Robotic Assisted Resection of Intralobar Pulmonary Sequestration

Pulmonary sequestration is a rare lung malformation comprising 0.15-6.4% of all congenital pulmonary malformations (1). The anomalous lung segment has systemic arterial supply, various forms of venous drainage and no connection to the tracheobronchial tree. The lung segment can be within the native pleura lining (intralobar) or have its own pleural investment (extralobar). The systemic arterial supply is variable with 74% originating from the thoracic aorta while the remaining from the abdominal aorta (1). Most intralobar sequestration are localized in the medial and posterior left lung (1).

Patients can be asymptomatic, but recurrent pneumonia, aspergillosis and fatal hemoptysis have been reported (2, 3). Computerized tomography angiography (CTA) can make the diagnosis. Open surgery using a posterior lateral thoracotomy has been the established approach (4, 5) usually resulting in a 3-4-day length of stay in the hospital. Other approaches have included endovascular exclusion of the aberrant arterial supply with (6) or without thoracoscopic resection of the lung segment (7). Recently minimally invasive approaches have included VATS lobectomy (8) as well as robotic assistance (9, 10). This video demonstrates the technique of robotic assisted resection of intralobar pulmonary sequestration with the aid of indocyanine green dye and near infrared imaging to define the extent of pulmonary resection. The patient is a 20-year-old with a history of chest pain and shortness of breath. CTA of chest demonstrated an anomalous systemic arterial branch extending from the superior abdominal aorta to the right lower lobe. The intralobar pulmonary sequestration was resected with robotic assistance.

The patient was discharged home on the 1st postoperative day. The robotic approach offers improved vision and imaging with a more stable platform resulting in reduced pain and hospital length of stay. In addition, no endovascular device is remaining in the patient.

References

1. Savic B, Bertel FJ, Tholen W, et al. Lung sequestration: Report of 7 cases and review of the 540 published cases. Thorax 1979; 34:96-101.
2. Morikawa H, Tanaka T, Hamaji M, et al. A case of aspergillosis associated with intralobar pulmonary sequestration. Asian Cardiovasc Thorac Ann 2011; 19:66-8.
3. Rubin EM, Garcia H, Horowitz MD, et al. Fatal massive hemoptysis secondary to intralobar sequestration. Chest 1994;106:954-5.
4. Hertzenberg C, Daon E, Kramer J. Intralobar pulmonary sequestration in adults: 3 case reports. J Thorac Dis 2012; 4:516-19.
5. Prasad R, Garg r, Verma SK. Intralobar sequestration of lung. Lung India 2009; 26:159-61.
6. Singh G, Bromberger B, Green R, et al. VATS resection for extralobar pulmonary sequestration with a large aberrant artery after endoluminal stenting and plug occlusion. Doi:10.25373/ctsnet.8244677.
7. Marine LM, Valdes FE, Mertens RM, et al. Endovascular treatment of symptomatic pulmonary sequestration. Ann Vasc Surg 2011; 25: 696.e11-5.
8. Gonzalez D, Garcia J, Fieira E, et al. Video-assisted thoracoscopic lobectomy in the treatment of intralobar pulmonary sequestration. Interact Cardiovasc Surg 2011;12: 77-9.
9. Melfi F, Viti A, Davini F, et al. Robot-assisted resection of pulmonary sequestration. How-to-do-it. European Journal of Cardio-thoracic Surgery 2011; 40:1025-26.
10. Konecna J, Karenovics W, Veronesi G, et al. Robot-assisted segmental resection for intralobar pulmonary sequestration. International Journal of Surgery Case Reports 2016;22:83-85.

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Disclosure

Jett is a Proctor and Speaker for Intuitive Surgical, Inc.