Thoracoscopic Resection of Extralobar Bronchopulmonary Sequestration

This video will demonstrate a thoracoscopic resection of a left extralobar bronchopulmonary sequestration in an eight month old girl. The diagnosis was made on fetal ultrasound when a discrete solid left thoracic mass with a systemic feeding vessel was seen. The patient was asymptomatic at birth and remained so. A CT scan was performed at 4 months of age to further define the lesion. An extralobar bronchopulmonary sequestration with a discrete systemic feeding vessel arising from the subdiaphragmatic aorta was seen. The patient also had a focal diaphragmatic eventation at the site of the sequestration. The options of observation versus resection were discussed with the family. They elected to have the child undergo a thoracoscopic resection with concomitant repair of the eventation. The patient was operated in a right semi-prone position with right main stem intubation. The sequestration is tethered to the diaphragm. Mobilization therefore starts by dividing the diaphragmatic pleura at the junction with the sequestration. This dissection is started with the hook cautery and continued with the ligature. Gentle traction on the sequestration and blunt dissection allows for visualization and division of its attachments to the diaphragm. One must remember that the feeding vessels will be within these tissues. As this dissection continues, the systemic feeding vessel comes into view. This vessel has to be skeletonized to allow for safe control and division. This is done by dividing the tissue adjacent to the vessel and creating a free plane behind the vessel. Once well skeletonized, 2 clips are placed on the vessel proximally, and the ligature is applied distally. After division of the vessels, the remaining attachments are also divided. A combination of sharp and blunt dissection is used to separate the sequestration from the diaphragm. A second vessel is identified more medially. It is likewise clipped and divided with ligature. With the vessels divided, the mass is easily separated from the diaphragm. The area is then irrigated and suctioned to confirm hemostasis. The associated focal eventation is repaired with two interrupted Oeffibo sutures. The mass is removed by slightly enlarging the most posterior trochar site. A chest tube is not placed. The patient was discharged home the day after the operation and had an excellent recovery. Her chest X-ray six weeks after surgery is shown here.