Presenter: Kanika A Bowen-Jallow, MD
Email: kabowen@utmb.edu
Authors: Mollie S Ahn, BA, MBA; Kanika A Bowen-Jallow, MD; University of Texas Medical Branch
Congenital pulmonary airway malformation (CPAM) and bronchopulmonary sequestrations (BPS) are the most common congenital lung malformation typically located intrathoracic predominantly affecting the lower lobes. Although these lesions can potentially be managed nonoperatively, surgical excision provides the benefit of a definitive historical diagnosis and is certainly indicated when symptoms are associated. Open resection is the most common approach for removal of intraabdominal BPS lesions; however, laparoscopy has been used in recent years. We present two successful cases of laparoscopic resection of intraabdominal extralobar BPS (IEBPS). Laparoscopic excision is a less invasive treatment with shorter recovery time, minimal narcotic usage, and avoids associated complications, such as infection and malignant degeneration. As evidenced by the cases discussed here, the laparoscopic approach is safe and feasible and should be considered when managing congenital lung malformations.
Intended audience: Healthcare professionals and clinicians.
This is a case series demonstrating laparoscopic excision of intraabdominal extralobar bronchopulmonary sequestrations in the pediatric patient population at the University of Texas Medical Branch in Galveston, Texas. This is a newborn girl born 39 weeks of gestation. Prenatal ultrasound taken at 27 weeks gestation, identified a lobulated echogenic mass measured 2.2 by 2.6 centimeters above the left kidney, concerning for pulmonary sequestration. Pediatric surgery was consulted. An MRI was performed at two days of life, which confirmed a 3.1 by 2.8 centimeter mass containing feeding vessels located under the diaphragm and above the left kidney. The arrows are pointing to the feeding vessels located within the mass. At 6 months of age, the patient was taken to the operating room for a laparoscopic mass excision. 4 ports were placed to aid in the mobilization of the mass. The posterior stomach is to the left, and the spleen is to the right. The short gastric vessels were transected using a 3 millimeter sealer device. The mass has been identified posterior and medial to the spleen, and mobilization has begun. The feeding vessel observed in the MRI was transected at this time. The mass was dissected off the diaphragm and the stomach. Pathology was consistent with a type 2 congenital pulmonary airway malformation and extra lobar bronchopulmonary sequestration hybrid lesion. The patient was discharged on postoperative day 1 without any complications. The patient has since been followed by a pediatrician for 6 months without any complaints. The next patient is a full-term girl born at 39 weeks gestation. Prenatal ultrasound at 27 weeks gestation identified a 2.3 by 2.6 hypeechoic mass with cystic components, and increased vascularity located above the left adrenal gland. Pediatric surgery was again consulted. A postnatal MRI demonstrated a well-circumcised heterogeneous T2 hyperdense mass with feeding vessels from the adjacent aorta, suggestive of an extra lobar bronchopulmonary sequestration. The patient underwent laparoscopic resection at 10 months of age. The same port placement was used to gain access to the mass. A liver retractor was placed, and the short gastrics were divided to gain access to the mass. A well-defined 3 centimeter mass adjacent to the left cura of the diaphragm was identified. Sharp and blunt dissection was used to mobilize the mass, and the feeding vessel was divided with a 3 millimeter sealer device. The green outline denotes the stomach while the red outlined structure denotes the mass. At this point, air was inflated into the stomach to test for a leak due to the mass being densely adherent to the stomach. No leak was observed and the stomach was desufflated. The mass was also densely adherent to the diaphragm, and a defect was created with excision of the mass. The diaphragm was closed with interrupted sutures using a 30 silk suture. Histopathological analysis showed congested pulmonary parenchyma and well-developed bronchiolar and alveolar epithelial elements, consistent with an extra lobar BPS lesion. The patient was discharged on postoperative day 2 after an uneventful postoperative course. She has since been followed by her pediatrician for 18 months without any issue. Congenital lung malformations are rare, and intraabdominal pulmonary sequestrations, or IEBPS account for 10 to 15% of extra lobar cases. Although surgical intervention is the most common in the United States, some surgeons elect for observation of asymptomatic patients with non-cystic small lesions. There's no consensus in the treatment of IEBPS and there is high variability in practice. This case series demonstrates the efficacy of a laparoscopic approach to correct such pediatric anomalies if the surgical route is chosen. Thank you for the opportunity to present our cases.
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