Article
Unrecognized middle lobe devascularization after right upper VATS lobectomy. Case Report
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Published: | October 14, 2013 |
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Objective: A case of a right upper VATS lobectomy with postoperative course complicated due to inadvertent and unrecognized middle lobe devascularization is presented. and clinical implications are discussed.
Methods: A 58-year-old patient with a small peripheral adenocarcinoma in S2 of the right upper lobe pT1aN0M0 underwent an uneventful VATS lobectomy with mediastinal lymphadenectomy.
Results: Persisting high flow rates led to open revisions on day 7 and day 10 with stapling of parenchymal leaks in S4 and S6. No clear signs of middle lobe venous congestion were present during these revisions.
Radiological evidence of a transected middle pulmonary vein, a cavity in the lateral segment of the middle lobe, persisting air leak and sepsis developing in the following days prompted the final fourth open procedure on day 24. Decortication of the trapped lower lobe was performed. A thin walled ruptured necrotic cavity in the middle lobe necessitated a middle lobectomy. Surprisingly, middle lobe artery was found to have been transected during the initial VATS, mistaken for a segmental artery for S2. This was confirmed by a retrospective analysis of the CT scans. Chest tubes could be removed on day 48 and the patient receiving a long term antimycotic treatment for Aspergillus infection was discharged on day 56.
Conclusion: The importance of preoperative review of patient’s anatomy, with 3D reconstruction of pulmonary angiography if available, is stressed. Complete transection of the pulmonary lobar vascular supply does not cause typical venous congestion, which was misleading during revisions. With bronchial arterial supply preserved, necrosis of the lobe develops slowly and may be complicated by mycotic infection.