Thoracoscopic resection of intradiaphragmatic bronchopulmonary sequestration

Here we present the case of an intra-diaphragmatic bronchopulmonary sequestration that was resected thoragoscopically. This was a 4 month old female who'd initially presented for evaluation after a prenatal ultrasound detected a 1 centimeter left congenital pulmonary airway malformation. The presence of this lesion was confirmed with a prenatal MRI as well as a postnatal CT angiography performed at 2 months. The CTA also revealed that the lesion received its blood supply from a feeding vessel from the thoracic aorta. This is a representative axial view of the CTA, highlighting the lesion here. And the feeding vessel here. Here is a representative coronal view of the CTA again highlighting the lesion here and the feeding vessel here. The decision was made to take the patient to the operating room for a planned thoracoscopic resection of the suspected bronchopulmonary sequestration. Since the lesion was on the patient's left side, single lung ventilation was performed after an intubation of the right main stem bronchus. The patient was placed in right lateral decubous position. And the various entry was achieved in the posterior axillary line of the fifth intercostal space. A 5 millimeter scope was inserted to gain visualization. After confirming that there was no injury upon access. 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. However, there was an irregularity of the diaphragm consistent with the abnormality that was seen on CTA. Care was taken in order to avoid both the phrenic nerve and the left ventricle of the heart, both of which were in close proximity to the lesion. Dissection was purposely started on the border of the lesion and the nerve in order to allow safer traction without injury to the nerve. The pleura, as well as the diaphragm skeletal muscle fibers were dissected off of the lesion with a combination of sharp dissection with electrocautery, as well as blunt dissection. As the lesion was mobilized, a vessel sealer was used in order to ligate and counter vessels. This technique was utilized both for the venous drainage. As well as for the feeding vessel from the thoracic aorta. This combination of sharp and blunt dissection along with vessel ligation was continued until the lesion had been completely resected. As the last of the lesion was resected free, the specimen was extracted through the 5 millimeter port and sent to pathology. Next, attention was turned to repair the diaphragmatic defect that remained in place after resection of the lesion. This defect was repaired primarily with the combination of a simple 30 vicral stitch, as well as an additional figure of 8 vicral stitch. Here's the diaphragm after a reapproximation of the defect was completed. Her final pathology revealed crowded bronchioles, bronchi, and large vessels, which was consistent with the diagnosis of extralobar pulmonary sequestration. The reason that we wanted to present this video is that there have only been 17 previously reported cases of an intra diaphragmatic bronchopulmonary sequestration. Of those 17 cases, only 7 were able to be treated thoracoscopically. We hope that our case can serve as an example for those who may encounter this exceedingly rare congenital malformation in the future.