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J Thorac Cardiovasc Surg 2006;131:917-918
© 2006 The American Association for Thoracic Surgery

Brief Communication

Video-assisted resection of bilateral intralobar pulmonary sequestrations

Christopher R. Morse, MD a , Michael B. Ishitani, MD b , Stephen D. Cassivi, MD, MSc a , *

a Division of General Thoracic Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
b Division of Pediatric Surgery, Mayo Clinic College of Medicine, Rochester, Minn.

Received for publication November 18, 2005; revisions received December 7, 2005; accepted for publication December 9, 2005.

* Address for reprints: Stephen D. Cassivi, MD, MSc, Mayo Clinic College of Medicine, 200 First St SW, Rochester, MN 55905. (Email: cassivi.stephen{at}mayo.edu).

Bronchopulmonary sequestrations (BPSs) are characterized by anomalous vascular and tracheobronchial connections and account for a small proportion of pulmonary malformations. Bilateral BPSs are extremely rare, and the traditional surgical approach has been sequential resections with staged thoracotomies. We report a single-stage, sequential, video-assisted thoracoscopic surgery (VATS) approach to bilateral intralobar pulmonary sequestrations (ILSs).

Clinical Summary

An otherwise healthy 7-year-old girl was referred with low-grade fevers, productive cough, and a right lower lobe infiltrate on standard chest radiographs. She was given 2 courses of antibiotics, with only partial resolution of her right lung infiltrate. Subsequent high-resolution computed tomographic imaging demonstrated bilateral lower lobe BPS (Figure 1, A). Arterial supply to both sides was from the abdominal aorta (Figure 1, B).


Figure 1
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  		Figure 1. A, Coronal computed tomographic image demonstrating bilateral bronchopulmonary sequestrations. B, Coronal computed tomographic image, with white arrow identifying left arterial feeding vessel and black arrow identifying right arterial feeding vessel, both originating from the abdominal aorta.

 
In the operating room, after achievement of general anesthesia with a single-lumen endotracheal tube and bronchial blocker, the patient was initially placed in the left lateral decubitus position. The lung was carefully inspected with a 5-mm, 30° thoracoscope through a 5-mm anterior ninth interspace thoracoport. A 5-cm access incision was made in the fifth interspace anteriorly, sparing the serratus anterior muscle. Visualization was improved by placing a figure-of-eight stitch in the tendinous portion of the diaphragm and drawing it down through the same ninth interspace thoracoport. A consolidated intralobar sequestration was noted in the posterior and lateral basilar segments of the right lower lobe, with the aberrant arterial supply located in the inferior pulmonary ligament. The arterial supply was dissected and divided with a vascular TA-30 stapler. A sequestrectomy was performed with multiple applications of an Endo GIA 3.5-mm linear stapler (Figure 2). A 20F chest tube was placed, the lung was inflated under direct vision, and the incisions were closed in layers. The patient was then turned to the right lateral decubitus position, access to the left pleural space was obtained through a 5-mm ninth interspace thoracoport, and a 5-cm access incision was made in the fifth interspace anteriorly. The lung was inspected, and a similar intralobar sequestration was observed in the posterior basilar segment of the left lower lobe. The aberrant arterial source in the inferior pulmonary ligament was isolated and divided, and sequestrectomy was performed in similar fashion. A single left chest tube was placed, and the patient was transferred to the pediatric intensive care unit. Both chest tubes were removed on the second postoperative day, and the patient was discharged to home on the fourth postoperative day. Final pathology showed bilateral intralobar sequestrations with severe inflammation.


Figure 2
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  		Figure 2. Excised right intralobar bronchopulmonary sequestration.

 
Discussion

ILSs are characterized by nonfunctioning lung tissue that lacks normal communication with the tracheobronchial tree. The arterial supply to ILSs is most often from the abdominal aorta, and venous drainage is usually through normal routes to the left atrium. Although children with BPSs are at risk for associated abnormalities, they occur less with intralobar than with extralobar sequestrations.

To date, there have been 12 reported cases of bilateral BPS in the literature, with only 5 intralobar cases. 1 Go All operative cases were approached with staged sequential thoracotomies. 1 Go More recently, surgical resection of BPSs has been accomplished with a VATS approach. 2-4 Go Lobectomy, sequestrectomy, and wedge resections have all been described, with excellent results and a small number of conversions to thoracotomy. 5 Go Because disease in this patient was limited to the basilar segments of the lower lobes, it was possible to perform sequestrectomies and preserve lung parenchyma. This unique case of bilateral ILS demonstrates the feasibility of a single-setting, sequential VATS approach to minimize postoperative pain and limit multiple or prolonged hospitalizations.

References

  1. Spinella PC, Strieper MJ, Callahan CW. Congestive heart failure in a neonate secondary to bilateral intralobar and extralobar pulmonary sequestrations. Pediatrics 1998;101:120-124.[Free Full Text]
  2. Wan IY, Lee TW, Sihoe AD, Ng CS, Yim AP. Video-assisted thoracic surgery lobectomy for pulmonary sequestration. Ann Thorac Surg 2002;73:639-640.[Abstract/Free Full Text]
  3. Sakuma T, Sugita M, Sagawa M, Ishigaki M, Toga H. Video assisted thoracoscopic wedge resection for pulmonary sequestration. Ann Thorac Surg 2004;78:1844-1845.[Abstract/Free Full Text]
  4. Klena JW, Danek SJ, Bostwick TK, Romero M, Johnson JA. Video-assisted thoracoscopic resection for intralobar pulmonary sequestration. single modality treatment with video-assisted thoracic surgery. J Thorac Cardiovasc Surg 2003;126:857-859.[Free Full Text]
  5. de Lagausie P, Bonnard A, Berrebi D, Petit P, Dorgeret S, Guys JM. Video-assisted thoracoscopic surgery for pulmonary sequestration in children. Ann Thorac Surg 2005;80:1266-1269.[Abstract/Free Full Text]



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