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Ann Thorac Surg 2002;73:639-640
© 2002 The Society of Thoracic Surgeons

Case report

Video-assisted thoracic surgery lobectomy for pulmonary sequestration

Innes Y.P. Wan, FRCSa, Tak Wai Lee, FRCSa, Alan D.L. Sihoe, MB, BChira, Calvin S.H. Ng, MBBS, (Hons)a, Anthony P.C. Yim, MD*a

a Department of Surgery, Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Shatin, Hong Kong, People's Republic of China

Accepted for publication May 25, 2001.

* Address reprint requests to Dr Yim, Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, People's Republic of China
e-mail: yimap{at}cuhk.edu.hk


   Abstract
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 Abstract
Introduction
 Comment
 References
 
Pulmonary sequestration is a rare developmental abnormality, and the patients usually present with recurrent pneumonia. We report a case of video-assisted thoracic surgery lobectomy in a 32-year-old woman with an intrapulmonary sequestration in the left lower lobe.


   Introduction
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 Abstract
 Introduction
Comment
 References
 
Pulmonary sequestration is a rare developmental abnormality characterized by nonfunctioning parenchymal lung tissue that lack a normal communication with the tracheobronchial tree. The patient usually presents with recurrent pneumonia without any endobronchial pathology. The treatment usually involves resection of the sequestrated segment or lobe. We report the use of video-assisted thoracic surgery (VATS) in the management of this condition with emphasis on our own technique.

A 32-year-old woman, who enjoyed good past health, presented with an 8-month history of recurrent left lower lobe pneumonia. Chest x-ray film showed a left lower zone shadow. Bronchoscopy failed to demonstrate any abnormality. Cytology and cultures of the bronchial aspirate were negative. Contrast computed tomography of the thorax showed consolidated segment of left lower lobe with suggestion of pulmonary sequestration (Fig 1). Magnetic resonance angiography demonstrated a feeding artery originating from the descending aorta to that particular segment of lung (Fig 2). Surgical exploration with VATS was planned.



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  		Fig 1. Computed tomography of the thorax showed sequestrated segment of left lower lobe of lung.

 


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  		Fig 2. Magnetic resonance angiography showed feeding artery arising from the descending aorta.

 
The patient was placed in a full right decubitus position with the table flexed at 30 degrees between the level of the nipples and the umbilicus to open up the upper intercostal spaces [1]. We used a 30-degree lens to avoid torquing of the telescope. VATS exploration of the left pleural cavity was performed showing an intrapulmonary sequestrated segment in the left lower lobe. A small utility thoracotomy without rib spreading was placed over the inframammary crease for dissection and later specimen retrieval. The feeding artery from the descending aorta was carefully dissected out and divided (Fig 3). Left lower lobe lobectomy was performed thoracoscopically using the technique that we have described before. We used suture ligation with extracoporeal knots [2] for pulmonary arterial branches to minimize the cost of consumables [3], although we still relied on the stapler-cutter (EndoGIA 30, USSC, Autosuture, Tyco Healthcare, Norwalk, CT) for the inferior pulmonary vein, the feeding artery, and the lower lobe bronchus.



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  		Fig 3. The feeding artery from the aorta was isolated and looped before division.

 
The patient made an uneventful recovery and was discharged on postoperative day 4. She required a minimal amount of analgesics during the postoperative period. The final pathology revealed intrapulmonary sequestration with organized pneumonic changes. The patient returned to work as an office assistant 2 weeks after surgery. She remained well at last follow-up 8 months after surgery.


   Comment
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 Abstract
 Introduction
 Comment
References
 
A high index of suspicion should be employed in making the diagnosis of pulmonary sequestration. Appropriate investigations should be carried out in order to identify the cause of the recurrent infection. Computed tomography of the thorax is useful in making the preliminary diagnosis. Magnetic resonance angiography is useful in delineating the vascular anatomy of the sequestration [4].

The definitive treatment of pulmonary sequestration is surgical resection, although limited success has been reported with the use of a simple ligation technique for the feeding artery. Resection either in the form of lobectomy for intralobar sequestration or sequestrectomy for extralobar sequestration was reported to result in excellent clinical outcome and minimal morbidity [5]. The conventional surgical approach for resection is through a posterolateral thoracotomy. VATS provides an alternative and a more patient-friendly approach to the surgical management of this condition. By minimizing access trauma, postoperative pain after VATS is markedly lessened and recovery accelerated compared to conventional surgery. This has been shown to reduce surgical trauma from both clinical and biochemical points of view [6, 7]. There was also evidence showing better preservation of lung function postoperatively [7]. Use of ligatures, instead of the endoscopic stapler-cutter for pulmonary vessels is important in minimizing the consumable cost of the operation, and this is particularly important in Asia where cost is a major deterrent in the development of VATS [3]. The need for thorough preoperative investigation should be emphasized in order to delineate the vascular anatomy, especially when a minimally invasive approach is to be adopted.


   References
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 References
 

  1. Yim A.P.C. Minimizing chest wall trauma in video-assisted thoracic surgery. J Thorac Cardiovasc Surg 1995;109:1255-1256.
  2. Yim A.P.C., Lee T.W. Homemade knot pusher for extracoporeal ties. Aust N Z J Surg 1995;65:510-511.[Medline]
  3. Yim A.P.C. Cost containment strategies in video assisted thoracoscopic surgery—an Asian perspective. Surg Endosc 1996;10:1198-1200.[Medline]
  4. Ko S.F., Wan Y.L., Ng S.H., et al. MRI of thoracic vascular lesions with emphasis on two-dimensional time-of-flight MR angiography. Br J Radiol 1999;72:613-620.[Abstract]
  5. Halkic N., Cuenoud P.F., Corthesy M.E., Ksontini R., Boumdhar M. Pulmonary sequestration: a review 26 cases. Eur J Cardiothorac Surg 1998;14:127-133.[Abstract/Free Full Text]
  6. Yim A.P.C., Wan S., Lee T.W., Arifi A.A. VATS lobectomy reduces cytokine responses compared with conventional surgery. Ann Thorac Surg 2000;70:243-247.[Abstract/Free Full Text]
  7. Nakata M., Saeki H., Yokoyama N., et al. Pulmonary function after lobectomy: video-assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 2000;70:938-941.[Abstract/Free Full Text]



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This Article
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