VATS Resection of Pulmonary Sequestration

This video shows a VATS resection of pulmonary sequestration in a previously healthy 55-year-old woman, who presented with chest pain. Pulmonary sequestration is a rare congenital abnormality of the lung consisting of nonfunctioning lung tissue that does not have normal communication with the tracheobronchial tree or pulmonary arteries. The lung receives its blood supply from the systemic circulation. The prevalence of sequestration is 0.15-1.8% of the general population (1).

Pulmonary sequestration is classified into two types – extralobar and intralobar. Extralobar sequestration is completely separate from the surrounding lung and has its own pleural encasing. It is typically located in the inferior portion of the thoracic cavity. It receives its arterial blood supply from the descending thoracic or abdominal aorta. Its venous drainage usually goes through the azygos or hemiazygos veins. Intralobar sequestration is surrounded by normal lung and does not have its own pleural investment. It usually receives its arterial supply from the descending thoracic aorta, which reaches the sequestered segment via the inferior pulmonary ligament. Its venous drainages usually occur through the pulmonary veins (2).

The clinical presentation of pulmonary sequestration can be variable. Many cases are found on routine prenatal ultrasound and affected newborns are asymptomatic. If symptomatic, neonates present with respiratory distress (1). Intralobar sequestration usually presents later in life with recurrent pulmonary infections. Often, sequestration is found incidentally on chest radiographs (2). Once identified, further imaging such as a CT or MRI can be done to characterize the lesion and localize the vasculature (1).

Management of the symptomatic patient requires surgical resection of the sequestration either with a wedge resection or lobectomy, depending on the size. Patients with asymptomatic extralobar sequestrations may be observed, as the malignant potential and recurrent infections are minimal. Asymptomatic patients with intralobar sequestration usually undergo surgical resection due to the risk of infectious complications (1). The approach for surgical resection is trending towards thoracoscopy, which has been shown to be equivalent to open thoracotomy (3).

References:                                                                                                                              

1. Chiu P, Langer JC. (2008). Mediastinal cysts and duplications in infants and children. Pearson’s Thoracic and Esophageal Surgery (1562-1580). Philadelphia, PA: Churchill Livingstone Elsevier.
2. Huddleston CB (2008). Congenital abnormalities of the lung. Pearson’s Thoracic and Esophageal Surgery (462-472). Philadelphia, PA: Churchill Livingstone Elsevier.
3. Wang LM, Cao JL, Hu J. Video-assisted thoracic surgery for pulmonary sequestration: a safe alternative procedure. J Thorac Dis. 2016; 8(1): 31-36.