Neonatal Lung Lesions with Dr. Steven Rothenberg
With Dr. Steven Rothenberg · hosted by Dr. Ian Glenn & Dr. Todd Ponsky · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Serial prenatal ultrasounds are the best way to follow cystic lung lesions; they are noninvasive, quick, and performed every couple of weeks.
Fetal MRI for lung lesions provides little additional benefit and does not change the management plan.
Anywhere from 6 to 40% of prenatally detected lung lesions will regress over time, and in some cases appear to completely disappear.
Fetal intervention (open surgery) for lung lesions is extremely rare; CHOP performs less than one open fetal surgery every couple of years.
Fetal thoracentesis or thoracoamniotic shunt is done only if the fetus shows significant distress or evidence of hydrops, which significantly increases mortality.
Steroids are given if larger cysts cause mediastinal shift, or to mature the lung if early delivery is anticipated.
A cyst volume ratio (CVR) greater than 2 has an extremely bad prognosis and is more likely to require fetal intervention.
Congenital lung lesions (CAMs, sequestrations, bronchogenic cysts) represent a spectrum; hybrid lesions are common on pathology.
Sequestrations are classified by the presence of a systemic artery (usually from the aorta); intralobar sequestrations share pleura with the lobe, extralobar have their own pleural lining.
If a baby is born doing well with no respiratory distress and a normal or mildly abnormal chest X-ray, the family can go home; CT scan is obtained at 4–6 weeks.
A chest X-ray or ultrasound is not adequate to prove a prenatally detected lung lesion has completely resolved; CT scan is required.
Some children with normal postnatal chest X-ray or ultrasound later present with pneumonia (9 months to 6–7 years) and are found to have an infected CPAM.
Depending on the series, 20–40% of untreated congenital lung lesions will develop a significant infection at some point.
The incidence of malignancy in untreated congenital lung lesions is over 1% in Rothenberg's series, which he considers significant.
Rothenberg prefers to operate by 3 months of age to avoid infection, because surgery is technically easier with smaller vessels and fresh anatomy, and to allow compensatory lung growth.
Even in asymptomatic children, waiting until around one year of age often reveals significantly enlarged lymph nodes and inflammation in the fissure, suggesting low-grade infection.
In Rothenberg's series, hospital stay, chest tube duration, recovery, and operative time were shorter in patients under 5 kg compared to those under 10 kg.
Most infants undergoing early lobectomy are discharged within 48 hours; by one month post-op, chest X-ray shows no evidence of surgery.
The key to success in small infants is proper setup and port placement; with the right approach, there is plenty of room to work.
Blood is typed and crossed for all lobectomies; it is one of the few pediatric cases where this is routine, because bleeding can be significant.
Most asymptomatic children on room air tolerate single-lung ventilation without problem.
Single-lung ventilation is achieved by main-stem intubation of the contralateral bronchus; bronchial blockers are difficult to place and add time, so are avoided.
After lung collapse, infants initially desaturate (low 90s to high 80s) due to shunting; saturations improve once shunting to the collapsed lung stops.
Anesthesiologists should use lower peak ventilatory pressures and increase rate (not pressure) to improve ventilation, avoiding high-pressure bagging that re-inflates the operative lung.
End-tidal CO₂ in the mid-40s is tolerable and does not cause significant acidosis during thoracoscopic lobectomy.
The surgeon and assistant stand at the patient's front (nipple side) in lateral decubitus position; there is more room from the front of the chest to the hilum than from the back.
The camera port is placed over the major fissure in the mid-axillary line (5th or 6th interspace for lower lobe), anterior to the scapula tip, to allow working from front to back without paradoxical instrument angles.
A fourth port is almost never needed; gravity and lung collapse provide adequate retraction in small children.
Rothenberg uses a 4 mm 30° short scope (20 cm) for wider angle view and to allow the assistant to stay close without interference.
Low-profile reusable 3 mm ports are essential in small infants; large-headed 5 mm ports cause instruments to collide in the limited space.
A 3 mm vessel sealer (bipolar technology) can seal vessels up to 5 mm in diameter.
The dual-seal technique: make two separate seals on a vessel 4–5 mm apart, then cut partway between them to confirm hemostasis before full division.
Vascular control is everything in thoracoscopic lobectomy; the dual-seal technique allows recovery if a seal fails, whereas full division without confirmation risks uncontrollable hemorrhage.
Clips can be knocked off vessels; the dual-seal technique with vessel sealing is safer than routine clipping.
Using energy devices that seal and cut simultaneously (e.g., Harmonic) on major vessels is a mistake and sets up the surgeon for unrecoverable bleeding.
Rothenberg had one case using a seal-and-cut device that failed, resulting in bleeding and conversion to open.
The first step in left lower lobectomy is to take down the inferior pulmonary ligament to check for a systemic vessel and to expose the inferior pulmonary vein.
The ease of lobectomy depends on fissure completeness; incomplete fissures require layer-by-layer completion using the vessel sealer, similar to finger fracture in liver surgery.
In a left lower lobectomy, the pulmonary artery trunk bifurcates into four basal segment branches; the superior segmental branch comes off higher and more posteriorly.
The bronchus sits directly underneath the pulmonary artery and can be palpated to aid dissection behind the artery.
If the main arterial trunk has good length, a 5 mm stapler can be used; otherwise, dissect and seal individual basal segmental branches for safer vascular control.
When using a stapler on a major vessel, always have proximal control (clamp) in place before firing, in case the staple line bleeds.
Rothenberg now works 'front to back' through the fissure (like turning pages of a book) rather than flipping the lung, because it is hard to change exposure thoracoscopically.
After dividing the artery, the next step is the bronchus (superior segmental first, then main trunk); the pulmonary vein lies directly behind the bronchus.
In children over 10 kg, a 12 mm stapler is needed for the bronchus; under 10 kg, a 5 mm stapler or clips suffice.
After dividing the bronchus, dissect the inferior pulmonary vein to its first bifurcation, seal the smaller branch for length, then staple the main trunk—never take the vein near the pericardium.
If a vascular device fails near the pericardium, the vessel retracts and the child will bleed to death before you can intervene; always ensure adequate length for proximal control.
Right lower lobectomy is the mirror image of left lower lobe; the key caution is that middle lobe vessels branch off just above the lower lobe artery.
For left upper lobectomy, retract the apex inferiorly to expose the apical/anterior arterial trunk at the apex of the chest; divide its branches first.
After taking the upper lobe arteries, retract the lung posteriorly to expose and divide the superior pulmonary vein and lingular vein.
In left upper lobectomy, the lingula is almost always taken with the upper lobe; on the right, the middle lobe is usually preserved.
Working through the fissure in upper lobectomy, the lingular artery is encountered first, then a large posterior segmental branch, then the upper lobe bronchus.
For right middle lobectomy, complete the minor fissure anteriorly; the pulmonary artery enters posteriorly and bifurcates into upper and lower branches.
If the lung has large cysts limiting visualization, use the vessel sealer to pop the cysts at the start of the case to decompress and improve exposure.
Extralobar sequestrations can have up to 6 systemic vessels; Rothenberg has seen vessels as large as 15 mm in diameter.
For sequestration vessels, use clips or vessel sealer with dual-seal technique; a 5 mm stapler can be used for very large vessels (e.g., 15 mm).
Never use both clips and energy sealing on the same vessel; energy changes the vessel wall, causing clips to lose purchase and leading to delayed bleeding.
Systemic vessels to sequestrations come off the aorta under higher pressure than pulmonary vessels, so meticulous technique is critical.
Extralobar sequestrations can become infected; Rothenberg removes them all thoracoscopically with no chest tube and next-day discharge, so embolization is not indicated.
Rothenberg historically performed complete lobectomy but now considers segmentectomy (superior segment of lower lobe, lingula) if CT shows disease confined to one segment; approximately 20 cases with no recurrence on follow-up.