Introduction

Compared with maximal medical management, lung volume reduction surgery (LVRS) has improved quality of life, pulmonary function, exercise tolerance, and survival for selected patients.¹ Although LVRS can be performed as video-assisted thoracic surgery (VATS) or a median sternotomy with the same morbidity, mortality, and benefits, the VATS approach costs less and provides earlier recovery.²

Patients who are candidates for LVRS are symptomatic despite maximal medical management, including inhalers, oxygen supplementation, and pulmonary rehabilitation. The latter helps to screen and treat patients. Patients with severe emphysema are deconditioned, and rehabilitation reconditions the leg muscles and reduces dyspnea. Better-conditioned patients are better prepared to cooperate with their postoperative tasks, such as immediate ambulation and use of the incentive spirometer, to reduce respiratory complications. Patients who do not cooperate well or fail at rehabilitation are poor candidates for LVRS. The most important selection factor is a heterogeneous pattern of emphysema identified on computed tomography (CT) and lung perfusion scanning.

Approach to Video-Assisted Lung Volume Reduction Surgery

Video-Assisted Lung Volume Reduction Surgery (Video 26)

Step 1. Incisions

♦ Incision 1: Through the sixth intercostal space in the mid-clavicular line, make a 2-cm incision as far inferiorly and medially as possible. This is usually one space below the inframammary crease. The dissection through this incision is angled posteriorly through the chest wall (away from the pericardium) so that instruments through this incision are automatically directed posteriorly toward the major fissure, not toward the heart. Check for adhesions with a finger through the incision (Figure 26-1).

♦ Incision 2: Through the ninth intercostal space in the mid-clavicular line, make a 5-mm incision for the 5-mm trocar and a 30-degree thoracoscope.

♦ Incision 3: Make a 2-cm incision in the fourth intercostal space in the mid-axillary line.

Figure 26-1 Incisions for lung volume reduction surgery.

Step 2. Decompression of Apical Bullous Disease

♦ Exposure: Retract the right upper lobe apically.

♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed superiorly.

♦ The bullous disease of the apex of the lung does not decompress well. With the Metzenbaum scissors (or electrocautery) through incision 3, cut into the parenchyma of the right upper lobe to decompress the bullous parenchyma of the upper lobe (Figure 26-2).

Figure 26-2 Metzenbaum scissors cutting the parenchyma of the upper lobe to decompress the upper lobe for resection.

Step 3. Lung Resection

♦ Exposure: Retract the right lower lobe directly apically.

♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed apically.

♦ As with any operation, exposure is the key (Figures 26-3 and 26-4). With a ring forceps through incision 3, hold the lung to line up the parenchyma for the stapler that passes through incision 1.

♦ The buttress on the stapler reduces the air leaks when the lung is stapled. Do not manipulate the stapler much, because this may tear the lung and cause air leaks. Before introducing the stapler, align the lung so that the stapler slides easily across the lung.

♦ If the lung is aligned incorrectly, the stapler will be oblique to the lung and can create a hole in the lung.

Figure 26-3 The stapler crosses the right upper lobe to start the lung volume reduction surgery.

Figure 26-4 The stapler continues the lung volume reduction surgery across the right upper lobe.

Step 4. Completion of Surgery

♦ Exposure: Retract the right lower lobe directly apically.

♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed apically.

♦ The buttressed stapler continues across the lung approximately 3 to 4 cm from the minor and major fissures laterally and close to the hilum medially. As the stapler is fired, move the ring forceps holding the lung closer to the area of lung that has just been stapled (Figures 26-5 to 26-7).

♦ When stapling is completed, cut the bridge of the buttress material that holds the specimen to the lung that remains (Figure 26-8).

Figure 26-5 Proximity of the staple line to the hilum.

Figure 26-6 The staple line continues parallel to and approximately 3 to 4 cm from the fissure.

Figure 26-7 Final firing of the stapler across the lung for lung volume reduction surgery.

Figure 26-8 Metzenbaum scissors cut the buttress to separate the lung to be removed.

Step 5. Specimen Removal

♦ Exposure: The lung does not need to be retracted because the LVRS has removed enough tissue to provide excellent exposure of the pleural cavity.

♦ Aim the thoracoscope anteriorly with the 30-degree lens pointed apically.

♦ Pull the lung specimen through incision 1 with a ring forceps (Figure 26-9).

Figure 26-9 The lung volume reduction surgery specimen is removed through incision 1.

Postoperative Care

♦ Respiratory care is essential.

Early ambulation twice daily in the hallway reduces the risk of pulmonary complications.

Aggressively use nebulizer treatments with chest physiotherapy.

No suction is applied to the chest tubes.

When the chest tube drainage is low, attach Heimlich valves to the chest tubes if there is still an air leak. This facilitates ambulation.

Even if patients do not retain carbon dioxide before the operation, they often have carbon dioxide pressures in the mid-60s (mm Hg) after LVRS.

Introduction

Compared with maximal medical management, lung volume reduction surgery (LVRS) has improved quality of life, pulmonary function, exercise tolerance, and survival for selected patients.¹ Although LVRS can be performed as video-assisted thoracic surgery (VATS) or a median sternotomy with the same morbidity, mortality, and benefits, the VATS approach costs less and provides earlier recovery.²

Patients who are candidates for LVRS are symptomatic despite maximal medical management, including inhalers, oxygen supplementation, and pulmonary rehabilitation. The latter helps to screen and treat patients. Patients with severe emphysema are deconditioned, and rehabilitation reconditions the leg muscles and reduces dyspnea. Better-conditioned patients are better prepared to cooperate with their postoperative tasks, such as immediate ambulation and use of the incentive spirometer, to reduce respiratory complications. Patients who do not cooperate well or fail at rehabilitation are poor candidates for LVRS. The most important selection factor is a heterogeneous pattern of emphysema identified on computed tomography (CT) and lung perfusion scanning.

Approach to Video-Assisted Lung Volume Reduction Surgery

Video-Assisted Lung Volume Reduction Surgery (Video 26)