Advances in the surgical management of pulmonary malformations

Congenital pulmonary malformations (CPMs), including congenital cystic adenomatoid malformations, sequestrations, and bronchogenic cysts, have benefited from continuous progress in pediatric minimally invasive surgery. Thoracoscopy, now feasible even in infants thanks to the use of 5 mm trocars and mechanical staplers, offers a safe alternative to thoracotomy. The emergence of thoracoscopic segmentectomies, guided by patient-specific three-dimensional imaging, allows for parenchymal-sparing resections when lesions are well localized, at the cost of a slightly increased risk of air leaks. Augmented imaging, particularly intravenous indocyanine green (ICG) for vascular mapping and inhaled ICG for delineating malformative areas, improves the precision of resections. At the same time, uniportal or “single port +1” approaches further reduce the surgical footprint, with encouraging aesthetic and functional outcomes. Robot-assisted surgery is feasible in expert centers but remains limited by costs and instrument size. From an anesthetic perspective, pulmonary isolation is optimized with bronchial blockers, while spontaneous ventilation remains experimental. Finally, the integration of ERAS protocols and more restrictive chest drainage management support enhanced postoperative recovery. Overall, the current trend favors earlier, more targeted, and less invasive interventions, integrating advanced imaging and optimized care pathways.