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Gharagozloo et al. Mini-invasive Surg 2020;4:55 I http://dx.doi.org/10.20517/2574-1225.2020.42 Page 9 of 13

Figure 11. The right MLPV is encircled. ULPV is seen. MLPV: middle lobe pulmonary vein; ULPV: upper lobe pulmonary vein

Figure 12. Removal of station #11 nodes off of the pulmonary artery in the fissure. PA: pulmonary artery; LN: lymph node station #11

nodal or parenchymal tissue. This branch can be followed superiorly to the main pulmonary artery. This
maneuver helps to elevate station #11 nodes off the pulmonary artery and to identify the artery branch to
the middle lobe. Next, the remainder of the fissure between the right middle lobe and right lower lobe is
divided in an anterior to posterior direction [Figure 12]. At times there is a vein branch to the middle lobe
which drains into the inferior pulmonary vein. This is divided into the remainder of the anterior fissure.

Next, the middle lobe bronchus is identified. It will be running from left to right in the fissure. It is
encircled and divided, taking care to avoid injuring the pulmonary artery branches that are located directly
behind it [Figure 13].

The middle lobe artery is encircled and divided with a vascular load. At times right middle lobe artery
branches come off directly from the main pulmonary artery instead of bifurcating from the common trunk
of a single middle lobe artery. These are encircled and divided in the same fashion [Figure 14].

Dissection of the fissure is then continued posteriorly until the main artery trunk and the superior
segmental artery branch are identified. After identifying the main artery, the Cadiere forceps in the left
hand is used to go under the transverse fissure in a posterior to anterior direction heading for the divided
superior pulmonary vein. A vessel loop is passed, and the fissure between the upper and middle lobes is