Resection of Pulmonary Blebs and Bullae—Video 27

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CHAPTER 27 Resection of Pulmonary Blebs and Bullae—Video 27

Cynthia S. Chin, Scott J. Swanson

Introduction

One of the earliest and most widespread uses for video-assisted thoracic surgery (VATS) was for treatment of patients with spontaneous pneumothoraces. Bleb resection by VATS has become a standard procedure, but the method for pleurodesis remains controversial. Studies of treatment of spontaneous pneumothorax have not been able to show one method of pleurodesis to be more successful than another. Video-assisted resection of bullae is part of lung volume reduction surgery for the treatment end-stage emphysema. Indications for this type of operation are too extensive to discuss in this chapter, which reviews important points for bleb and bullae resection.

Approach to Video-Assisted Resection of Pulmonary Blebs and Bullae

Order of Operative Steps

The order of the steps of the operation is lysis of adhesions, visualization and palpation of the bleb, resection planning, resection with pericardial strips, and checking for air leaks. The final step of pleurodesis is discussed in Chapter 21.

Key Points

♦ Adhesions may be present secondary to previous pneumothoraces and pleural irritation.

♦ Lung malignancy has been found within blebs and bullae.

Video-Assisted Resection of Pulmonary Blebs and Bullae (Video 27)

Step 1. Port Placement

♦ Place the camera port in the seventh intercostal space in the anterior axillary line; it is modified depending on heart size.

♦ Place the access port in the fourth intercostal space in the mid-axillary line.

♦ Place the posterior port in the sixth intercostal space just inferior to the tip of the scapula.

Step 2. Lysis of Adhesions

♦ Exposure: Retract the lung away from the adhesion.

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

♦ Patients may have pleural adhesions from the pleural irritation that occurs with a previous pneumothorax. Lyse these adhesions so the entire lung can be mobilized (Figure 27-1).

♦ Adhesions to the lateral and posterior walls are evident with lung isolation. However, adhesions on the medial wall may be less obvious.

♦ If there is tension on the lung as it is mobilized, be wary of medial adhesions. Take down these adhesions with an electrocautery or ultrasonic dissector.

♦ Failure to recognize an adhesion may lead to torn visceral pleura. In this patient population, this may become the source of a prolonged postoperative air leak.

Figure 27-1 Lysis of adhesions with an ultrasonic scalpel.

Step 4. Resection Planning

♦ Exposure: Retract the lung with a ring forceps through the posterior port. Place a second pair of ring forceps through the anterior port to plan the line of resection.

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

♦ The two ring forceps are used in the anterior and posterior ports to help plan the resection.

♦ One ring should hold the lung, and the other ring should be placed where the stapler will be fired.

♦ Adjustments can be made more easily with a ring forceps than with the larger stapler.

♦ Compress the lung with a ring forceps to allow the stapler to slide across the lung more readily.

Step 5. Resection with Pericardial Strips

♦ Exposure: A ring forceps through the posterior port stabilizes the lung.

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

♦ It is best to bring the stapler through the anterior access port because the rib spaces are wider anteriorly and because there is less chance of postoperative neuralgia from the relatively large and rigid stapler.

♦ Reinforce the staple lines with bovine pericardium or polytetrafluorethylene if the lung parenchyma is very emphysematous (Figure 27-3). In certain patient populations, the use of these materials has been shown to decrease postoperative air leaks and chest tube duration.

♦ For patients with a spontaneous pneumothorax caused by an isolated bleb, we usually do not reinforce the staple line unless the lung parenchyma appears to be abnormal. For patients who have more diffuse lung disease, we buttress the staple line.

♦ After the bleb is resected, bring it out through the anterior access port in an EndoCATCH bag (Covidien, Mansfield, Mass), to protect the port site in case of an incidental lung cancer or subclinical infection, such as Mycobacteria avium-intracellulare.

Figure 27-3 Wedge resection of a bleb using pericardial strips.

Step 6. Checking for Air Leaks

♦ Exposure: Bring a dental pledget on a long Allis clamp through the posterior port to gently hold the staple line in water while the lung is reinflated.

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

♦ To check for residual air leaks, place a dental pledget on a long Allis clamp, and bring it in through the posterior port. Use this to hold the area of interest down when the lung is reinflated.

♦ Instill water in the chest cavity and reinflate the lung.

♦ If there is no air leak, isolate the lung again, and place two chest tubes.

♦ Place the camera in the posterior port to confirm good reinflation of the lung.

Related

Atlas of Minimally Invasive Thoracic Surgery (Vats)