Utilizing Indocyanine Green During Robotic-Assisted Thoracoscopic Surgery for Pulmonary Sequestration

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Pulmonary sequestrations are rare congenital anomalies that result in a segment of nonfunctional lung tissue with a lack of a direct connection to the tracheobronchial tree. They are classified into two categories: intralobar and extralobar sequestrations.  

Intralobar sequestrations maintain normal venous drainage via the pulmonary veins, share pleura with the functional lung, and connect to functional lung parenchyma at the small airway level. However, their arterial blood supply is anomalous off of the aorta.  

Extralobar sequestrations have both aberrant arterial blood supply and venous drainage to visceral veins. Extralobar sequestrations do not connect to normal lung parenchyma and do not share a pleura. In some rare cases, they can even be found extrathoracically in the abdominal cavity. Surgical resection is usually indicated to treat recurrent infections, hemorrhage, or high-output cardiac failure. 
 
A 42-year-old patient presented for a second opinion after undergoing a video-assisted thorascopic left lower lobe wedge resection for soft tissue sarcoma pulmonary metastasis. She also had a history of recurrent right-sided pneumonias. Computed tomography imaging findings of her chest revealed no concerning pulmonary nodules or evidence of recurrence of her soft tissue sarcoma. However, there was an anomalous arterial branch arising from the aorta supplying lung parenchyma in the right lower lobe. The anomalous arterial branch was localized in the right inferior pulmonary ligament, raising concerns for an intralobar sequestration. 
 
She underwent a robotic-assisted thoracoscopic right lower resection. Routine entry into the thoracic cavity was achieved, and the inferior pulmonary ligament was dissected, skeletonizing the abnormal arterial vessel supplying the pulmonary sequestration. This vessel and remaining pulmonary ligament were then divided using an endovascular gastrointestinal anastomosis stapler. Once the lung was separated from the aberrant arterial vessel, intraoperative adjunct of intravenous indocyanine green (ICG) dye was administered. This allowed for clear visualization and demarcation of the segment of lung that was now devascularized. The pulmonary sequestration was outlined with cautery and subsequently resected using stapler loads. After the operation, the patient experienced an uncomplicated postoperative course and was discharged home. During the past year following her resection, she has not had any more bouts of pneumonia. 
 
This case demonstrates how the utilization of ICG during robotic-assisted surgeries allows for precise identification of the parenchyma involved with the sequestration, limiting the resection of otherwise healthy functional lung. 

The views expressed are those of the authors and do not necessarily reflect the official views of the US National Institutes of Health (NIH). 

References

1. Kravitz, R. M. (1994/06/01). Congenital Malformations of the Lung. Pediatric Clinics of North America, 41(3). https://doi.org/10.1016/S0031-3955(16)38765-X
2. NIH Image Gallery. (2015). Aerial view of the Mark O. Hatfield Clinical Research Center (Building 10), NIH Campus, Bethesda, MD. [Digital Image]. Flickr. https://flic.kr/p/x4iQ96
3. Wang, L.-M., Cao, J.-L., & Hu, J. (2016/01). Video-assisted thoracic surgery for pulmonary sequestration: a safe alternative procedure. Journal of thoracic disease, 8(1). https://doi.org/10.3978/j.issn.2072-1439.2016.01.25
4. Wani, S. A., Mufti, G. N., Bhat, N. A., & Baba, A. A. (2015). Pulmonary Sequestration: Early Diagnosis and Management. Case Reports in Pediatrics, 2015(1), 454860. https://doi.org/https://doi.org/10.1155/2015/454860

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