Right middle and lower bilobectomy using a modified fissureless technique: a case report

BACKGROUND: Fissureless lobectomy has been shown to prevent air leaks in patients with fused or incomplete interlobar fissures or emphysema. The technique is also beneficial in advanced lung cancers involving adjacent lobes, where interlobar manipulation is technically difficult. Although this technique is widely used in standard lobectomies, reports on bilobectomy remain scarce. CASE PRESENTATION: A 57-year-old woman with left-sided tongue cancer (pT2N0M0, Stage II) underwent subtotal glossectomy followed by postoperative concurrent chemoradiotherapy. Eighteen months after the surgery, imaging revealed a mass in the right lower lobe. Bronchoscopy confirmed squamous cell carcinoma, and the patient was referred to our department with suspected pulmonary metastasis. Over the 3 weeks following initial presentation, the lung tumor enlarged rapidly. The tumor was centered in the lower lobe with invasion of the middle and upper lobes, and the distal lung parenchyma was complicated by obstructive pneumonia. Although antibiotics were administered, the fever and inflammatory markers persisted; thus, we decided to proceed with surgery for infection control. Due to the presence of incomplete lung fissure and the lower lobe tumor invading the other lobes, pneumonectomy was the initial option. However, to preserve lung capacity, we decided to perform a fissure-last right middle and lower bilobectomy with division of the interlobar pulmonary artery prior to resection of the bronchus. The patient was discharged 16 days after surgery without complications. CONCLUSIONS: We report a case of bilobectomy using a modified fissureless technique and describe the technical details of how we dissect the pulmonary artery prior to resection of the bronchus. Being familiar with the fissureless bilobectomy technique is an important option for avoiding right pneumonectomy.