Koga Hiroyuki, Nakamura Hiroki, Murakami Hiroshi, Hirayama Shunki, Imashimizu Kota, Nishimura Kinya, Suzuki Kazuhiro, Kuwatsuru Ryohei, Inada Eiichi, Suzuki Kenji, Yamataka Atsuyuki
1 Department of Pediatric General and Urogenital Surgery, Juntendo University School of Medicine, Tokyo, Japan.
2 Department of Thoracic General Surgery, Juntendo University School of Medicine, Tokyo, Japan.
J Laparoendosc Adv Surg Tech A. 2019 Mar;29(3):415-419. doi: 10.1089/lap.2018.0168. Epub 2019 Feb 8.
Thoracoscopic pulmonary lobectomy (TPL) is extremely challenging in cases where severe incomplete fissure causes densely fused pulmonary lobes (DFPL) since pulmonary arteries (PAs) are buried and completely concealed by DFPL. We describe TPL for DFPL including a technical tip to prevent pitfalls.
Four congenital pulmonary airway malformation (CPAM) and DFPL (left-upper: 2, left-lower: 1, right-middle: 1) were treated. During TPL, DFPL prevent interlobar PAs from being identified and searching for them only promotes bleeding and air leakage, serious pitfalls that affect the safety and success of TPL. Our tip is to ligate and divide the pulmonary veins (PVs) at the pulmonary hilum and the hilar PA supplying the CPAM lobe to expose the bronchus of the lobe, which is then ligated and divided. The main PA supplying the lobe running underneath the DFPL is exposed and visible from the pulmonary hilum allowing the PA supplying the lobe to be ligated and divided safely. A line demarcating the fused fissure becomes apparent, and an endoscopic stapler or EnSeal device can be used to divide the DFPL along the line taking great care not to injure the main PA or interlobar PAs.
There were no intra-/postoperative complications in any case. All patients performed well without respiratory tract-related symptoms after a mean follow-up of 4.6 years.
TPL for DFPL in children with CPAM can be performed safely and successfully as a virtually bloodless procedure and without incidence of air leakage by ligating and dividing the PA after dividing the PVs and bronchus to the lobe.
在严重不完全性肺裂导致肺叶紧密融合（DFPL）的情况下，胸腔镜肺叶切除术（TPL）极具挑战性，因为肺动脉（PA）被DFPL包埋并完全隐匿。我们描述了针对DFPL的TPL，包括预防陷阱的技术要点。
治疗了4例先天性肺气道畸形（CPAM）合并DFPL（左上叶：2例，左下叶：1例，右中叶：1例）。在TPL过程中，DFPL会妨碍识别叶间PA，仅寻找它们会导致出血和气漏，这是影响TPL安全性和成功率的严重陷阱。我们的要点是在肺门处结扎并切断肺静脉（PV）以及供应CPAM肺叶的肺门PA，以暴露该肺叶的支气管，然后结扎并切断支气管。供应该肺叶且走行于DFPL下方的主PA得以暴露，从肺门可见，从而能够安全地结扎并切断供应该肺叶的PA。一条界定融合肺裂的线变得明显，可使用内镜缝合器或EnSeal装置沿该线切断DFPL，同时要格外小心，避免损伤主PA或叶间PA。
所有病例均未出现术中/术后并发症。平均随访4.6年后，所有患者情况良好，无呼吸道相关症状。
对于患有CPAM的儿童DFPL，通过在切断肺叶的PV和支气管后结扎并切断PA，TPL可以安全、成功地进行，且几乎无出血和气漏发生。
