BACKGROUND: Sublobar surgeries involving the left anterior segment of the lung can be challenging due to its central location within the left upper lobe (LUL) and among multi-segments. However, there have been no reports specifically analysing the anatomical patterns of this segment. Therefore, this study aimed to comprehensively investigate the subsegmental bronchovascular patterns and relationship between variations and surgical strategies. METHODS: The branching patterns of the left anterior segment bronchi and pulmonary vessels were assessed retrospectively and categorised using three-dimensional reconstruction images of 647 consecutive patients. RESULTS: Anatomical distribution patterns of the left anterior segmental bronchus, artery, and vein analysed in 635 valid cases were 6, 38, and 6, respectively. For the first time, branches of the sub-subsegmental level were demonstrated and reclassified in the anterior segment. Additionally, all 102 cases (16.06%) of interlobar (IL) arterial variations were found in the lateral subsegmental artery. Interestingly, only the lateral subsegmental artery patterns were not independent of the types associated with the anterior segmental bronchus, artery, and vein in the left upper division. Based on the observed anatomical variant patterns of the artery and bronchus, we developed a decision-making theory to assist in selecting surgical approaches for nodules located within the lateral subsegment of the anterior segment of the lung. CONCLUSIONS: The study elucidated the sub-subsegmental level of the left anterior segmental bronchovascular distribution patterns. This study also indicated a correlation between the lateral subsegmental arterial patterns and the patterns observed in the anterior bronchus and the left upper division vein (LUDV). By taking these findings on arterial and bronchial variations into account preoperatively, we might contribute to formulating a more concise operation procedure and optimizing the selection of surgical approaches.