IntroductionVideo-assisted thoracic surgery (VATS) has become routine and widely accepted for the removal of solitary pulmonary nodules of unknown etiology. Thoracosopic techniques continue to evolve with better instruments, robotic applications, and increased patient acceptance and awareness.Several techniques have been described to localize peripheral pulmonary nodules, including pre-operative CT-guided tattooing with methylene blue, CT scan guided spiral/hook wire placement, and transthoracic ultrasound.As pulmonary surgeons well know, the lung and visceral pleura may appear featureless on top of a pulmonary nodule.Case descriptionThis paper presents a rapid, direct and inexpensive approach to peripheral lung lesion resection by marking the lung parenchyma on top of the nodule using direct methylene blue injection.MethodsIn two patients with peripherally located lung nodules (n = 3) scheduled for VATS, we used direct methylene blue injection for intraoperative localization of the pulmonary nodule. Our technique was the following: After finger palpation of the lung, a spinal 25 gauge needle was inserted through an existing port and 0.1 ml of methylene blue was used to tattoo the pleura perpendicular to the localized nodule.The methylene blue tattoo immediately marks the lung surface over the nodule. The surgeon avoids repeated finger palpation, while lining up stapler, graspers and camera, because of the visible tattoo. Our technique eliminates regrasping and repalpating the lung once again to identify a non marked lesion.ResultsThree lung nodules were resected in two patients. Once each lesion was palpated it was marked, and the area was resected with security of accurate localization. All lung nodules were resected in totality with normal lung parenchymal margins. Our technique added about one minute to the operative time. The two patients were discharged home on the second postoperative day, with no morbidity.ConclusionVATS with intraoperative tattooing is a safe, easy, and accurate technique to streamline and efficiently resect solitary pulmonary nodules.
In the pig model, small pockets of free intraperitoneal gas detected by CT scanning are expected to resolve by postoperative day 2 following laparoscopic surgery. Persistence of pneumoperitoneum beyond this interval is abnormal and may represent a perforated viscus. Whereas a prospective CT imaging study in humans is not ethically feasible, we believe that parallel conclusions between the pig and human may be drawn.
INTRODUCTION: Intrapulmonary teratomas (IPT) are a rare extra-gonadal manifestation of teratomas and are a challenging diagnosis to make. We present a patient with IPT presenting with hemoptysis.CASE PRESENTATION: A 49-year-old man presented with intermittent non-massive hemoptysis throughout the previous year. Labs were normal with the exception of normocytic anemia with hemoglobin of 12.1 g/dL. CT chest with contrast revealed a necrotic mass in the central left upper lobe invading the left upper lobe bronchus and obliterating the left pulmonary artery with severe bronchiectatic changes. Multiple mediastinal lymph nodes were enlarged. Flexible bronchoscopy was performed and demonstrated occlusion of the left upper lobe with a dense, white mass, and hair-like material within the bronchus. Attempts at biopsy with the cryoprobe demonstrated friable mucosa that easily bled. No intervention was necessary as spontaneous hemostasis occurred. Attempts at forceps biopsy were unsuccessful because of dense, calcified material. As a result, the cryoprobe was used. Cryoprobe biopsies revealed inflammatory cells without evidence of malignancy. Cultures including bacterial, fungal, and AFB were negative. Lack of diagnosis, severe bronchiectasis, and recurrent hemoptysis prompted the recommendation for resection, and he underwent left thoracotomy with interpleural pneumolysis. Due to involvement of the left pulmonary artery, lung sparing surgery could not be safely achieved and ultimately required a left pneumonectomy. Final pathology was consistent with a lung teratoma.DISCUSSION: Teratomas are germ cell tumors commonly located in the sacrococcygeal region, anterior mediastinum, retroperitoneum, cranium, ovary, or gonads. Rarely they are intrapulmonary in location (1). Less than 100 IPT cases have been reported to date, and usually reported in the left upper lobe. (2,7). Patients present with chest pain, cough, fever, dyspnea, bronchiectasis, or recurrent pneumonia (5). Patients may expectorate hair (trichoptysis), which is considered pathognomonic (3). Untreated, patients are at risk of malignant transformation, tumor rupture, hemoptysis, and airway obstruction from compression. (5). CT chest shows well-defined round or lobulated masses that are smooth in contour with areas of peripheral translucency and may contain fat, calcium, or fluid (5,6). Irregular or ill-defined margins can suggest malignant transformation (4).The only definitive treatment is complete surgical resection and diagnosis is often made concomitantly from the gross pathology. Early resection is crucial in order to prevent complications (6).CONCLUSIONS: IPT is a rare cause of endobronchial obstruction and highlights the need for early bronchoscopic evaluation of hemoptysis. Early diagnosis and resection of IPT is critical to prevent complications and provide definitive treatment.
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