Single-incision video-assisted thoracic resection for extrapulmonary sequestration: a case report

Pulmonary sequestration is a rare congenital abnormality of the lower respiratory tract and occurs in 0.15% - 6.4% of all pulmonary malformations[1]. We describe the first case of an extralobar pulmonary sequestration resected via minimally invasive single-incision thoracoscopic surgery (SITS). Furthermore, we discuss the advantages and disadvantages of several practical treatments.

Pulmonary sequestration is a rare lesion of the lung parenchyma with an unknown etiology that lacks a normal connection with the tracheobronchial tree and has a blood supply directly from the descending aorta. Surgery is the treatment of choice, which is usually performed through a posterolateral thoracotomy[1], and more recently via VATS because it is minimally invasive, and results in less postoperative pain and faster recovery[2]. Therefore, it has become a commonly used technique for thoracic tumor surgeries[3]. In particular, single-port VATS is useful for specific diseases, such as pneumothorax[4]. To the best of our knowledge, the present report is the first on the use of single-port VATS for pulmonary sequestration. Because only one intercostal space is typically involved in a pulmonary sequestration, the possible advantages of SITS include less postoperative pain, fewer postoperative drainage days, shorter hospital stays, and improved cosmesis compared with the conventional three-port VATS. Some authors have reported less postoperative pain and less paresthesia in patients who underwent minor procedures using a single-port approach compared with the classical three-port approach[5, 6]. Careful employment is preferred for intrapulmonary lesions because they tend to require more challenging anatomical or near-anatomical resections as opposed to extrapulmonary lesions.

There are obvious technical problems with SITS. It is not a naturally ergonomic procedure, because the traditional thoracoscopic principles of triangulation are omitted. In addition, positioning of multiple devices through a single small incision in the chest poses problems because instruments can often interfere with each other in the pleural as well as extrapleural spaces, where attachments, such as a camera light can often impede movement. Therefore, to overcome these limitations, the development of new instruments is needed. For example, increasing the length of the camera shaft will allow an assistant to assume a position that did not interfere with that of the surgeon. Furtheremore, the use of a roticulating endograsper aids in achieving triangulation, is compatible with the use of other devices, and can achieve good results.

In the present case, the tumor was resected through a 2.5 cm incision, even though it was 4.2 cm in diameter. A wound retraction system should provide for wound dilation and protection when a specimen requires removal through a small incision. However when the diagnosis is suspected preoperatively, using single-port VATS can avoid obvious excessive invasion.

In conclusion, we recommend minimally invasive single-port VATS for resecting an extralobar sequestration.

We believe that single-port VATS is a great alternative to the traditional three-port VATS for extralobar sequestration.

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor- in- chief of this journal.