Thoracoscopic Left Lower Lobectomy for Congenital Pulmonary Airway Malformation

This video will demonstrate a thoracoscopic left lower lobectomy for a hybrid congenital pulmonary airway malformation in an infant. The malformation was diagnosed prenatally, and the patient was asymptomatic at birth. A CT scan performed at 4 months of age showed a left lower lobe CPAP with a systemic blood supply arising from the sub-diaphragmatic aorta. The patient remained asymptomatic, and the operation was performed at 9 months of age. The left lung is isolated by right main stem intubation. The patient is placed in the right lateral de tuberous position, and the surgeon and assistant operate facing the patient. A large arterial vessel is seen coming through the diaphragm medial to the inferior pulmonary ligament and entering the left lower lobe, confirming a hybrid lesion. The inferior pulmonary ligament is divided all the way to the border of the inferior pulmonary vein in order to mobilize the left lower lobe of the diaphragm. This allows some stretching of the systemic arterial vessel, which is then skeletonized with hook cautery. Once well skeletonized the vessel is then double clipped proximally. A ligature device is then applied distally to coagulate and divide the vessel. This approach will be used repeatedly for control of several major vessels. Attention is then turned to the fissure. A good fissure is seen in this patient. It is completed using ligature and sharp dissection. Division of the pulmonary parenchyma in the fissure allows for visualization of the pulmonary artery branches to the lower lobe. The dissection should be kept as bloodless as possible. Any bleeding from the divided parenchyma should be controlled early with the ligature. Excellent visualization is essential for adequate vascular control. The pulmonary arterial supply to the left lower lobe can now be seen. A right angle dissector is extremely useful in skeletonizing the vessels. If applied precisely, this dissection allows for gaining adequate distance on the vessels to allow safe ligation. Dissection in the fissure always proceeds from medial to lateral. Once a vessel is well skeletonized, the right angle dissector is used to gain the maximum length possible. While the ligature can be used as the sole method of vessel control, I prefer to apply clips proximally if adequate vessel length has been achieved, as in this case. The pulmonary artery trunk to the lower lobe has been divided. The remaining pulmonary parenchyma, constituting the most posterior aspect of the fissure, is now divided. Once the pulmonary artery and all pulmonary parenchy and the fissure is divided, the bronchus comes into view. Attention is then turned to the inferior pulmonary vein, which is similarly skeletonized. The right angle dissector is again very useful in delineating the vessels. A small tributary of the inferior pulmonary vein is well dissected. The main trunk of the vein is also dissected for a very adequate distance. This small tributary is taken with a ligature device. The junction of the inferior pulmonary vein and the left atrium can be clearly seen as a result of this dissection. Division of the remaining fibers of the inferior pulmonary ligament allows for complete mobilization of the vein. In addition to one or more small tributaries, as was seen here, it is quite common for the inferior pulmonary vein to consist of two major tributaries that join as they approach the left atrium. This is seen here. In these cases, it is best to dissect each tributary separately. The anterior tributary of the vein is controlled first, again by clipping the vein on the cardiac side and applying the ligature on the pulmonary side. The posterior tributary of the inferior pulmonary vein is further dissected and likewise clipped and divided with ligature. The left lobe is now hanging by the bronchus. Hook cautery is used to clean the bronchus of surrounding lymphatic and adventitial tissue. An endo GIA device is introduced directly through the chest wall and used to staple and divide the bronchus. The specimen is extracted by slightly enlarging the posteriormost port site. A chest tube is placed and the operation is terminated. The patient was extubated at the end of the procedure and discharged on the 2nd postoperative day. He had an excellent recovery. His chest X-ray, 2 years after the procedure is shown here.