PMC5650659_01
a: Chest X-ray on postoperative day (POD) 1 shows complete atelectasis of the right middle lobe. b: Bronchoscopic image shows a slit-like obstruction in the segmental bronchi of the middle lobe. c: Chest X-ray after bronchoscopy shows an improvement in atelectasis.
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On postoperative day (POD) 1, although his general condition was stable, a chest X-ray showed complete atelectasis of the right ML (Fig. 1a). Bronchoscopy revealed that the right segmental bronchi of the ML (B4, B5) were obstructed with mucosal redness; there was no mucoid impaction and the spur of B4/B5 was visible (Fig. 1b). Chest X-ray performed after the bronchoscopy showed re-expansion of the ML (Fig. 1c).
a: Chest X-Ray on POD2 shows increased opacification in the collapsed middle lobe (ML). b: Enhanced computed tomography (CT) shows the surgical staple placed in the horizontal fissure in contact with the right lower lobe (arrow head). It should be on the opposite side (outlined arrow head). c: The frontal plane of the enhanced CT shows an abnormal course of the pulmonary artery of the ML (arrow head).
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On POD 2, a chest X-ray showed increased opacification in the collapsed ML (Fig. 2a). We rechecked the CT and found that the staple placed in the horizontal fissure was in contact with the right lower lobe (Fig. 2b).
a: Intraoperative photo shows that the staple of the middle lobe (ML) fired on the horizontal fissure (arrow heads) is in contact with the right lower lobe. RLL: right lower lobe, RML: right middle lobe. b: Intraoperative photo after detorsion shows that the staple (arrow heads) was restored to the normal location, specifically the cranial surface of the ML. c: Bronchoscopic image taken after rethoracotomy shows patent segmental bronchi of the ML.
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The ML was slightly inflated by the injected air and twisted clockwise by 240 ; it was reddish in appearance, but not necrotic (Fig. 3a). Prior to the procedure, we asked the anesthesiologist to pay attention to possible arrhythmia and increase in airway secretion and subsequently rotated the ML counterclockwise 240 (Fig. 3b). Postoperative bronchoscope showed patent ML segmental bronchi (Fig. 3c).