Role of 3-dimensional computed tomography in a rare mediastinal A5 and A9 variation in video-assisted thoracoscopic surgery left upper lobectomy-a case report

Background: Video -assisted thoracoscopic surgery (VATS) lobectomy has been accepted as a standard approach for early pulmonary malignancy. Disadvantages of VATS lobectomy compared to thoracotomy include lack of tactile sensation and stereotypic vision. Moreover, anatomical variation is commonly seen in pulmonary resection especially vein and artery. To overcome the shortfalls, preoperative three-dimensional (3D) computed tomography (CT) image reconstruction is imperative as 3D -CT reconstruction is reported to help in identifying pulmonary artery branching, lowering incidences of postoperative complications and reducing operative time than those without 3D reconstruction. Case Description: We present a case of centrally located left upper lobe adenocarcinoma cT2N1M0, whom we planned for VATS left upper lobectomy and lymph node dissection. In view of suspicious tumour infiltration into the superior pulmonary vein on the CT thorax, we reconstructed the 3D -CT image. We detected an extremely rare anomalous pulmonary artery: mediastinal A5 and A9, which were confirmed intraoperatively. The surgery went smoothly, and he was discharged home on day two of surgery. Conclusions: The preoperative 3D -CT reconstruction helped to identify the rare anomalies and prevent unnecessary extended resection of the lung and surgical complications. Hence this simple non-invasive investigation should be performed in all VATS anatomical lung resection preoperatively and this case re-emphasizes its importance.