PMC4491585_01
Perioperative pictures during VATS. All photographs were taken from the camera port distally with the patient lying on his left side and the arm in 90 degrees so the respective sides of these photographs concur with apical, ventral, distal, and dorsal positions, respectively. On the ventral side, the right internal mammary artery and vein running near the sternum can be seen. Pictures (a) to (d) display the different fissures as shown with long shaft instruments. RUL: right upper lobe; RML: right middle lobe; RLL: basal segments of the right lower lobe; RLL*: apical segment of the right lower lobe. Solid white arrows: horizontal fissure; blue arrow: oblique fissure; orange solid arrow: superior accessory fissure of the right lower lobe.
CRIPU2015-954769.001.jpg
PMC4491585_01_CRIPU2015-954769.001.jpg
fig1
During VATS, we discovered an interesting anatomical variation of the lower lobe of the right lung; that is, the superior segment of the right lower lobe appeared separated from its native lobe through an extra fissure (Figures 1(a)-1(d)), thus giving this lung the image of a four-lobed organ.
Plain X-rays. (a) anteroposterior X-ray; (b) lateral X-ray. Blue arrows show the superior accessory fissures (R = right side).
CRIPU2015-954769.002.jpg
PMC4491585_01_CRIPU2015-954769.002.jpg
fig2
This finding was not visible on the plain X-ray (Figures 2(a)-2(b)) or detected during routine examination of the preoperative CT scan (Figures 3(a)-3(d)).
CT scan. (a)-(b) Coronal sections showing the bifurcation of the bronchus to the apical segment and the basal segments. There is no evidence of accessory branching, so no morphological extra lobe; hence there is only an accessory fissure (arrows). CT scans (a) and (b) have respiratory artifacts as seen at the level of the diaphragm. (c)-(d) Transversal sections showing the superior accessory fissure of the lower lobe of the right lung.
CRIPU2015-954769.003.jpg
PMC4491585_01_CRIPU2015-954769.003.jpg
fig3
This finding was not visible on the plain X-ray (Figures 2(a)-2(b)) or detected during routine examination of the preoperative CT scan (Figures 3(a)-3(d)).