Thoracoscopic Resection of Bronchopulmonary Foregut Malformation

This video will demonstrate a thoracoscopic resection of a bronchopulmonary forgot malformation in a 2 month old girl. The patient presented with 3 days of significant stridor. The condition was presumptively diagnosed as croup, and she was placed on intravenous steroids. She developed an upper gastrointestinal bleed and was intubated for upper endoscopy. The procedure diagnosed a steroid induced stress gastritis. The endoscopist also noted unusual angulation and some extrinsic compression of the esophagus. The scope was left in place and a chest x-ray was performed. It showed significant deviation of the scope and endotracheal tube to the right. A CT scan was subsequently performed, which showed a posterior mediastinal cystic mass causing significant tracheal compression. The endotracheal tube was advanced into the right main stem bronchus to isolate the left lung and facilitate a left throchoscopic approach. A bougie was introduced into the esophagus to clearly delineate it during the dissection. The cyst can be clearly seen in proximity to the aortic arch. The posterior pleura is opened to start the mobilization of the cyst. The dissection is then carried anteriorly around the cyst margins. The cyst is intentionally punctured and decompressed of its mutinous contents. This significantly aids in the resection, particularly during its separation from the esophageal wall. The plural investments are completely divided to delineate the cyst relationships, particularly to the esophagus. Traction on the cyst reveals its close relationship to the esophagus and the common wall shared by the two structures. This confirms an esophageal duplication. The esophagus, stented by the bougie, is clearly seen, and the area of the esophageal wall containing the cyst is identified. The esophageal muscle fibers investing the cyst are carefully divided very close to the cyst wall to avoid esophageal perforation. Once the first few fibers are divided, the junction of the cyst and esophageal wall becomes more clear, and this plane of dissection is continued. The dissection is continued until the cyst is completely separated from the esophagus. The integrity of the esophagus is examined throughout the dissection. The resection bed is shown with the aortic arch and esophagus clearly seen. The patient was extubated on the first postoperative day and had an uneventful recovery.