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Ann Thorac Surg 1996;61:1836-1837
© 1996 The Society of Thoracic Surgeons

Case Report

Video-Assisted Thoracoscopic Resection of Pulmonary Sequestration in an Infant

Maurizio Mezzetti, MD, Carlo A. Dell'Agnola, MD, Marilia Bedoni, MD, Roberto Cappelli, MD, Franco Fumagalli, MD, Tiziana Panigalli, MD

Division of Thoracic Surgery, European Institute of Oncology, Istituti Clinici di Perfezionamento, University of Milan, Milan, Italy

Accepted for publication December 21, 1995.


   Abstract
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Pulmonary sequestration is a congenital anomaly of lung parenchyma that can be definitively treated only with surgical resection. We report a case of an intralobar sequestration of the right lower pulmonary lobe in an infant successfully treated with video-thoracoscopic surgical removal of the involved lobe at 6 months of age.


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See also page 1837.

Pulmonary sequestration is a congenital anomaly of lung parenchyma that consists of a partial or complete separation of a portion of a lobe of the lung without appropriate bronchial and vascular connections. Two varieties are recognized: extralobar (25% of the total) [1, 2], which is enveloped by its own pleural covering, and intralobar, which is embedded in otherwise normal lung. Pulmonary sequestration may have the same origin as cystic pulmonary lesions (ie, from accessory lung buds detached from the main pulmonary tree when the bronchial bud is moving from the gut) [3]. It often occurs in the basal segments of the lower lobes, mainly on the left side. The lung tissue in pulmonary sequestration is characterized by an internal fluid-filled cavity with columnar or cuboidal epithelium within a normal lobar parenchyma. Surgical resection is the treatment of choice for pulmonary sequestration.

A 3,130-g male infant was born at 40 weeks' gestation by spontaneous vaginal delivery. The Apgar scores were 9 and 10 at 1 minute and 5 minutes. Ultrasound examination at the 25th week revealed the presence of a cystic malformation in the right lung with mediastinal shift. At birth a chest roentgenogram revealed a right upper mediastinal enlargement with a roughly rounded lesion inside. The neonatal period was normal.

At 2 months of age a computed tomographic scan (Fig 1Go) showed a large cystic mass in the right lower lung field with moderate enhancement after injection of contrast medium consistent with intralobar sequestration. No aberrant arterial supply could be demonstrated; the contrast medium was supposed to reach the sequestration passing through the pulmonary ligament. For this reason and the young age of the patient no further invasive examinations were undertaken.



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  		Fig 1. . Lung computed tomographic scan at age 2 months showing the affected parenchyma of the right lower lobe.

 
At 6 months of age the patient underwent a video-assisted thoracoscopic right lower pulmonary lobectomy. The procedure was performed under general anesthesia by placing a double-lumen endotracheal tube (a small caliber Marraro tube) to allow ipsilateral lung collapse. After exclusion from ventilation of the right lung, a 5-mm trocar was introduced in the fifth intercostal space at the midaxillary line for the initial video-assisted thoracoscopic exploration of the pleural cavity; this revealed normal-appearing right upper and middle lobes. The posterior basal segment of the lower lobe was airless and congested with a clear demarcation from the adjacent parenchyma and was adherent to the diaphragm and to the chest wall near the phrenocardiac angle. These adhesions seemed not to be caused by previous parenchymal infections. We decided to perform a standard right lower lobectomy leaving the severing of the adhesions as the last step of the procedure. Two 12-mm trocars were placed in the sixth intercostal space at the posterior axillary line and in the eighth intercostal space at the midaxillary line. The major fissure was prepared to reach and dissect the artery, then the inferior pulmonary vein was dissected and both vessels were sectioned with a vascular Endo-GIA stapler (Autosuture; United States Surgical Corporation, Norwalk, CT). The lower lobe bronchus and the apical lower bronchus were dissected and sectioned separately by means of an Endo-GIA parenchymal stapler. The pulmonary ligament was opened and during the dissection of the adhesion with the diaphragm an apparently anomalous systemic artery of 4 mm in diameter feeding the anomalous area of lung parenchyma was exposed, dissected, and sectioned with a vascular Endo-GIA stapler. To extract the specimen from the chest cavity, the site of insertion of the first trocar was converted to a very small (3 cm in length) service thoracotomy and the lower lobe was removed with an Endo catch. No bleeding or air leak was observed either during the surgical procedure or in the postoperative course. The lowest intercostal access site used for the video-assisted thoracoscopic approach was used at the end of the procedure for the placement of the chest tube, which was removed 48 hours postoperatively. The postoperative course was uneventful and the boy was discharged on the sixth postoperative day. Pathologic examination of the operative specimen showed abnormal lung parenchyma with large, dilated bronchioles and alveolar ducts (Fig 2Go). No inflammation was present. The histology of the lung, the systemic blood supply, and the lack of patent tracheobronchial connection are consistent with the diagnosis of intralobar pulmonary sequestration.



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  		Fig 2. . Gross appearance of pulmonary sequestration with its anomalous arterial blood supply.

 

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Video-assisted thoracoscopy is a rapidly evolving surgical technique [4]. Although its indications for malignancies are still controversial, its use for benign masses is widely accepted [5]. We report our personal experience in video-assisted thoracoscopic treatment of pulmonary sequestration. This approach should be considered in infants either for better aesthetic results or more rapid resumption of general conditions.


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Address reprint requests to Dr Mezzetti, Department of Thoracic Surgery, European Institute of Oncology, Via Ripamonti 435, 20141 Milan, Italy.


   References
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 References
 

  1. Piccione W Jr, Burt ME. Pulmonary sequestration in the neonate. Chest 1990;97:244–6.
  2. Nicolette LA, Kosloske AM, Bartow SA, Murphy S. Intralobar pulmonary sequestration: a clinical and pathological spectrum. J Pediatr Surg 1993;28:802–5.[Medline]
  3. Hernanz-Schulman M. Cysts and cystlike lesions of the lung. Radiol Clin North Am 1993;3:631–48.
  4. Cooper JD. Perspectives on thoracoscopy in general thoracic surgery. Ann Thorac Surg 1993;56:697–700.[Medline]
  5. Hazelrigg SR, Landreneau RJ, Mack MJ, Acuff TE. Thoracoscopic resection of mediastinal cysts. Ann Thorac Surg 1993;56:659–60.[Abstract]

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