# Posterior Single-Direction Approach for Thoracoscopic Combined S2+S6 Segmentectomy in Fused Fissure: A Case Report

## TL;DR

This case report describes a new surgical technique for segmentectomy in patients with fused fissures, avoiding complications by using a posterior single-direction approach.

## Contribution

The first reported use of a posterior single-direction approach for combined S2+S6 segmentectomy in fused fissures.

## Key findings

- The posterior single-direction approach avoided fissure manipulation and achieved complete oncologic resection.
- The technique was performed successfully in a patient with a tumor in an incomplete right interlobar fissure.
- The postoperative recovery was uneventful, demonstrating the safety of the approach.

## Abstract

Segmentectomy in cases with fused fissures poses technical challenges due to increased risks of air leakage, as reported in lobectomy. The single-direction approach avoids fissure manipulation through hilar-first dissection but has been rarely reported for posterior segments. We report the first case of a posterior single-direction approach for combined S2+S6 segmentectomy in a patient with a tumor located in an incomplete right interlobar fissure.

A 52-year-old woman with bilateral multiple ground-glass nodules presented with a 22-mm heterogeneous ground-glass nodule located in an incomplete fissure between the right upper and lower lobes. Preoperative CT revealed a fused fissure and concomitant S2 lesions, including a 15-mm subpleural nodule and a 7-mm deeper parenchymal nodule, as well as a 7-mm S6 lesion. Three-port thoracoscopic S2+S6 segmentectomy was performed with the surgeon positioned dorsally and ports placed posteriorly. Selective segmental inflation was performed prior to hilar dissection to mark intersegmental planes. Sequential division of V6 and the common trunk of ascending A2 and A6 was performed from the posterior hilar approach, followed by B6 division using a suction-device trick. After intersegmental division of S6 to improve hilar exposure, B2 was divided using the same approach, followed by V2 division and completion of S2+S6 segmentectomy. The postoperative course was uneventful.

The posterior single-direction approach successfully achieved complete oncologic resection without fissure manipulation, providing a safe alternative for posterior segmentectomy in patients with fused fissures.