This report shows the safety and utility of ICG fluorescence-guided thoracoscopic pulmonary resection for intralobar pulmonary sequestration. Although several studies have reported the utility of identifying the segmental line using NIR fluorescence imaging with ICG [
3‐
13], there are few reports in which ICG was used for identification of demarcation line of intralobar pulmonary sequestration [
11]. Management of asymptomatic pulmonary sequestration is controversial. Although surgical resection of pulmonary sequestration has been recommended because of the likelihood of recurrent infection and the possibility of hemorrhage, lobectomy is often required [
14]. Although thoracotomy has conventionally been required for resection of pulmonary sequestration, VATS has been increasingly frequently performed [
15]. Sublobar resection is usually performed for small sequestration, and it is important to identify an adequate boundary. Traditionally, the boundaries were identified intraoperatively with inflation/deflation of the target segment by clamping and unclamping the relevant bronchus. However, the inflated lung may obstruct the view of the target region, particularly in VATS. The identification rate of the boundary of the target segment ranged from 90–100%. ICG is generally considered safe, and the incidence of severe adverse reactions has been reported to be 0.05% [
16,
17]. In previous studies, the dose of ICG used for lung segmentectomy ranged from 0.25 to 5 mg/kg (for example 15 to 300 mg of ICG applied to a patient weighing 60 kg), and no complications were attributed to ICG [
3‐
6,
8,
12]. However, the incidence of anaphylactic shock due to ICG used for angiography at doses of 25 to 75 mg was reported to be 0.05% [
17]. Although the dose of ICG was quite low at 5 mg in the present case, the demarcation line of target segment was clearly identified, so this dose of ICG was sufficient for identification of the segmental line. Using such a low dose of ICG is safe, as well, by helping avoid anaphylactic shock.
The difficulty of resection for pulmonary sequestration is the identification of the aberrant artery. Most of the aberrant arteries were present in the inferior pulmonary ligament [
18]. Inflammatory changes caused by recurrent infections would develop dense adhesions accompanied with proliferative vessels, and this situation might make the surgical field bloody and blurred. It is important to image the location of the target vessels; three-dimensional CT was useful for identification of the aberrant artery in our case. Because the aberrant artery would be thickened or fragile due to recurrent infections, proximal ligation of the thickened or fragile aberrant artery with a stapling device before cutting it is considered to be important [
18].