Wedge resection for pulmonary sequestration guided by indocyanine green fluorescence and 3-dimensional reconstruction

Pulmonary sequestration (PS) is a rare congenital lung malformation with an often-indistinct boundary between sequestered and normal lung tissue, leading to lobectomy and potential loss of lung function. This study evaluated whether watershed analysis combined with intraoperative indocyanine green fluorescence can accurately delineate the PS boundary and enable wedge resection.

We analyzed consecutive patients who underwent surgical resection for PS at our center between January 2023 and September 2025. Preoperative contrast-enhanced computed tomography with 3-dimensional reconstruction was used to simulate the PS boundaries of normal lung tissue and to assess whether wedge resection was feasible. During video-assisted thoracoscopic surgery, the PS-feeding systemic artery was divided, followed by rapid intravenous indocyanine green injection and fluorescence imaging to visualize the interface between sequestered and normal lung tissue, allowing completion of the wedge resection.

Forty-seven patients were included: 35 underwent watershed-guided wedge resection and 12 underwent lobectomy. In all cases, intraoperative fluorescence accurately matched the preoperative 3-dimensional watershed simulation. By preoperative simulation of the expected boundary, wedge resection was feasible in 74.5% (35/47) of patients in this cohort. Compared with lobectomy, watershed-guided wedge resection was associated with shorter operative time, less blood loss, shorter chest tube duration, and shorter length of stay.

The watershed topographic mapping technique we developed can accurately predict the boundaries of PS preoperatively, perform fluorescence verification intraoperatively, and allow for wedge resection of PS to avoid lobectomy, while ensuring that the surgical procedure is safe and reliable.