Left VATS Pneumonectomy in Pediatric Pulmonary Mucoepidermoid Carcinoma

Pulmonary mucoepidermoid carcinoma (PMEC) is a rare salivary-gland–type endobronchial malignancy in children and may present with recurrent unilateral infections despite a deceptively subtle chest radiograph. The authors present an educational case of an adolescent male with months of febrile respiratory episodes treated as pneumonia, including hypoxemia requiring oxygen and repeated hospital admissions. Subsequent bronchoscopy demonstrated a near-occlusive distal left main bronchus lesion, and positron emission tomography/computed tomography (PET/CT) localized an fluorodeoxyglucose (FDG)-avid approximately 2 to 2.3 cm endobronchial mass with post-obstructive distal changes and hilar distortion. 

For central airway tumors, the surgeons prioritize lung-sparing sleeve resection when safe margins and reconstruction are feasible. In this case, the lesion was centered at the distal left main bronchus near the bifurcation region, with extension toward the lobar bronchi, limiting confidence in achieving a wide, clean proximal margin with sleeve techniques. Given the anatomic constraints, downstream parenchymal compromise, and the need for definitive oncologic clearance, left video-assisted thoracoscopic surgery (VATS) pneumonectomy was selected to ensure complete (R0) resection with a controlled technique. Baseline physiology and cardiac evaluation supported tolerance for major resection. 

This video demonstrates a reproducible, safety-first strategy for left hilar control during VATS pneumonectomy, including port placement (camera in the eighth intercostal space at the posterior axillary line and an approximately 4 cm utility incision in the fifth intercostal space at the mid-axillary line to create a straight stapler path to the main pulmonary artery and proximal bronchus). Key steps included early division of the inferior pulmonary ligament, meticulous adhesiolysis to mobilize the lung and expose the hilum, controlled division of the pulmonary veins and main pulmonary artery (with the order adapted to adhesions and visualization), and proximal bronchial transection with a straight staple line while protecting the pulmonary artery posterior to the bronchus. Systematic mediastinal and hilar nodal sampling and dissection were performed. 

High-yield “stop rules” were emphasized: Never fire a vascular stapler until the vessel is flat and fully within the jaws; stop and reposition ports if the trajectory is awkward; and convert early when circumferential vascular control or unambiguous anatomy cannot be achieved. Early post-pneumonectomy radiograph evolution and red flags, such as unexpected mediastinal shift or sudden air–fluid level drop, were reviewed. Final pathology confirmed low-grade PMEC with negative margins and reactive/negative nodes.  

References

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