Robotic Sublobar Resection of Intralobar Bronchopulmonary Sequestration

A sixty-three-year-old male patient was newly diagnosed with intralobar bronchopulmonary sequestration. It was found in the right lower lobe after a diagnosis of COVID-19 prompted a CT scan of the chest. He had reported recurrent pneumonia since he was a child growing up in eastern Europe. He had a seven-pack-a-year smoking history and last smoked thirty-one years ago. 

After receiving therapy for his latent tuberculosis and a thorough preoperative workup, he was cleared for surgery. 

The robot was docked to the patient, and the right lower lobe was retracted anteriorly. The inferior pulmonary ligament was inspected and mobilized. This normally avascular plain had engorged small vessels traveling through it. The bipolar device struggled to maintain hemostasis despite thorough attention to technique. 

In dissection of the posterior leaflet of the inferior pulmonary ligament, a feeding branch off the aorta was encountered that could not be controlled with bipolar energy. It was isolated and clipped twice proximally. In dissection of the anterior leaflet of the inferior pulmonary ligament, a dilated vessel arising from near the phrenic nerve was identified. It was isolated and clipped twice proximally. The robotic clip applier was again used for this task. Then the inferior pulmonary vein was isolated with gentle spreading and bipolar energy dissection. The medial segmental basilar venous branch was isolated, double clipped, and divided. 

After division of all the vascular structures, the lesion in the right lower lobe became readily identified. It was noted to have blanched and appeared fibrotic. It was then resected from the normal parenchyma with blue and green robotic staple loads. Care was taken to evaluate positioning and trajectory of the resection to ensure sparing of healthy parenchyma. Appropriate staple load selection is important to prevent a prolonged postoperative air leak. 

Next the specimen was removed with an endo catch. A 24 French straight chest tube was placed in the apex, and the lung was inflated. 

Postoperatively the patient had the chest tube removed and was discharged to home on postoperative day two. 

The pathology showed varying amounts of fibrous cystic changes and inflammation consistent with intralobar sequestration. All specimens were negative for malignancy. The patient was seen in follow-up and reports no issues. 

References

1. Konecna J, Karenovics W, Veronesi G, Triponez F. Robot-assisted segmental resection for intralobar pulmonary sequestration. Int J Surg Case Rep. 2016;22:83-85.
2. Melfi FM, Viti A, Davini F, Mussi A. Robot-assisted resection of pulmonary sequestrations. Eur J Cardiothorac Surg. 2011 Oct;40(4):1025-6.
3. Savic B, Birtel FJ, Tholen W, Funke HD, Knoche R. Lung sequestration: report of seven cases and review of 540 published cases. Thorax. 1979;34(1):96-101.

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