Thoracoscopic Right Middle Lobe Lobectomy for Congenital Pulmonary Airway Malformation Using Small-Diameter Instruments: A Rare Affected Lesion and Procedure

Abstract

Introduction:

Minimally invasive surgery greatly contributes to the physical growth and development of children. Thoracoscopic surgery has many advantages in comparison with open surgery, ¹ including less chest asymmetry, less scoliosis, less nipple asymmetry, and wider intercostal spaces. ² Vessel sealing systems and staplers are used all over the world; however, these instruments are sometimes too large for pediatric patients. Small-diameter instruments that are suitable for pediatric patients have recently been developed. ^{3 –5} We report a case of thoracoscopic right middle lobectomy for congenital pulmonary airway malformation (CPAM), a rare affected lesion and procedure, using small-diameter instruments.

Patients and Operative Procedures:

The patient was a boy who was prenatally diagnosed with CPAM. We planned to perform thoracoscopic right middle lobe lobectomy at 15 months of age. He had no symptoms (e.g., dyspnea) and no history of pneumonia before the operation. Under general anesthesia, the patient was placed in the left lateral position. A 5-mm port was inserted at the sixth intercostal space with the optical method and an artificial pneumothorax was established using CO₂ insufflation (5 mm Hg, 1 L/min). Then, three additional ports were inserted. The targeted lesion in the middle lobe could be seen just under the endoscope port. The cyst walls of CPAM were taken down progressively using a 3-mm vessel sealer device (JustRight Surgical LLC, Louisville, CO). This procedure makes possible to obtain sufficient surgical space and identify the anatomical location in a small thoracic cavity. Next, the lung fissure was opened. The lung fissures were clearly divided and the interlobar pleura was dissected from the ventral side of the lung using a monopolar probe until the pulmonary artery was identified. Each branch of the artery was perfectly identified. The artery was lifted with a right-hand forceps using 4-0 absorbable monofilament suture to adjust the axis orthogonally with a left-hand forceps. A polymer clip (Weck^® Hem-o-lok^®; Teleflex, Morrisville, NC) was applied at the proximal end of the artery, which was then coagulated with a 3-mm vessel sealer and divided by 3-mm scissors. Similarly to the artery, the pulmonary vein was identified from the dorsal side of the lung. Double polymer clips were applied, and then the vein was coagulated with 3-mm vessel sealer and divided by 3-mm scissors. After dissecting the vessels, the middle lobar bronchus was clearly identified. The bronchus was clamped using a 5-mm stapler (JustRight Surgical LLC), and blocking of divided lung ventilation was removed by an anesthesiologist. Only the upper and lower lobe were perfectly ventilated, so we could confirm that only the middle lobar bronchus was clamped. The bronchus was then stapled and divided using a 5-mm stapler. A 10F Blake drain was inserted through the trocar wound.

Results and Conclusion:

There were no intra- or postoperative complications. The patient was discharged on postoperative day 5. Neither growth impairment nor chest wall deformity was observed in 4 months of postoperative follow-up. In this case, small-diameter instruments were effective and useful, even in the small space between the upper and lower lobes.

No competing financial interests exist.

Runtime of video: 4 mins 59 secs