Thoracoscopic resection of intradiaphragmatic bronchopulmonary sequestration

Prenatal ultrasound detected a 1 centimeter left congenital pulmonary airway malformation in this 4-month-old female patient

The lesion presence was confirmed with prenatal MRI and postnatal CT angiography performed at 2 months

CTA revealed the lesion received blood supply from a feeding vessel from the thoracic aorta

Single lung ventilation was performed after intubation of the right main stem bronchus for a left-sided lesion

Patient was placed in right lateral decubitus position for thoracoscopic access

Initial entry was achieved in the posterior axillary line of the fifth intercostal space with a 5 millimeter scope

Two additional 3 millimeter stab wounds were placed under direct visualization, one at mid-axillary line and one further posterior

Upon visualization of the left lower lobe, no attached lesion was identified on the lung itself

An irregularity of the diaphragm was identified consistent with the abnormality seen on CTA

The phrenic nerve and left ventricle of the heart were both in close proximity to the lesion

Dissection was purposely started on the border of the lesion and the nerve to allow safer traction without injury to the nerve

The pleura and diaphragm skeletal muscle fibers were dissected off the lesion with combination of sharp dissection with electrocautery and blunt dissection

A vessel sealer was used to ligate and control vessels including both venous drainage and the feeding vessel from the thoracic aorta

The specimen was extracted through the 5 millimeter port and sent to pathology

The diaphragmatic defect remaining after resection was repaired primarily with combination of a simple 3-0 Vicryl stitch and an additional figure-of-8 Vicryl stitch

Final pathology revealed crowded bronchioles, bronchi, and large vessels, consistent with diagnosis of extralobar pulmonary sequestration

There have only been 17 previously reported cases of intradiaphragmatic bronchopulmonary sequestration

Of the 17 previously reported cases of intradiaphragmatic bronchopulmonary sequestration, only 7 were able to be treated thoracoscopically