VATS S6 segmentectomy is simple to perform, while individual basilar segmentectomy, including subsegmentectomy, is technically challenging. The reason is the deep intraparenchymal location of the hilar structures (vein, artery, bronchus), frequent anatomical variations, challenging stapling of the intersegmental plane, etc.
The traditional method for this procedure is to manage the hilar structures from the interlobar fissure. The artery and bronchus are located deeply from the fissure when performing S9 or S10 segmentectomy. The intersegmental veins are sometimes hardly distinguishable in some patients.
We had been adopting the concept of vein 1st strategy to perform lung segmentectomy using 3DCT reconstruction and developed non-fissure approaches for these removals since 2009. The vein is easily visible when we observe the basilar segments from the caudal or dorsal side, and we trace and dissect the lung parenchyma along the inter-segmental veins. Then we find the confluence of intra-segmental veins and transect those of the target segment. It leads to the hilar bronchus, and we manage the bronchus and artery. The final step is the division of the intersegmental plane. As for this kind of segmentectomy, the right basilar segment anatomy is more complex than the left as S7 is present.

I will introduce the key concept, operation videos, and the postoperatieve results of this procedure.