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Clinical Case

PNEUMOTOMY FOR THORACOSCOPIC RESECTION OF A VOLUMINOUS PULMONARY NODULE


M Grigoroiu, MD, D Gossot, MD, Institut Mutualiste Montsouris, Paris, France

1. Summary


Solitary pulmonary nodules of small size (<2 cm) situated in subpleural position are more often approached by thoracoscopy nowadays. Large or intraparenchymal nodules are still an indication for thoracotomy. We present the case of a large size, intraparenchymal pulmonary nodule which was removed by thoracoscopy using a pneumotomy/suturing technique.

2. Keywords


Solitary pulmonary nodule, pneumotomy, thoracoscopy

3. Patient


Woman, 54 years old

4. Past medical history


Tubal ligation; one packet of cigarettes per day, stopped smoking 2 months ago.

5. History of present illness


A solitary pulmonary nodule was discovered in the lower left lobe during an anti-smoking outpatients’ clinic program. This nodule was already present on a radiograph taken 18 months previously. It did not increase in size.

6. Workup


6.1. Lung CT scan/radiography

About 20 mm opacity, regular, with a few calcifications, situated in the lower left lobe.

6.2. CT scan

23 mm solitary pulmonary nodule in the lower left lobe. It is close to the bronchial and arterial vessels of the inferior portion of the hilum, and is in contact with the posterior basal segmental bronchus of the left lower lobe, which is patent. The clear and regular contours are partly calcified. Hamartochondroma was evoked.

6.3. Bronchial fiber-endoscopy

Normal

7. Clinical progression


The lesion seems stable and has the features of a benign tumor. With a history of chronic smoking and in the absence of diagnosis, a surgical treatment was decided upon. Despite the strong likelihood of a benign lesion, the first surgeon consulted by the patient suggested left lower lobe resection because of the localization and size of the nodule. The patient asked for a second opinion. An attempt at minimally invasive conservative surgical treatment was proposed.

8. Treatment


A left thoracoscopy was performed. The parietal pleura and the pulmonary parenchyma were normal. The nodule was found in the left lower lobe during exploration. The large volume of the tumor and its deep localization did not allow for a stapling resection. Opening of the parenchyma was performed over the bulge caused by the nodule.
The parenchyma was divided over a length of 4 cm with ultrasonic scissors. Frozen section of the specimen showed a benign tumor, suspected to be a hamartochondroma was suspected. The nodule was totally resected once a few neighboring vessels had been divided with ultrasonic scissors. The specimen was extracted in an extraction bag. Pneumotomy was closed with a running 3.0 polyglactin suture.

9. Anatomopathological examination


Hamartochondroma

10. Postoperative period


The operative outcome was uneventful. The tube was removed on postoperative day 2. The patient was discharged on postoperative day 6.

11. Discussion


Thoracoscopic resection of solitary pulmonary nodules is a recognized surgical option, but the only technique used is the wedge resection with stapling. Yet this technique does not apply to voluminous nodules or those situated deeply as endoscopic staplers do not allow for safe stapling (risk of tearing the parenchyma and bleeding). As a result, these nodules are always approached by thoracotomy to permit lung opening under visual and manual control.
To manage nodules situated deeply which are not accessible to stapling, Landreneau et al. described a method of “superficialization” of the nodule, resorting to a circular pneumotomy with Nd:YAG laser supplemented by hemostasis of vessels using clips. This technique has not been reused by other authors because of its complexity and the scarcity of lasers in thoracic surgery operating rooms.
We applied a technique used in conventional open thoracic surgery: pneumotomy with enucleation of the nodule and suture. Yet every step of the procedure was performed by thoracoscopy. To our knowledge, this technique has not been described in thoracoscopy. The use of ultrasonic scissors greatly facilitates the performance of this technique as it limits bleeding when the lung parenchyma is opened.

12. References


  1. Eichfeld U, Tannapfel A, Steibnert M, Friedrich T. Evaluation of Ultracision in lung metastatic surgery. Ann Thorac Surg 2000; 70:1181-4.
  2. Ginsberg MS, Kahn S, Go BD, Yoo HE, Schawartz LH, Panicek DM. Pulmonary nodules resected at video-assisted surgery: Etiology in 426 patients. Radiology 1999; 213: 277-82.
  3. Landreneau RJ, Herlan DB, Johnson JA et al. Thoracoscopic neodymium: yttrium garnet laser-assisted pulmonary resection. Ann Thorac Surg 1991; 52: 1176-8.