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.

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.

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