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Removal of aberrant azygos lobe containing positron emission tomography positive nodule with the use of video-assisted thoracic surgery.

Shakir HA - Int J Surg Case Rep (2013)

Bottom Line: Chest x-ray revealed a lung nodule in the right lung field.The Azygos lobe is a well-known anatomical variant but such a lobe is rarely found to contain a malignant lesion.This case illustrates that gentle caudal traction on the azygos lobe will allow circumferential exposure to the lobe and identification of the bronchovascular pedicle thereby eliminating the need for thoracotomy and or extensive azygos vein dissection/division.

View Article: PubMed Central - PubMed

Affiliation: St. Mary's Hospital, Passaic, NJ 07055, USA. Electronic address: hashakir@hotmail.com.

No MeSH data available.


Related in: MedlinePlus

CAT scan of chest showing nodule within azygos lobe.
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fig0005: CAT scan of chest showing nodule within azygos lobe.

Mentions: A 67-year-old female with known severe chronic obstructive pulmonary disease presented with increasing shortness of breath. Chest X-ray revealed a lung nodule in the right lung field. PET/CT imaging delineated a 1.6 cm × 1.2 cm speculated lesion in an aberrant azygos lobe (see Fig. 1). Pulmonary function tests were consistent with severe obstructive disease. Conventional biopsy was deemed too high risk by interventional radiology due to medial nature of the lesion. The patient was taken to the operating room for video-assisted thoracic surgery to remove the azygos lobe in toto. The patient was placed in the left lateral decubitus position. Hips were slightly flexed to allow optimal operative intrathoracic instrumentation. External pressure points were padded. After the patient was prepped and draped, a 10 mm incision was made in the 5th intercostal space in the anterior axillary line. Two more similar incisions were made in the 7th intercostal space in the mid-axillary line and in the 4th space in the posterior axillary line respectively. The right upper lobe was grasped and retracted laterally thus exposing the mediastinum and the azygos vein and the azygos lobe. The azygos vein was seen to course over the azygos lobe (see Fig. 2). Careful dissection was used and the vein was gently dissected off of the visceral pleura of the azygos lobe. Without significant mobilization of the azygos vein, the azygos lobe was grasped with a VATS sponge forcep (Ralph Lewis, Basking Ridge, NJ). The azygos lobe was retracted in a caudal manner until the entire lobe was delivered from beneath the azygos vein. With entire azygos lobe circumferentially exposed and in view and the hilum to the azygos lobe visible, a 60 mm thick tissue Echelon (Ethicon Inc.) stapler was used to divide the bronchovascular pedicle using the technique described by Lewis.2 Frozen section of the specimen revealed a poorly differentiated adenocarcinoma with negative tumor margins. Lymph node dissection was done in the Level 4 lymph node compartment and was negative for metastatic disease. Final TNM staging was pT1a, N0, M0; stage 1A. Her postoperative course was uneventful and she was discharged home on the third postoperative day.


Removal of aberrant azygos lobe containing positron emission tomography positive nodule with the use of video-assisted thoracic surgery.

Shakir HA - Int J Surg Case Rep (2013)

CAT scan of chest showing nodule within azygos lobe.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC3921653&req=5

fig0005: CAT scan of chest showing nodule within azygos lobe.
Mentions: A 67-year-old female with known severe chronic obstructive pulmonary disease presented with increasing shortness of breath. Chest X-ray revealed a lung nodule in the right lung field. PET/CT imaging delineated a 1.6 cm × 1.2 cm speculated lesion in an aberrant azygos lobe (see Fig. 1). Pulmonary function tests were consistent with severe obstructive disease. Conventional biopsy was deemed too high risk by interventional radiology due to medial nature of the lesion. The patient was taken to the operating room for video-assisted thoracic surgery to remove the azygos lobe in toto. The patient was placed in the left lateral decubitus position. Hips were slightly flexed to allow optimal operative intrathoracic instrumentation. External pressure points were padded. After the patient was prepped and draped, a 10 mm incision was made in the 5th intercostal space in the anterior axillary line. Two more similar incisions were made in the 7th intercostal space in the mid-axillary line and in the 4th space in the posterior axillary line respectively. The right upper lobe was grasped and retracted laterally thus exposing the mediastinum and the azygos vein and the azygos lobe. The azygos vein was seen to course over the azygos lobe (see Fig. 2). Careful dissection was used and the vein was gently dissected off of the visceral pleura of the azygos lobe. Without significant mobilization of the azygos vein, the azygos lobe was grasped with a VATS sponge forcep (Ralph Lewis, Basking Ridge, NJ). The azygos lobe was retracted in a caudal manner until the entire lobe was delivered from beneath the azygos vein. With entire azygos lobe circumferentially exposed and in view and the hilum to the azygos lobe visible, a 60 mm thick tissue Echelon (Ethicon Inc.) stapler was used to divide the bronchovascular pedicle using the technique described by Lewis.2 Frozen section of the specimen revealed a poorly differentiated adenocarcinoma with negative tumor margins. Lymph node dissection was done in the Level 4 lymph node compartment and was negative for metastatic disease. Final TNM staging was pT1a, N0, M0; stage 1A. Her postoperative course was uneventful and she was discharged home on the third postoperative day.

Bottom Line: Chest x-ray revealed a lung nodule in the right lung field.The Azygos lobe is a well-known anatomical variant but such a lobe is rarely found to contain a malignant lesion.This case illustrates that gentle caudal traction on the azygos lobe will allow circumferential exposure to the lobe and identification of the bronchovascular pedicle thereby eliminating the need for thoracotomy and or extensive azygos vein dissection/division.

View Article: PubMed Central - PubMed

Affiliation: St. Mary's Hospital, Passaic, NJ 07055, USA. Electronic address: hashakir@hotmail.com.

No MeSH data available.


Related in: MedlinePlus