Thoracoscopic Left Lower Lobectomy for Congenital Pulmonary Airway Malformation
The malformation was a hybrid congenital pulmonary airway malformation diagnosed prenatally.
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The patient was asymptomatic at birth and remained asymptomatic through 9 months of age.
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CT scan at 4 months showed a left lower lobe CPAM with systemic blood supply arising from the sub-diaphragmatic aorta.
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The operation was performed at 9 months of age.
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The left lung is isolated by right main stem intubation.
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The patient is placed in the right lateral decubitus position with surgeon and assistant operating facing the patient.
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A large arterial vessel coming through the diaphragm medial to the inferior pulmonary ligament and entering the left lower lobe confirms a hybrid lesion.
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The inferior pulmonary ligament is divided all the way to the border of the inferior pulmonary vein to mobilize the left lower lobe off the diaphragm.
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Division of the inferior pulmonary ligament allows stretching of the systemic arterial vessel for skeletonization with hook cautery.
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The systemic arterial vessel is double-clipped proximally and divided distally with a ligature device.
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The approach of proximal clipping and distal ligature division is used repeatedly for control of several major vessels.
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The fissure is completed using ligature and sharp dissection.
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Division of pulmonary parenchyma in the fissure allows visualization of pulmonary artery branches to the lower lobe.
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The dissection should be kept as bloodless as possible, with any bleeding from divided parenchyma controlled early with ligature.
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Excellent visualization is essential for adequate vascular control.
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A right angle dissector is extremely useful in skeletonizing vessels and gaining adequate distance for safe ligation.
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Dissection in the fissure always proceeds from medial to lateral.
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While ligature can be used as the sole method of vessel control, the surgeon prefers to apply clips proximally if adequate vessel length has been achieved.
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Once the pulmonary artery and all pulmonary parenchyma in the fissure is divided, the bronchus comes into view.
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The inferior pulmonary vein is skeletonized using a right angle dissector.
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The junction of the inferior pulmonary vein and the left atrium can be clearly seen after adequate dissection.
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It is quite common for the inferior pulmonary vein to consist of two major tributaries that join as they approach the left atrium, in addition to one or more small tributaries.
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When the inferior pulmonary vein has two major tributaries, it is best to dissect each tributary separately.
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Each pulmonary vein tributary is controlled by clipping on the cardiac side and applying ligature on the pulmonary side.
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Hook cautery is used to clean the bronchus of surrounding lymphatic and adventitial tissue.
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An endo-GIA device is introduced directly through the chest wall and used to staple and divide the bronchus.
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The specimen is extracted by slightly enlarging the posteriormost port site.
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A chest tube is placed at the end of the operation.
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The patient was extubated at the end of the procedure.
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The patient was discharged on the 2nd postoperative day with excellent recovery.
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