VATS Nonanatomical Wedge Resection for Fourteen-Year-Old Boy

The patient featured in the video below is a fourteen-year-old boy who came to emergency room with fever and shortness of breath. He had no history of previous respiratory disorders and no antenatal or postnatal diagnosis of congenital pulmonary airway malformation (CPAM)—a rare presentation in the adolescent population. A chest X-ray was done, revealing a large right pneumothorax for which a chest tube was inserted. Next, a CT scan was done. It revealed a multiloculated air-filled cystic lesion in the medial basal segment of the right lower lobe that was later diagnosed as CPAM.

 The Surgery

Single lung ventilation was given as the preferred type of anesthesia, and the patient was placed in a left lateral decubitus position with his right arm abducted overhead. A 10 mm port was placed in the intrascapular region, along with two 12 mm ports placed using the camera in the posterior axillary line in the sixth and ninth intercostal space. This allowed surgeons to appreciate a multiloculated air-filled cystic lesion in the medial basal segment of right lower lobe. Few adhesions that required a blunt dissection were present. 

Next, the nonanatomical wedge resection was done using an Ethicon 45 mm stapler with white load. The staples were inserted between the pathological tissue and normal lung tissue. Then, they were fired, using the camera, without holding any major vessels. Staplers are necessary to achieve proper hemostasis, as well as to separate the pathological lesion from the normal lung tissue by cutting with the white loads. Staplers also have the advantage of being able to seal air leaks and small airways to prevent further pneumothorax. 

The specimen was then separated, retrieved, and sent for pathological examination. The external surface of the specimen was cystic in nature and lined by the staplers. A cross-section of the specimen showed cystically dilated spaces, which were lined with flattened to cuboidal-ciliated epithelium surrounded by fibrous and smooth muscle cells. The focal area showed alveoli with numerous red blood cells. As a result of this information, the specimen was considered a benign cystic lesion of the lung. The lung was expanding well, and a chest drain was placed. 

References

1. Is thoracoscopy superior to thoracotomy in the treatment of congenital lung malformations? An updated meta-analysis, Junhua Xie, Yuhao Wu, and Chun Wu
2. Congenital Pulmonary Airway Malformation, Pooja A. Mehta; Girish Sharma.

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