Thoracoscopic Resection of a Bronchogenic Cyst in a Premature Infant

Abstract

Introduction: Bronchogenic cysts are benign congenital anomalies of the embryonic foregut and belong to a class known as foregut duplication cysts that include esophageal duplications, bronchopulmonary sequestrations, and congenital pulmonary airway malformations. Bronchogenic cysts represent the most common type of intrathoracic foregut cyst and often present in the mediastinum. Cyst excision can be delayed beyond the newborn period unless there is respiratory distress due to compression of local structures. A thoracoscopic approach in the removal of a bronchogenic cyst allows for improved visualization, avoids the morbidity of a thoracotomy, and has been associated with shorter postoperative courses. This patient is a 5-week-old, former 30-week premature infant who required intubation at birth and was transferred to our Neonatal ICU after failing several extubation attempts. A chest CT scan showed a 3.2×1.8×1.7 cm posterior mediastinal cyst. Due to compression of the left main stem bronchus, there was significant air trapping in the left lung and rightward deviation of the mediastinum. After failing extubation in our Neonatal ICU, we proceeded with thoracoscopic cyst resection in this 1.7 kg infant. Materials and Methods: The patient was placed in the left lateral decubitus/prone position at 45°. A 3-mm trocar was placed in the right axilla and a pneumothorax (4 mm Hg) was created. An additional 5-mm step trocar was placed just posterior to the tip of the right scapula and a 3 mm incision in the fifth intercostal space, also in the mid-axillary line, and another 3 mm incision through the seventh intercostal space just posterior to the posterior axillary line. With gentle retraction of the lung anteriorly, the esophagus, vagus nerves, and azygous vein were easily visualized and dissected off of the cyst using hook cautery and gentle blunt dissection. The cyst was somewhat adherent to the posterior wall of the trachea and the left bronchus but could be dissected free with minimal difficulty. Decompression of the cyst (clear and viscous fluid) allowed for an easier dissection and removal through the 5-mm trocar. No chest tube was placed and, on the postoperative chest X-ray, the patient's mediastinum had returned to its normal position with good aeration of both lungs and no pneumothorax. The patient tolerated the procedure well without any postoperative complications, had minimal blood loss, and was extubated on postoperative day 2. Results and Conclusions: Congenital mediastinal cysts may cause airway compression requiring early surgical intervention. Even in premature infants with a significant mediastinal shift, a thoracoscopic approach should be considered, which can provide excellent visualization and avoid the morbidity of a thoracotomy. No competing financial interests exist. Runtime of video: 4 mins 32 secs