H.Ahmed, T.Lehnert, R.Metzger, H.Till Department of Pediatric Surgery

1. Impact of Thoracoscopy on Pulmonary Sequestration H.Ahmed, T.Lehnert, R.Metzger, H.Till Department of Pediatric Surgery Leipzig University Hospitals/Germany Department of Pediatric Surgery Benha University Hospitals/Egypt 2008

2. Introduction ◊Thoracoscopy was first developed by Jacobeus a Swedish internist in 1910 as a method of lysis of intrapleural adhesions. ◊ From 1960 to 1970, the development of endoscopic instruments, fibroptics and better anesthetic techniques permit to perform therapeutic thoracoscopy. ◊ Since the early 1990’s, video-assisted thoracoscopic surgery (VATS) became a safe and effective approach involving a wide variety of diagnostic and therapeutic procedures that can be done in the pediatric age group.

3. ►Pulmonary sequestration (PS) is a congenital lung lesion defined as non functioning pulmonary tissue lacking normal communication with the tracheobronchial tree. ► PS is supplied by a systemic arterial supply from an aberrant aortic branch and is drained by the pulmonary veins or the azygous or hemiazygous system. ► Most of the patients had no symptoms, but they may present with: * persistent dry cough * chest infections * dyspnea, cyanosis, * feeding difficulties * high output CHF * spontaneous pulmonary or pleural hemorrhage

4. Two forms of PS are recognized: * Extrapulmonary (EPS) account for 15-25%, separated from the lung tissue by a separate lining of pleura. * Intrapulmonary (IPS) account for 75-85%, embedded in the normal lung sharing with it a common pleural investment. • The combination of an aberrant systemic blood supply (identified by color-flow Doppler sonography) and an echogenic lung mass is pathognomonic for the prenatal diagnosis of PS. l

5. Patients & Methods • Three patients with (PS) were diagnosed antenatally by routine prenatal ultrasound. • One patient with IPS and two with EPS. • No associated cardiac or diaphragmatic anomalies were noted. • No associated hydrops fetalis or maternal polyhydramnios.

6. ► Diagnosis was confirmed postnatally by: * Chest X-Ray. * Color flow Doppler sonography. * MRI angiography or * Computed tomography of the chest.

7. Plain chest X-Ray Frontal and lateral chest X-RAY shows a rounded, well marginated, soft-tissue mass in the left hemithorax.

8. MRI angiography shows an aberrant arterial supply to a left basal EPS MRI angiography

9. Color flow doppler sonography Color flow Doppler sonography shows the vascular supply from the celiac trunk to a left basal EPS

10. The infant with (IPS) underwent thoracotomy at 3 months of age, with atypical resection of segments 8,9 and 10. • The other two infants with (EPS) underwent video-assisted thoracoscopic resection with ligasure at 6 months of age. • All VATS procedures were performed with the patient in the lateral decubitus position with single-lung ventilation.

11. Technique of VATS • General anesthesia with selective-one lung ventilation. • Full lateral decubitus position. • The surgeon and the assistant stood facing the child‘s back. • Three to four endoscopic ports (5mm) were used. • A 30° thoracoscopic camera was placed at the 7th intercostal space mid-axillary line. • The sequestration was found as a greyish red oval mass between the left hemidiaphragm and the left basal lobe. • After the aberrant artery being identified and isolated, it was controlled by Ligasure vessel sealing system. • Delivery of the sequestration outside the chest by extending the camera port. • Closure with intercostal tube drainage.

12. Diaphragm EPS EPS lung

13. Dissection of the vascular pedicle with Ligasure

14. Aberrant artery Venous drainage Aberrant artery

15. Transection of the aberrant vascular pedicle using Ligasure

16. Good hemostasis following transection of the vascular pedicle by using Ligasure

17. Results • All patients had an uneventful intra and post-operative course. • Mean operative time for VATS was 120 minutes. • Mean post-operative analgesic time was 4 days. • Average hospital stay was 3-4 days. • Follow-up at 1, 3 and 6 months revealed that all the 3 patients were in a good clinical condition and had fully expanded lungs on X-ray. • Cosmotic results were satisfactory.

18. Discussion.I • Surgical resection is the definitive treatment for pulmonary sequestration. • Although open resection through posterolateral thoracotomy is still used, the ability of VATS to be used as both a diagnostic and therapeutic intervention has been discribed. • MR angiography and color Doppler sonography are the most reliable diagnostic tools for acurrate delination of the sequestration and localization of the aberrant arterial supply preoperatively.

19. Discussion.II • VATS resection has been advocated for PS because it‘s technically feasible, provides clear anatomy , reduces post-operative pain and decreases recovery period. • The use of Ligasure vessel sealing system as an operative technique in the treatment of PS is a safe and effective modality that provides a shorter hospital stay and shorter operation time as well.

20. Conclusion • Pulmonary sequestrations are a heterogenous group of congenital lung lesions with a favourable outcome. • Video assisted thoracoscopic surgical resection(VATS)using ligature for EPS seems simple and safe. • Open resection remains a valuable option for IPS with a lung spearing strategy. • Ligasure use in PS had easy application, provided sufficient hemostasis, and shortened the operative time.

21. Thank you