begin by transecting the inferior pulmonary ligament to allow superior traction of the lower lobe, which exposes the mediastinal pleura over the inferior pulmonary vein. Open the pleura at this site to access the hilum. Dissect and divide the hilar structures anterior to posterior in a single direction in the following sequence: inferior pulmonary vein, anterior part of the major fissure, inferior pulmonary artery, lower lobe bronchus, and finally the remaining fissure.
  • Key pitfalls include recognizing anatomic variations in the lower lobe arterial supply, particularly the superior segmental artery, which can have variable origins. Dissection of the inferior pulmonary vein occurs in the posterior hilum, best visualized after applying upward traction on the lower lobe. In contrast, the remainder of the hilar dissection is performed via the anterior approach.[18][38] 
  • The uniportal VATS technique hilum sequence is similar to the conventional VATS technique.[41]
• Left upper lobectomy: hilar approach
  • Begin by opening the mediastinal pleura over the anterior hilum, exposing the pulmonary artery (superior) and pulmonary vein (inferior). Dissect and divide the hilar structures from anterior to posterior in a single direction in the following sequence: upper lobe vein, anterior truncus of the pulmonary artery, left upper bronchus, posterior arteries to the upper lobe, lingular artery, and finally the fissure.
  • Pitfalls: Left upper lobectomy is often considered the most technically challenging lobe resection. The tunnel (fissure-first) technique can be advantageous in complex anatomy. Be alert for a common trunk of the superior and inferior pulmonary veins and for frequent arterial anatomical variants of the upper lobe.
  • The sequence of hilum dissection in the uniportal VATS should be from anterior to the superior and posterior to the inferior hilum; this is called the tangential sequence technique. Also, in uniportal VATS, the fissure-first technique permits adequate exposure of arterial branches when these are short and challenging to individualize.
• Left inferior lobectomy: hilar approach
  • The hilar approach and sequence of hilar structure division mirror those of the right lower lobectomy. However, a key distinction is that the utility port incision is typically placed in the middle axillary line to accommodate the heart's position.[18][38]
  • Pitfalls: Be alert for an inferior pulmonary vein sharing a common trunk with the superior pulmonary vein and arterial anatomical variants. Important variations include a mediastinal lingular artery that may arise from a common trunk with the inferior basal artery and the possibility that the superior segmental artery sends branches to the upper lobe.[9][41] 
  • The uniportal VATS technique is similar to the right lower lobectomy.
• Lymph node management
  • Lymph node management uses the recommendations of the International Association of the Study of Lung Cancer (IASLC) or the National Comprehensive Cancer Network (NCCN) in lung cancer.[42][18]

Postoperative Management

The most important features following lobectomy are pain control, pulmonary physiotherapy, and chest tube management.[20][43]

Complications

Lobectomy complications incidence depends on etiology, patient diagnosis, and the resected lobe.[44] Complications after lobectomy usually occur in the early postoperative period (within 48 hours), unlike pneumonectomy, which presents late complications due to the risk of pleural fluid infection.[45] A National Cancer Database review found that lobectomy mortality is 2.6%, and morbidity is 10% to 50%; mortality and comorbidity risks increase in patients over 75 years.[46][47] 

The main postoperative lobectomy complications are prolonged air leak (15%–18%), subcutaneous emphysema, pneumonia/mucus plugging/atelectasis (6%), pleural empyema (1%–3%), persistent space (9.5%) atrial fibrillation (33%), right middle lobe torsion (0.09–0.4%), hemorrhage (2.9%), chylothorax (0.7%–2%), phrenic nerve injury and recurrent laryngeal nerve injury, wound infection, tumor embolization (less than 1%) and very rarely bronchopleural fistula.[45][48] 

Robotic-assisted lobectomy has seen rapid growth in utilization across the United States, yet comparative evidence regarding its safety relative to open lobectomy and VATS lobectomy remains limited. A large multi-institutional study evaluated 26,140 lobectomy cases, comprising 5337 (20.4%) robotic, 12,680 (48.5%) VATS, and 8123 (31.1%) open procedures. The analysis demonstrated that robotic and VATS were associated with lower overall complication rates, reduced hospital length of stay, and decreased perioperative mortality compared with open procedures. However, robotic surgery was uniquely associated with a modest but statistically significant increase in perioperative respiratory complications (adjusted odds ratio 1.10, P = 0.010).[49]

Clinical Significance

The effectiveness of lobectomy surgery depends on the etiology and the surgical approach, including open lobectomy and VATS lobectomy. VATS has been the preferred approach, mainly due to the improved results in postoperative recovery. However, when VATS is not indicated, open lobectomy is performed to improve patient transoperative safety.[3][50] VATS lobectomy for infectious focal bronchiectasis or cavities can be performed safely with low rates of mortality (0%–1%) and morbidity (9%–23%).

The mean length of hospital stay is 4 days. VATS lobectomy for congenital lung diseases is feasible and effective in selected patients, with a conversion rate of 4%. NCCN recommends VATS lobectomy for lung cancer resection; research has shown VATS lobectomy to have a lower rate of minor complications and better long-term survival compared to open thoracotomy lobectomy for NSCLC.[14][51][52] Lately, consistent data from meta-analyses have shown that VATS lobectomy has lower complication rates and improved quality of life. Survival advantages in lung cancer resection compared with open lobectomy are moderate.[53] 

Enhancing Healthcare Team Outcomes

Effective lobectomy care requires a coordinated, multidisciplinary strategy to optimize outcomes and ensure patient safety. Surgeons and advanced clinicians must possess highly developed technical skills in both open and minimally invasive approaches and strong preoperative assessment capabilities to identify candidates with adequate cardiopulmonary reserve. Anesthesiologists and perioperative nurses play key roles in intraoperative management, including lung isolation techniques and hemodynamic monitoring. Respiratory therapists provide critical postoperative support through pulmonary hygiene and early mobilization strategies to reduce complications such as atelectasis and pneumonia. Pharmacists contribute by managing perioperative antibiotics, analgesics, and anticoagulation protocols to balance infection prevention and thrombosis risk while minimizing adverse drug events. Effective preoperative planning, such as structured prehabilitation and smoking cessation programs, also requires coordinated input from all team members.

Interprofessional communication and structured care pathways are essential to seamless transitions across the perioperative continuum. Daily multidisciplinary rounds, clear documentation of goals of care, and standardized protocols for pain management, chest tube care, and early ambulation enhance patient-centered care and reduce variability in outcomes. A culture of shared decision-making ensures that patients and families remain informed partners, while checklists and team briefings promote patient safety by reducing errors. By fostering mutual respect and clear communication among surgeons, advanced practitioners, nurses, pharmacists, and allied health professionals, the care team can improve recovery trajectories, shorten hospital stays, and ultimately enhance patient outcomes and team performance.