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 ¤ Case Report
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 Table of Contents     
Year : 2022  |  Volume : 18  |  Issue : 2  |  Page : 314-316

Indocyanine green imaging to identify intralobar pulmonary sequestration for uniportal thoracoscopic resection

Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan

Date of Submission08-May-2021
Date of Acceptance18-Jul-2021
Date of Web Publication01-Nov-2021

Correspondence Address:
Mong-Wei Lin
Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung-Shan South Road, Taipei 10002
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jmas.jmas_142_21

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 ¤ Abstract 

Surgical excision of pulmonary sequestration is a definite treatment, but dissection of the arterial supply from systemic circulation and determination of the boundary are always challenging. We reported a case utilising pre-operative three-dimensional reconstruction and indocyanine green injection to make the procedure minimally invasive, precise and safe.

Keywords: Indocyanine green, pulmonary sequestration, three-dimensional reconstruction

How to cite this article:
Lian KH, Lin MW. Indocyanine green imaging to identify intralobar pulmonary sequestration for uniportal thoracoscopic resection. J Min Access Surg 2022;18:314-6

How to cite this URL:
Lian KH, Lin MW. Indocyanine green imaging to identify intralobar pulmonary sequestration for uniportal thoracoscopic resection. J Min Access Surg [serial online] 2022 [cited 2022 Jul 2];18:314-6. Available from:

 ¤ Introduction Top

Pulmonary sequestration is a rare congenital anomaly that might lead to chronic inflammation and hemoptysis; surgical resection is the treatment of choice.[1] For intralobar sequestration, precisely identifying the intersegmental plane between normal and abnormal lung parenchyma is difficult. Conventionally, the plane is identified by direct thoracoscopic visualisation. Two previous reports used indocyanine green (ICG) fluorescence imaging to identify the intersegmental plane using conventional three- or four-port video-assisted thoracoscopic surgery (VATS).[1],[2] Recently, thoracic surgeons have started to perform uniportal VATS to reduce post-operative pain, improve cosmetic outcomes, and shorten the hospital stay. Here, we report the first case in which ICG fluorescence imaging was integrated into a uniportal VATS excision of intralobar pulmonary sequestration.

 ¤ Case Report Top

A 25-year-old previously healthy female was reported to have nodular consolidation in the left lower lobe (LLL) by occupational screening radiography half a year before presentation. She works as a nurse in the thoracic surgery division ward and had a contact history with her grandmother, who was diagnosed and treated for pulmonary tuberculosis. Chest computed tomography (CT) showed nodular consolidations in the LLL, along with bronchiectasis; a supplying artery from the descending thoracic aorta implied intralobar pulmonary sequestration [Figure 1]. Another 1-cm pure ground-glass nodule (GGN) was incidentally found in the left upper lobe (LUL). Bronchoalveolar lavage was negative for malignant cells, acid-fast stains, bacterial, mycobacterial and fungal cultures. She remained asymptomatic for 6 months, and repeated chest CT showed that the LUL GGN appeared stationary. Surgical intervention was planned for both the sequestration and GGN. three-dimensional (3D) reconstruction by an image analysis system (Synapse Vincent, Fujifilm Corp., Tokyo, Japan) demonstrated a single arterial supply from the lower thoracic aorta [Figure 1].
Figure 1: (a) Pre-operative chest computed tomography revealed nodular consolidation in the posterior left lower lobe (asterisk), and a 1-cm ground-glass nodule in the left upper lobe (arrowhead); (b and c) Illustration of an aberrant arterial branch from the lower thoracic aorta (arrow)

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Under general anaesthesia, the patient was placed in a right decubitus position, and a 3-cm incision was created at the 6th intercostal space in the anterior axillary line. Wedge resection was first performed to remove the LUL GGN based on pre-operative CT-guided dye localization.[3] The inferior pulmonary ligament was divided, followed by meticulous dissection and division of the aberrant artery from the thoracic aorta using endo-stapler [Figure 2]a. Then, ICG (0.15 mg/kg) was injected into a peripheral vein, and the pulmonary sequestration boundary was identified and marked under near-infrared fluorescence thoracoscopy Olympus, Tokyo, Japan; [Figure 2]b. Finally, stapled intralobar pulmonary sequestration resection was performed along the border. The operation lasted 148 min, with <50 mL in blood loss.
Figure 2: (a) Dissection of the arterial supply from the lower thoracic aorta (arrow); (b) The intralobar pulmonary sequestration border, highlighted by indocyanine green perfusion; (c) The lower lobe sequestration specimen

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The GGN was confirmed to be minimally invasive adenocarcinoma. The resected sequestration size was 10.0 cm × 7.0 cm × 3.5 cm [Figure 2]c. The 14 Fr pigtail drainage tube was removed on the post-operative day 2, and the patient was discharged on the following day. Her post-operative course was uneventful for 3 months.

 ¤ Discussion Top

Pulmonary sequestration is typically found in the lower lobes and could be classified as extralobar or intralobar sequestration based on the presence of its own visceral pleura. For intralobar sequestration, a lack of connection to the bronchial tree makes it difficult to identify the intersegmental plane by direct visualisation or the inflation technique. Therefore, intravenous ICG injection with near-infrared thoracoscopy could be ideal when the feeding artery was divided.[4] Allergic reactions have rarely been reported when the dose was <5 mg/kg; Precise excision reduces recurrent symptoms related to sequestration and preserves pulmonary function.

Moreover, dissecting the artery from the inflammation-related adhesions is challenging.[1],[2] In this case, we used a newly-developed 3D image analysis system (Synapse Vincent), which enables pre-operative reconstruction of the pulmonary vessels and the tracheobronchial trees from multi-detector CT images. This helps detect anatomical variations before the surgery. After the pre-operative simulation, vessel dissection was done more confidently, using this minimally invasive technique.

 ¤ Conclusion Top

We showed a safe, accurate and efficient use of uniportal thoracoscopic surgery for intralobar pulmonary sequestration resection with integrated 3D image reconstruction and ICG fluorescence imaging. ICG fluorescence imaging can be routinely used in uniportal VATS sequestration resection.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initial s will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This work was supported by National Taiwan University Hospital, Taipei, Taiwan (NTUH109-S4659). The funding was only used for financial subsidies of English editing.

Conflicts of interest

There are no conflicts of interest.

 ¤ References Top

Motono N, Iwai S, Funasaki A, Sekimura A, Usuda K, Uramoto H. Indocyanine green fluorescence-guided thoracoscopic pulmonary resection for intralobar pulmonary sequestration: A case report. J Med Case Rep 2019;13:228.  Back to cited text no. 1
Yamanashi K, Okumura N, Nakazono C, Matsuoka T. Surgery for intralobar pulmonary sequestration using indocyanine green fluorescence navigation: A case report. Semin Thorac Cardiovasc Surg 2018;30:122-4.  Back to cited text no. 2
Lin MW, Tseng YH, Lee YF, Hsieh MS, Ko WC, Chen JY, et al. Computed tomography-guided patent blue vital dye localization of pulmonary nodules in uniportal thoracoscopy. J Thorac Cardiovasc Surg 2016;152:535-44.e2.  Back to cited text no. 3
Okusanya OT, Hess NR, Luketich JD, Sarkaria IS. Infrared intraoperative fluorescence imaging using indocyanine green in thoracic surgery. Eur J Cardiothorac Surg 2018;53:512-8.  Back to cited text no. 4


  [Figure 1], [Figure 2]


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