Most congenital lung lesions need to be excised, but the timing varies depending on the clinical circumstances: in utero, at birth using an EXIT strategy, urgently or semi-urgently in the newborn period, or after a several-month period of maturation and close observation. A CCAM might regress in the third trimester and for a time after birth, but it will rarely disappear completely. Most cases of true congenital lobar emphysema will present acutely in the newborn period and need to be excised urgently or emergently. In the rare case of a CLE under tension, a decompressive thoracotomy performed at the bedside can be a life-saving maneuver. Fetuses that develop hydrops clearly require some form of intervention: induction and delivery for near-term infants with severe hydrops, thoraco-amniotic shunting for macrocystic lesions, thoracotomy with EXIT, or, rarely, fetal surgery. Asymptomatic patients with a CCAM, sequestration, or hybrid lesion can be safely observed for a period of weeks or even months after birth, which makes general anesthesia somewhat safer and the operation technically more straightforward.
The thoracoscopic approach is an advanced minimally invasive procedure that is being offered only at selected centers, but in the absence of an indication for urgent intervention or a contraindication to the approach, parents should be offered the option of having their baby’s care transferred to a center where there is experience with this technique. In preparation for any operation that might involve lung lobectomy, it is always sensible to review the relevant anatomy beforehand. The operation itself should be done with single-lung ventilation, usually best accomplished in an infant by main-stem intubation under fluoroscopic guidance. The most significant hurdle to successful thoracoscopic resection is an incomplete major fissure, the dissection of which frequently results in bleeding and troublesome air leaks. Because the tissues are so delicate and the vessels so prone to tearing, the most important technical aspects of the operation are patience and absolutely meticulous dissection. Most importantly, the surgeon needs to resist the temptation to use aggressive blunt dissection, which, although it is the trademark of the accomplished laparoscopist, can quickly lead to exsanguinating hemorrhage.