Unilateral lung hypoplasia in a remnant pleural cavity identified via thorascopic approach - diagnostic difficulties

The development of diagnostic imaging and its increasing availability have unquestionably increased the number of correctly made diagnoses and appropriate therapeutic decisions. However, none of the methods used provides 100% certainty of correct diagnosis. The purpose of this paper is to present possible diagnostic difficulties, where despite the selection of appropriate imaging methods used in this type of disease, the preoperatively made diagnosis turned out to be wrong.

A 2-month-old male infant was referred to the pediatric surgery department, with suspected right diaphragmatic hernia right-sided diaphragmatic hernia. On admission, physical examination revealed a markedly muffled alveolar murmur over the pulmonary field on the right side. The gastrointestinal passage performed showed contrast-filled bowel under the diaphragm and uniform shading of the right half of the chest. The left lung was airy, the left diaphragmatic-femoral angle was free. In view of diagnostic doubts, the patient was referred for computed tomography angiography (angio-CT) of the chest and abdominal cavity (Figure 1). The study description showed a hernia gate in the posterior part of the right side of the diaphragmatic dome, 4 cm wide, through which a large part of the right diaphragm passed into the chest a large part of the right lobe of the liver measuring 5 x 7 cm and the upper pole of the right kidney. On CT description The hernia filled about 3⁄4 of the volume of the thorax on the right side, leaving an airy lung only in the peak and subpectoral region. The heart was slightly displaced to the right side. The displacement of the liver and the upper pole of the kidney to the chest was confirmed by the also the abdominal ultrasound examination performed.

Making a definitive diagnosis was only possible with a procedure performed using the thoracoscopic technique. The choice of this technique, which has all the advantages of being minimally invasive, instead of the traditional technique, proved advantageous for making a complete diagnosis in the unusual situation visualized during the procedure. Convenient access to the thorax provided by the use of a high-definition (HD) video track allowed for a thorough review of the entire space and proper diagnosis of the abnormalities present without the need for a classic opening of the chest and avoiding the adverse consequences of thoracotomy in young children. We submit for consideration whether the use of the traditional technique in such a small patient, such as a 2-month-old infant would allow us to see additional pathology of the pleural cavity - probably not.