Secure the left endobronchial double-lumen tube, allowing single-lung ventilation for the duration of the resection. Place the patient in the left lateral decubitus position and make a right posterolateral thoracotomy. A muscle-sparing thoracotomy is a feasible alternative, but should never be allowed to hinder the resection.

Retract the lung inferiorly and posteriorly and divide the pleura around the hilum.

Identify the superior pulmonary vein and dissect along it distally up to the lung parenchyma. Mobilize around the vessel in the appropriate plane. Identify and preserve the middle lobe vein, which typically enters the superior pulmonary vein. Be alert to aberrant venous drainage, including occasional direct connections to the vena cava.

The pulmonary artery lies just posterior and superior to the vein (Fig. 27.1A). Gently develop the appropriate plane, and dissect proximally and distally. The pulmonary artery is an extremely delicate and unforgiving vessel. Great care and attention to detail will aid in successful mobilization. Mobilize circumferentially and place an umbilical tape loosely around it to provide proximal control should bleeding occur.

Distal dissection will identify the truncus anterior (apicoanterior) branch. Dissection should be circumferential and should avoid spreading of surrounding tissue. Gently passing a blunt curved clamp can help define planes. Never pass the clamp against resistance. “Peanut” dissection is often useful for better defining the anatomy after you are in the correct plane. Free the pulmonary artery from the upper lobe branches and any attachments to the azygos vein.

Retract the lung anteriorly and incise the pleura overlying the bifurcation of the upper lobe bronchus and bronchus intermedius.
Careful use of electrocautery will control small bronchial vessels in this area. Reliably, a lymph node is located at this point and is swept anteriorly. Anterior to the lymph node is the superior segment branch of the pulmonary artery to the lower lobe, which is much better seen from this aspect than by the anterior approach. After you have identified this branch, any intact portion of the posterior aspect of the major fissure can be completed (divided) with staplers. This posterior approach to the superior segment branch greatly improves the anatomic division and is rather efficient (Fig. 27.1B).

Divide the apical segmental vein, crossing the anterior segmental artery, either with vascular staples or with suture ligatures.

Mobilize and divide the superior arterial trunk with a vascular stapler or suture ligature. Ligate apical and segmental branches.

Remember that the azygos vein arches from posterior to anterior immediately superior to the root of the right lung, and that, at least conceptually, the plane of the major pulmonary veins is anterior to that of the arteries. The right pulmonary artery, at the point where it leaves the pericardial sac, is anterior and somewhat inferior to the right main-stem bronchus. It enters the minor fissure and passes inferolaterally anterior to the upper lobe bronchus. Slightly before it enters the minor fissure, it gives off a superior branch from its superior aspect, which can supply all three segments of the upper lobe. Frequently, however, the superior trunk supplies only the apical and anterior segments, whereas the posterior segment is supplied by an ascending artery that branches off the superior aspect of the main pulmonary artery, somewhat distal to the superior branch.