Thoracoscopic resection of intradiaphragmatic bronchopulmonary sequestration

Prenatal ultrasound detected a 1 centimeter left congenital pulmonary airway malformation in a 4-month-old female.

The presence of the lesion was confirmed with prenatal MRI and postnatal CT angiography performed at 2 months.

The CTA revealed that the lesion received its blood supply from a feeding vessel from the thoracic aorta.

Single lung ventilation was performed after intubation of the right main stem bronchus for a left-sided lesion.

The patient was placed in right lateral decubitus position for the thoracoscopic approach.

Initial entry was achieved in the posterior axillary line of the fifth intercostal space with a 5 millimeter scope.

Two additional 3 millimeter stab wounds were placed under direct visualization, one at the mid-axillary line and the other further posterior.

Upon visualization of the left lower lobe of the lung, no attached lesion was identified, but there was an irregularity of the diaphragm consistent with the abnormality seen on CTA.

The phrenic nerve and the left ventricle of the heart were both in close proximity to the lesion, requiring careful dissection.

Dissection was purposely started on the border of the lesion and the nerve to allow safer traction without injury to the nerve.

The pleura and diaphragm skeletal muscle fibers were dissected off the lesion with a combination of sharp dissection with electrocautery and blunt dissection.

A vessel sealer was used to ligate and control vessels, including both the venous drainage and the feeding vessel from the thoracic aorta.

The specimen was extracted through the 5 millimeter port and sent to pathology.

The diaphragmatic defect remaining after resection was repaired primarily with a combination of a simple 3-0 vicryl stitch and an additional figure-of-8 vicryl stitch.

Final pathology revealed crowded bronchioles, bronchi, and large vessels, consistent with the diagnosis of extralobar pulmonary sequestration.

There have only been 17 previously reported cases of an intradiaphragmatic bronchopulmonary sequestration.

Of the 17 previously reported cases of intradiaphragmatic bronchopulmonary sequestration, only 7 were able to be treated thoracoscopically.