Thoracoscopic Upper Lobectomies for Symptomatic Congenital Pulmonary Airway...

Pulmonary upper lobectomies are more technically challenging than lower lobectomies, especially following infection. This video will demonstrate left and right throchoscopic upper lobectomies in children with symptomatic lung cysts. The first patient is a 12-year-old boy who presented with a left upper lobe pneumonia surrounding a cystic malformation. A repeat CT scan 6 weeks after first presentation showed resolution of the pneumonia but persistence of the cyst. The upper lobectomy was performed with the patient in the right lateral decubitus position using 4 trochars as shown in the picture. A dual lumin endotracheal tube and low flow chest insufflation were used to collapse the left lung. Inflammatory adhesions can be seen between the left upper lobe and the chest wall. The cystic lesion is clearly visible in the left upper lobe. The fissure is opened by retracting the lobes apart. The ligature is used to open the pleura overlying the fissure. The fissure is completed by dividing the pulmonary tissue starting anteriorly and proceeding posteriorly. Once the fissure is completed, attention is then turned to the high limb. The phrenic nerve is identified and the hilar pleura is opened. The superior pulmonary vein is identified but not divided. This allows a further cephalid retraction of the upper lobe. The segmental pulmonary arteries can then be identified and dissected. A combination of clips and ligature is used to divide the segmental arteries. Enlarged lymph nodes can be seen in the fissure. Each vessel is carefully dissected prior to its division, where distance allows the segmental vessels are clipped proximally prior to division with the ligature. We then return to the hilum to dissect the superior pulmonary vein. In this patient, the tributaries of the superior pulmonary vein are dissected and controlled separately. 10 millimeter clips are used to control each Venous tributary separately. The veins are then divided with the ligature or simply cut with scissors. The bronchus is now visible. The segmental bronchus to the lingular segments is divided with an endo GIA. The final segmental pulmonary artery is found and once again controlled and undivided. The remainder of the left upper lobe bronchus is again divided with an endo GIA to free the left upper lobe. Finally, the inferior pulmonary ligament is divided to allow the lower lobe to rise in the chest. The second case is a 1-year-old girl with a similar presentation in the right upper lobe. Resection was performed 3 months after resolution of the pneumonia. Left main stem intubation was used to isolate the right lung. Again, segmental inflammatory adhesions are present and have to be taken down and freed before dissection of the upper lobe. One can see persistent inflammation of the upper lobe and adhesions to the middle lobe. Dissection then starts at the hilum after visualizing the phrenic nerve. The hilar pleura is divided with hook cautery in this case. The segmental arteries to the right upper lobe are then identified. The arteries are much smaller in this younger child and can be taken with a ligature after deliberate dissection. The most superior and largest of the segmental arteries is finally identified. This artery is clipped proximally prior to application of the ligature. The superior pulmonary vein is then identified in a slightly more superficial plane than the arteries. This is similarly clipped and then divided after application of the ligature. Attention is then turned to a transverse fissure. Remaining adhesions, as well as bridging pulmonary tissue, has to be divided to completely open the fissure. The recurrent segmental artery to the upper lobe arising from the main pulmonary trunk is found in the fissure and divided. The bronchus is finely divided with an endo GIA, as before. Both patients had excellent outcomes. The postoperative chest X-rays showing complete expansion of the left lung in the first patient and the right lung in the second patient are shown here.