VATS Lobectomy for Fourteen-Month-Old Infant

The patient was a fourteen-month-old infant who was born at term with an antenatal diagnosis of congenital pulmonary airway malformation. The infant was otherwise healthy and never had any episode of chest infection. Her CT chest showed mixed micro and macro cystic lesions, occupying 50 percent of the right lower lobe, without evidence of synchronous sequestration. After general anesthesia and positioning, a 5mm camera port and 10mm utility port were inserted into the seventh intercostal space, and a 20mm working port was inserted in the fifth intercostal space. On inspection, the cystic lesion was found in the lower lobe as expected. There was no adhesion, and the oblique fissure was grade 1. 

The inferior pulmonary ligament was divided first. The right inferior pulmonary vein was skeletonized and found to be converged with the right superior pulmonary vein before entering the pericardium. After this, the pleural reflection at the back of the hilum was dissected. Then the pleura and connective tissue in the oblique fissure were divided to expose the pulmonary artery branch and bronchus to the right lower lobe. The lesions were located in the basal four segments, so wedge resection was attempted first to spare the apical segment of the right lower lobe. A Covidien powered stapler with 45mm purple reloads was used. Because of the patient’s body size, part of the reload was outside the chest cavity. All the lesions were included in the wedge excised. 

However, the apical segment didn’t expand even with manual recruitment maneuver. Therefore, completion lobectomy was followed. Then the right lower lobe pulmonary artery branch was isolated and divided by the same stapler with a 30mm vascular reload. 

Next the right inferior pulmonary vein was divided. The right lower lobe bronchus and the remaining fissure were then clamped by the stapler with a 45mm purple reload. 

Before firing the stapler, the right lung was ventilated to ensure the middle lobe bronchus was not included. After this, the surgical field was cleaned and hemostasis achieved. No lymph node sampling was performed as it is not indicated for this benign pathology and children tend to have higher risk of chyle leak. The upper and middle lobes expanded well when the right lung was ventilated. Then, a 20 French chest drain was inserted. The patient was extubated immediately post-op. The recovery was uneventful, and patient was discharged on day four. 

Reference

1. Bonnard A. Thoracoscopic Lobectomy for Congenital Pulmonary Airway Malformation: Where Are We in 2019? Eur J Pediatr Surg. 2020 Apr;30(2):146-149. doi: 10.1055/s-0040-1702221. Epub 2020 Mar 8. PMID: 32146716.

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