Lung Volume Reduction Surgery—Video 26

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CHAPTER 26 Lung Volume Reduction Surgery—Video 26

Robert J. McKenna, Jr.

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

Order of Operative Steps

Video-assisted LVRS is performed most commonly as a staged, bilateral procedure with the patient in the lateral decubitus position. Unless there is a massive air leak after the first side is completed, the patient is turned over for LVRS on the opposite side. The area to be resected is determined by the preoperative workup. The preoperative CT and perfusion scans to determine the area to be resected (usually the upper lobes). These areas do not deflate well intraoperatively because of poor elastic recoil.

Key Points

♦ Work anteriorly to posteriorly over the top of the lung.
♦ Resection starts in the anterior segment of the upper lobe, just above the middle lobe on the right and the lingula on the left.
♦ Tiny air leaks may take weeks to heal. Limit the manipulation and contact with the lung. A severely emphysematous lung is very soft, and minimal contact with the lung, such as touching it with a stapler, can make a hole in the lung.
♦ Repeat operations to close an air leak are rarely indicated.

image 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.
image

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).
image

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.
image

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

image

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).
image

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

image

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

image

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

image

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).
image

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

Postoperative Care

♦ Extubate the patient in the operating room.
♦ Pain relief is imperative to allow patients to ambulate, cough, and use the incentive spirometer. Use an epidural catheter initially and then narcotics for pain relief. Use a patient-controlled analgesia (PCA) pump if the epidural is not working well. Pain must be controlled immediately after the operation so that uncontrolled pain does not lead to pneumonia.
♦ Respiratory care is essential.

image Early ambulation twice daily in the hallway reduces the risk of pulmonary complications.
image Aggressively use nebulizer treatments with chest physiotherapy.
image No suction is applied to the chest tubes.
image When the chest tube drainage is low, attach Heimlich valves to the chest tubes if there is still an air leak. This facilitates ambulation.
image 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.

♦ Arrhythmias, especially atrial fibrillation, occur in about 20% of patients. The cause often is hypoxemia and atelectasis.
♦ Gastrointestinal complications are common. If the patient has not had a bowel movement by day 2, aggressively use laxatives. Air swallowing, pain medicine, and the epidural can cause severe abdominal distention and even colonic perforation.

References

1 Naunheim K., et aland the NETT Research Group. Long-Term Follow-up of Patients Receiving Lung-Volume-Reduction Surgery Versus Medical Therapy for Servere Emphysema. Ann Thorac Surg. 2006;82:431-443.

2 McKenna R.j., et alfor the National Emphysema Treatment Trial (NETT) Research Group. National Emphysema Treatment Trial: A Comparision of Median Sternotomy versus VATS for Lung Volume Reduction Surgery. J Thorac Cardiovasc Surg. 2004;127:1350-1360.

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