LLL intra lobar JRS

Dorroscopic left lower lobectomy for intrapulmonary sequestration with associated CPA and bronchogenic cyst, a rule for safe early intervention. 4 month old 7.6 kg female with a prenatally diagnosed sequestration and CAM was brought to the OR at 4 months of age for an elective thogoscopic left lower lobectomy after an upper respiratory infection. Prenatal imaging showed a 4.5 by 4 by 4 centimeter left lower lobe mass. A chest X-ray at birth showed diffuse hazy lungs with no discrete masses. A CT at 3 months of age showed a dense focal opacity in the left lower lobe. With the feeding vessel arising from the celiac axis below the diaphragm and branching within the sequestration, several cysts at the periphery of the lesion were noted. An anterior approach shown here was used using three ports a 4 millimeter through the posterior axillary line for the telescope, 23 millimeter ports placed in the anterior axillary line, and the lower port was later changed to a 5 millimeter port for access of the 5 millimeter stapler and 5 millimeter clip applier. Cystic changes noted in the lung. Adhesions were taken down inferiorly with the combination of blunt dissection and the 3 millimeter sealer. Several enlarged lymph nodes were also present within the inferior pulmonary ligament adjacent to the artery was a cystic structure from which mucinous material was expressed. The systemic artery was then dissected. And double clipped on both sides. And then divided with the 3 millimeter scissors. The adjacent cystic structure was then carefully dissected. And then transsected. Using the 5 millimeter stapler. And the 3 millimeter scissors. The inferior pulmonary ligament was further divided up to the inferior pulmonary vein. An incomplete major fissure was identified. And was opened. Using a combination of the 5 millimeter stapler. 3 millimeter scissors. And the 3 millimeter sealer device. The major fissure was completed in a plane that was superficial to the pulmonary artery branches. Note that the 3 millimeter sealer was first applied to the tissue to allow for cautery as well as crushing of the tissue prior to applying the 3 millimeter scissors. This plane was continued posteriorly, staying superficial. To the arterial branches By dissecting the pulmonary arteries in the left lower lobe parenchyma, the branches were then sealed on both sides. And then divide it sharply between the sealed points. This exposed the lower lobe bronchus and was dissected into the parenchyma up to the branch points. Each of the two segmental bronchi was then divided using the 5 millimeter stapler. The pulmonary vein was dissected to a branching point in the lower lobe. And divided with the stapler device. Note the placement of the Maryland clamp at the base of the vessel prior to firing of the stapler. This provides a protective measure in case the staples do not incorporate the entire line of transaction. With this, the lobe was completely freed. And the arterial stump remained controlled. The lowest incision was expanded from 5 millimeters to 1 centimeter, and the specimen removed piecemeal in its entirety. Postoperatively, the chest tube was removed on post-op day 1 and the patient discharged home on post-op day 2. The final pathology showed lung lobe with sequestration and secondary changes of cystic pulmonary airway malformation. This case illustrates that early thoraroscopic surgery can be safely performed in infants with complex congenital lung malformations. In this patient's case, there are multiple lesions contained within one lobe. The 3 millimeter sealer and 5 millimeter stapler facilitate a thorough dissection and complete excision of tissue. This early approach promotes conservation of lung parenchyma and reduces postoperative thoracic musculoskeletal deformity.