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174 Lung volume reduction surgery
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EXPLORATION AND LYSIS OF ADHESIONS
Sternal retraction is gradually increased until sufficient
3
room has been created to insert a hand or sponge stick
into the thorax. Most patients have scattered areas of filmy
adhesions, which may be vascular, resulting from past
inflammatory processes. Taking care not to tear these, the
surgeon carefully retracts the lung, and the adhesions are
divided with electrocautery as they are encountered. Overly
aggressive retraction may cause the lung, rather than the
adhesion, to tear and this occurrence may result in a prolonged postoperative air leak. On rare occasions, we have
encountered severe, dense adhesions that had not been anticipated preoperatively and that caused us to abort the procedure on that side. We do not, as a routine, incise the inferior
pulmonary ligament.
3
4a
PARENCHYMAL RESECTION 1
Once the lung is fully mobilized, the areas for
4a
somewhat u-shaped strip of tissue from the upper lobe (in the
ideal patient who has upper-lobe-predominant disease) can
be resected with several firings of the stapler, with a single
continuous staple line created from the most caudad portion
of the upper lobe to the extreme apex. This strip generally
constitutes approximately 40–50% of the upper lobe. In
patients who have disease that by ventilation-perfusion scan
and computed tomography is not localized to the apices, we
target the areas of resection to the regions of worst disease
and often resect portions of the middle or lower lobes.
sometimes must be deflated to obtain enough space to insert
a stapler. In these cases, once the portion of lung is deflated by
incising into the lung, resection proceeds more expeditiously.
In patients who have minimal function in the right upper
lobe, we have rarely performed a formal right upper lobectomy on that side.
resection are chosen. Ideally, a single, large oblique,
As mentioned, the target areas usually remain inflated and
Operation 175
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Because the chest is typically extremely deep in these
4b
ing the table slightly to the side of interest is often useful to
float the lung up into the operative field, which facilitates the
resection.
patients, filling the hemithorax with saline and rotat-
4b
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PARENCHYMAL RESECTION 2
The lung in the target area is grasped with either a Duval
5
clamp or a ring clamp – lung not to be resected is left
undisturbed – and the staple line is begun beneath the
clamps. For the median sternotomy technique, we use an
80-mm Endo GIA stapling device with 4.8-mm staples and
0.35-mm polytetrafluoroethylene(PTFE) inserts to buttress
the staple lines to minimize postoperative air leaks (see inset).
As the staple line is progressively created, each reloaded stapler is placed exactly at the ‘crotch’ created by the previous
staple line. We believe that some postoperative air leaks occur
at points where staple lines cross.
How much parenchyma to remove cannot be easily quantitated, but approximately 20% of the volume on each side is
targeted. More is removed, certainly, in hemithoraces containing more areas of severely diseased lung; less is removed
in hemithoraces containing less severely diseased lung. If too
much is resected, postoperative oxygenation may be compromised; if too little is resected, one fails to accomplish the
intent of the operative procedure. One index that can be used
is that the resection should result in a small to moderate
residual apical space when the lung is reinflated. If no such
space is visible after initial reinflation, one should consider
removing more tissue. Not uncommonly, we resect additional tissue from the superior segment of the lower lobe in
those with primarily apical disease. Early in the surgeon’s
experience, the most likely outcome is the resection of too
little parenchyma.
Excised lung
parenchyma
Lung parenchyma stapled between strips of PTFE
Linear stapler
fitted with strips
of PTFE
5
EVALUATION FOR AIR LEAKS
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Once the resection on the first side is completed, the lung
6
is gently re-expanded while the staple line is submerged
in saline to evaluate for air leaks. We are extremely careful to
keep peak inspiratory pressures at less than 25 cm H2O at the
time of lung re-expansion and from this point forward during the procedure. Ideally, no air leaks are identified at this
time. Occasionally, leaks occur adjacent to the buttressed staple line. Small leaks are tolerated if found, as attempts to
repair them often lead to worsening of the air leaks. The rare
large air leak may be repaired by restapling the area or occasionally by careful placement of 000 absorbable suture incorporating strips of buttress material. Needless to say, the
emphysematous parenchyma is not a particularly hospitable
environment for suture placement. For this reason, once
more effective sealant materials are developed than those currently available, they may find application in LVR. Although
others routinely create a pleural tent, we have not noted a
high enough rate of prolonged air leaks to justify the time
required for and potential morbidity of this additional procedure.
Once the procedure on the first side is completed, we check
arterial blood gas as the patient is ventilated with both lungs.
If severe hypercarbia is identified (P
70 mmHg in patients with no preoperative CO2retention),
we ventilate both lungs for several minutes to reduce the CO
toward normal before reinstituting single-lung ventilation.
The opposite lung is then collapsed, and the procedure
described earlier is repeated on the second side. Peak pressures on the previously operated lung, which is now being
ventilated, are kept at a minimum.
CO
higher than
2
Operation 177
6
2
7
CLOSURE
Generally, one 28-Fr thoracostomy tube is placed on
each side via separate lateral inframammary incisions
7
and positioned at the apex posteriorly. A mediastinal tube is
placed only if an unusual amount of bleeding occurs. The
tubes are left to water seal with no suction applied.
The sternum is closed with three wires in the manubrium
and no less than four others in the body of the sternum. These
wires are secured tightly but without tearing through the sternum. A Robicsek-type weave with the sternal wires may be
necessary in some patients with fragile sterna, such as older,
osteoporotic women. This maneuver involves weaving a single wire longitudinally around all of the costal cartilages proceeding from superior to inferior and back on each side;
transverse wires are then placed around the longitudinal wire
struts. The upper abdominal fascia is closed with a few interrupted 0 nylon sutures. The presternal fascia is closed with
running 0 absorbable suture, the subcutaneous tissue with
running 00 absorbable suture, and the skin with running subcuticular 000 absorbable suture.
178 Lung volume reduction surgery
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Video-assisted thoracoscopy
The goal of the operation remains the same whether the procedure is performed via median sternotomy or VATS. We
tend to favor VATS over sternotomy in those older than 65
years and in others who appear to be more severely compromised by a variety of clinical criteria but who nevertheless
remain reasonable candidates for the procedure. Epidural
analgesia is as important with VATS as with the median sternotomy incision.
INCISIONS
The incisions pictured are optimal for the usual patient
8
with upper-lobe-predominant disease. The locations of
the ports must be altered if the target areas are not apical. The
initial incision is placed just posterior to the level of the anterior superior iliac spine in approximately the sixth intercostal
space. An introducer for the 30-degree, 10-mm videothoracoscope is placed here. Two additional incisions are made as
pictured for placement of a ring clamp used for grasping the
lung and the linear stapler. No introducers are used for these
instruments – they are placed directly through the incision
into the chest. The port for grasping is made one or two ribs
superior and slightly posterior to the first incision; the port
for the stapling is made at the same level but approximately 8
cm anterior to the first incision.
We have found that this arrangement of ports facilitates
visibility and gives a reliable angle allowing removal of large
wedges of parenchyma from the upper lung.
We perform the VATS procedure with the patient in the
lateral decubitus position, even though this approach
requires that the patient be repositioned before working on
the second side. The operation can be performed with the
patient supine and the arms positioned over the head without
the need for repositioning, but we see no advantage to this
approach because all patients benefit from a period of twolung ventilation to reduce PCO2before beginning on the second side.
Upper lobe
Middle lobe
Ring
clamp
Lower lobe
Stapler
Camera
8
PARENCHYMAL EXCISION
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Just as with the median sternotomy approach,
9a,b
parenchyma, proceeding from the inferior aspect of the
upper lobe to its apex. Because the VATS approach is lateral
rather than anterior, however, we have found it most effective
during VATS to remove the initial strip from the posterior
aspect of the upper lobe, beginning near the confluence of the
fissures and proceeding around the apex.
The tendency to remove too little tissue is compounded
during the VATS approach by the magnification provided by
the video camera and the limited jaw opening of endoscopic
staplers. Thus, removing additional wedges of tissue is more
common with VATS. Common sites for these additional
excisions in the patient with apical-predominant disease are
as shown from the anterior aspect of the upper lobe and the
superior segment of the lower lobe. Furthermore, either
increasing or compressing the poorly collapsing lung tissue
with a long Kelly clamp to facilitate placement of the stapling
device is often useful.
we excise a large oblique strip of lung
Operation 179
Right lung
Typical line of excision
Common additional
lines of excision
9a
Left lung
Typical line of excision
Common additional
line of excision
We have chosen to buttress the staple lines when using
the VATS approach with Seemguard (Goretex, Inc). The
literature indicates that buttresses do reduce the mean duration of air leaks but at a cost approximately equal to the cost
of the extra days spent in the hospital.
Most adhesions that are encountered can be taken down
during VATS as during sternotomy. If very dense adhesions
9b
are encountered, conversion to an open procedure may be
necessary, and we prefer to use a vertical axillary muscle-sparing thoracotomy incision to accomplish this conversion. As
previously discussed, great care must be taken to avoid tearing the fragile lung parenchyma while lysing adhesions in
patients with emphysema, and this goal can be more difficult
to achieve when working via a VATS approach.
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CLOSURE
A single 28-Fr chest tube is tunneled submuscularly
10
for the camera (because placing the tube directly through the
port incision without a tunnel can lead to air entry when the
tube is removed in these frequently very thin patients). The
tube is positioned at the apex of the chest posteriorly and left
to water seal. The lung is carefully re-expanded under direct
vision. The incisions are closed with interrupted 00
absorbable suture on the muscle, running 000 absorbable
suture on the subcutaneous tissue, and a running 0000
absorbable subcuticular stitch.
then into the chest at the intercostal incision made
Staple lines
After the first side is completed, the patient is repositioned
while both sides are ventilated, with inspiratory pressures
minimized. The procedure is completed on the second side in
similar fashion, and the patient is then awakened and extubated.
POSTOPERATIVE CARE
The patient can virtually always be extubated in the operating
room, and this maneuver is of great importance to minimize
prolonged positive pressure on the staple lines in the fragile
emphysematous lung tissue. Occasionally, one must wait up
to 30 minutes in the operating room after the placement of
the dressings for a significant respiratory acidosis with CO
narcosis to improve before extubation. It is fairly routine,
however, for these patients to be extubated with PCO2levels in
the 80s. These values typically return to the patients’ preoperative values within several hours of operation.
Chest tubes are placed to water seal and not to suction. The
highly compliant emphysematous lung does not require negative suction in the pleural space for it to expand, and air
leaks tend to be more severe and persistent when the tubes are
placed to suction. We tolerate an initial postoperative pneumothorax (typically an apical space) of up to 20% without
placing the tubes to suction in an effort to resolve the space.
Generally, such small pneumothoraces resolve over the first
2–4 postoperative days if no large air leak is present. If a
pneumothorax of greater than 20% is present, we place the
chest tube on that side to –10 cm H
leaks have resolved, we remove chest tubes despite the presence of a small residual space. If any question exists of a small,
persistent air leak, we clamp the tube for several hours and
check for stability on chest radiogram before tube removal.
Unilateral persistent air leaks beyond 1 week after operation occur in about 10% of patients. In these remaining
patients, if they are otherwise clinically well, we cut the chest
tube close to the chest and place a Heimlich valve. The
2
patients can be discharged to home with the valve in place, on
oral antibiotics, with follow-up in the office twice weekly
until the air leak resolves and the tube can be removed.
All patients are instructed and aided in vigorous pulmonary toilet from the time they arrive in the recovery room.
They are encouraged to cough and use the incentive spirometer, and chest physiotherapy is used when indicated for difficulty in clearing secretions. Although it is unusual, we
O temporarily. Once air
2
Chest
tube
10
Further reading 181
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occasionally perform bronchoscopy on a patient who is
unable to clear secretions; and if this procedure is required
more than twice, we place a minitracheostomy tube through
the cricothyroid membrane to allow suctioning on a regular
basis.
Thoracic epidural catheters are kept in place for 5 days
before converting to oral narcotic analgesia. Nebulized bronchodilators are used routinely for 5 days before converting to
whatever inhaled bronchodilators the patient was taking preoperatively. Although we do not routinely administer antibiotics beyond the perioperative period, we have a low
threshold for restarting them in those patients with any indication of tracheobronchitis or pneumonia. The cultures that
are routinely sent from the preoperative bronchoscopy are
useful to direct this therapy.
Patients are made to ambulate at least three times per day
beginning on postoperative day 1, and our physical therapists
work closely with them to maximize physical activity as early
as possible.
OUTCOME
We have collated data from all pre-NETT published series of
LVR that use the now-standard stapled, bilateral approach
(including both median sternotomy and thoracoscopic incisions). The mean increase in FEV1from these reports is 52%.
The mean decrease in residual volume in those studies that
measured this parameter is 28%, and scores on the 6-minute
walk test increased an average of 25%. These benefits were
achieved with a mean operative mortality of 6.0% and a mean
length of stay of 15 days. Furthermore, all studies that have
looked at quality of life or dyspnea scores have shown marked
improvement in these measures. The author’s personal experience corroborates these results.
The impressive results of the NETT trial are readily available to readers and will not be reviewed in detail here. Suffice
it to say that this study proved that appropriately selected
patients with heterogeneous disease and low exercise capacity
not only benefit from dramatic improvements in quality of
life but also from greater survival. Even patients with hamogeneous disease, if their exercise capacity is low, may benefit
from a dyspnea and quality of life standpoint.
FURTHER READING
Brantigan OC, Kress MB, Mueller EA. The surgical approach to
pulmonary emphysema. Diseases of the Chest 1961; 39: 485–501.
Cooper JD, Trulock EP, Triantafillou AN, et al. Bilateral pneumectomy
(volume reduction) for chronic obstructive pulmonary disease.
Journal of Thoracic and Cardiovascular Surgery 1995; 109: 106–19.
Fishman A, Martinex F, Naunheim K, Piantadosi S, Wise R, Ries A,
Weinmann G, Wood DE. National Emphysema Treatment Trial
Research Group. A randomized trial comparing lung-volumereduction surgery with medical therapy for severe emphysema. New
England Journal of Medicine 2003; 348: 2059–73.
Hazelrigg SR, Boley TM, Naunheim KS, et al. Effect of bovine pericardial
strips on air leak after stapled pulmonary resection. Annals of
Thoracic Surgery 1997; 63: 1573–5.
National Emphysema Treatment Trial Research Group. A randomized
trial comparing lung-volume-reduction surgery with medical therapy
for severe emphysema. New England Journal of Medicine 2003; 348:
2059–73.
Shrager JB, Kaiser LR. Lung volume reduction surgery. Current Problems
in Surgery 2000; 37: 253–317.
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Videothoracoscopic bullectomy for spontaneous
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pneumothorax
TOMÁS ANGELILLO MACKINLAY
British Hospital of Buenos Aires, Capital Federal, Buenos Aires, Argentina
18
HISTORY
No specific milestones exist in the evolution of bullectomy
except for the advent of video assisted thoracic surgery
(VATS). In the past posterolateral thoracotomy was usually
indicated for persistent leaks after tube thoracostomy.
Subsequently, during the 1970s and 1980s a tendency towards
limited thoracotomies emerged, and bullae were preferably
resected through small axillary thoracotomies. In the 1990s
the advent of VATS introduced a radical change in the surgical approach for this disease. Different methods of producing
bullae disappearance and air leakage control were implemented, such as endostapling, YAG laser, argon beam, and
endo-looping. Of all of these techniques, endostapler bullae
resection prevailed as the most effective and rational surgical
technique.
PRINCIPLES AND JUSTIFICATION
Bullectomy is the surgical removal of a bulla or bleb usually
performed during a spontaneous pneumothorax episode
with the expectation that the bulla represents the leaking
source. A bulla has been defined as an emphysematous space
more than 1 cm in diameter during the distended state.
Unruptured bullae do not have surgical indication unless
they progress in size to the degree that they compress the
adjacent normal lung parenchyma. When this phenomenon
occurs, the giant bulla occupies more than one-third of the
entire hemithorax. Blebs are small intrapleural collections of
air representing forms of interstitial emphysema and have no
epithelial lining. Rupture of bullae or blebs produces spontaneous pneumothorax.
The aim of the operation is threefold:
1 To eliminate the leakage point
2 To re-establish negative pressure within the chest restor-
ing normal ventilation
3 To avoid septic contamination of the pleural cavity.
Spontaneous pneumothorax may be primary (PSP) or secondary (SSP). Primary spontaneous pneumothorax occurs in
young patients, 85% of whom are less than 40 years of age.
Apart from the pain and mild dyspnea, the patients tolerate
the episode fairly well without jeopardizing their respiratory
capacity. Ruptured blebs are usually responsible for this situation, which rarely leads to tension pneumothorax or to hemorrhage from a torn adhesion.
Secondary pneumothorax usually is the consequence of a
ruptured bulla and occurs in older people (50–65 years of
age). They have a worse functional tolerance because of comorbid pathology and poorer cardiorespiratory reserve, since
most of them suffer from chronic obstructive pulmonary disease (COPD). This group comprises a population at high risk
and should be treated accordingly by prompt drainage of the
pneumothorax by means of a thoracostomy tube in the emergency room. The incidence of tension pneumothorax and
hemopneumothorax is also higher in these patients.
Mortality rates as high as 16% have been reported in this population. The size of the pneumothorax is not as important as
the cardiorespiratory response to it. Definitive treatment
should wait until medical and cardiorespiratory stability have
been reached.
The options for treatment of spontaneous pneumothorax
are:
1 Clinical observation with optional oxygen therapy
2 Tube thoracostomy (which can be associated with talc
slurry pleurodesis in selected cases)
3 Bullectomy, either by thoracotomy or videoassisted tho-
racic surgery (VATS) with or without pleurodesis.
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