MMCTS
(April 25, 2005). doi:10.1510/mmcts.2004.000265
Copyright © 2005 European Association for Cardio-thoracic Surgery
Procedure
Video-assisted thoracoscopic surgery (VATS) bullectomy for emphysematous/bullous lung disease
Calvin S.H. Ng and
Anthony P.C. Yim
Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, NT, Hong Kong SAR, China
* Corresponding author: * Tel.: +852-26-322629; fax: +852-26-478273. E-mail: yimap{at}cuhk.edu.hk
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Summary
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Video-assisted thoracic surgery (VATS) is now considered by many to be the approach of choice in bullectomy. We present our technique below.
Key Words: Bullectomy • Emphysema • Endoscopic stapler • Video-assisted thoracic surgery
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Introduction
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Pulmonary bulla(e) that is associated with emphysema as a result of chronic smoking is one of the commonest form of bullous disease. Other forms of lung bulla(e) may be associated with  -1-antitrypsin deficiency or other genetic defects of connective tissue, or be idiopathic, particularly in young male smokers. Bullous disease usually involves the upper lobes, although it may be present in any lobe of the lung, with sizes ranging from 1 to more than 20 cm (Photos 1, 2, 3). In some instances, the pulmonary bullae can be monitored and conservatively treated. Indications for surgical intervention include the presence of a very large bulla which may be expanding; causing compression of adjacent lung tissue leading to dyspnoea and physical disability; as a manifestation of lung carcinoma; or associated with the development of recurrent pneumothorax or infection [1].
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Photo 1 Chest radiograph of a 65-year-old gentleman with a large left lower lung bulla causing some contralateral mediastinal (tracheal) shifting.
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Photo 2 Computed tomography scan of the large left bulla causing significant mediastinal and tracheal shifting.
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Photo 3 Computed tomography scan showing left bulla extending and occupying almost the entire left lower pleural cavity with associated adjacent lung parenchyma compression.
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Over the years, a number of thoracoscopic techniques for bulla treatment have been investigated. These include thoracoscopic bullous endoloop ligation (first described in 1991 using a pre-tied Roeder knot [2]), thoracoscopic intracavitary bullous drainage [3], thoracoscopic laser bullae ablation [4] and thoracoscopic bullous fibrin glue treatment [5], all of which have been reported with variable success. However, the latter techniques are suitable only for small bulla(e). Endoscopic stapled bullectomy remains the preferred procedure for bullectomy [6,7]. We describe our institution's surgical technique and management of these patients.
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Surgical preparation and technique
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The chest is the most suitable body cavity for the minimal access approach, because once the lung is collapsed (with selective one lung ventilation), there is plenty of room for instrument manoeuvring. The use of carbon dioxide insufflation and hence valved ports, is therefore unnecessary. In fact, there is evidence that thoracic carbon dioxide insufflation during VATS has an adverse effect on the patient's hemodynamics compared with selective one lung ventilation [8].
There are additional strategies in VATS that can assist in minimizing chest wall trauma and hence post-operative pain [9]: - avoiding the use of trocar ports by introducing instruments directly through the wound to avoid intercostals nerve compression;
- avoiding torquing of the thoracoscope by visualizing with an angled lens (30° scope);
- using smaller telescopes (5 mm) when clinically allowed;
- delivering specimens through the anterior port because the anterior intercostals spaces are wider.
The patient should be in full lateral decubitus position with flexion of the operating table to 30° just inferior to the level of the nipples, to open up the upper intercostals spaces for thoracoscope insertion and instrumentation [9]. The team (principle surgeon, an assistant, scrub nurse and anesthesiologist) remains in the same position during the procedure. Under general anesthesia, selective one-lung ventilation should be confirmed with the anesthesiologist prior to port incision. Patients with severe underlying lung disease or poor lung function may not be able to tolerate the selective one-lung ventilation during general anesthesia. We advocate the use of the conventional thoracic instruments like the sponge-holding forceps whenever possible because they are less expensive and are more familiar to the surgeon [10].
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Surgical procedure
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1. Incision and port placement
The 3-port technique is utilized for the procedure. The thoracoscope port is placed at the 7th or 8th intercostals space along the mid-axillary line for the insertion of a 0° telescope (which may be changed to a 30° telescope as necessary). Two further instrument ports should be inserted under direct thoracoscopic vision (Photo 4):- in front of the tip of the scapula along the posterior axillary line;
- 5th or 6th intercostals space, anterior axillary line.
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Photo 4 Positions of ports for VATS bullectomy: the inferior thoracoscope port at 7th or 8th intercostals space mid-axillary line, posterior port in front of the tip of the scapula posterior axillary line, and anterior port 5th or 6th intercostals space anterior axillary line.
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Additional ports may be made for lung retraction, but this is rarely necessary. The trocar sites should be at a suitable distance from the target bulla(e) to provide space for manipulation. Furthermore, the instrument and camera ports should be sufficiently far apart in a "triangulation" manner to prevent instrument "fencing", and be within the same 180° arc to avoid mirror imaging. In female patients, an attempt should be made to strategically place the instrument ports over the submammary fold to improve cosmesis.
2. Exploration
The entire hemithorax is carefully examined and the target region with the bulla(e) identified (Video 1). Blunt instruments such as the sponge-holding forceps may be used to help collapse the lung, and for manipulation to complete the exploration. The minimal amount of lung holding and manipulation should be done with atraumatic instruments to avoid lung injury and subsequent air leak. The large bulla(e) can be punctured and collapsed with diathermy to improve the thoracoscopic view, to allow more room for instrumentation, and to better delineate the borders of the bulla(e) with the healthy lung tissue (Video 2). Pleural adhesions may be present and require adhesiolysis to facilitate complete lung collapse and achieve a good operating field. Adequate traction and good hemostasis are important during adhesiolysis (Video 3).
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Video 1 After introduction of the thoracoscope, the entire hemithorax is carefully examined for the target region with the bulla(e), adhesions and any associated pathology.
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Video 2 The large bulla(e) is punctured with diathermy to allow collapse improving the thoracoscopic view and enable instrumentation.
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Video 3 Pleural adhesiolysis is facilitated by good tissue traction, and careful hemostasis by diathermy is important.
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3. Release of the inferior pulmonary ligament
The inferior pulmonary ligament is divided up to the inferior pulmonary vein. Adequate traction of the inferior part of the lower lobe with atraumatic instruments (such as sponge-holding forceps), and use of mounted dental swabs for blunt dissection can significantly facilitate this process (Video 4).
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Video 4 The inferior pulmonary ligament is divided up to the inferior pulmonary vein.
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4. Stapled resection of bulla(e)
The edge of the bulla(e) can be delineated by thoracoscopic vision and through instrumentation. The endoscopic stapler resection line, which should be across relatively healthier lung tissue, is marked by sponge-holding forceps (Video 5). Digital dilatation of the port site to allow admission of 2 fingers' breath may be required to facilitate endoscopic stapler insertion into the pleural cavity. Endoscopic stapled bullectomy with mounted bovine pericardial buttress reinforcement (Peri-Strips Dry®, MMCTSLink 29) is performed. It is important not to cross staples to avoid staple malfunctioning and air leak from staple line (Video 6).
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Video 5 The stapler resection line is identified across relatively healthier lung tissue and is marked by sponge-holding forceps.
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Video 6 Endoscopic stapled bullectomy is performed with mounted bovine pericardial buttress reinforcement.
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End of the procedure
The staple line, areas of adhesiolysis and port sites are inspected for bleeding and hemostasis secured (Video 7). The pleural cavity is irrigated with warm saline. Through the anterior and inferior port sites, two 24Fr chest drains are positioned under direct videoscopic vision, one to the apex lying antero-laterally, and the other to the lower pleural cavity lying posteriorly. The lung is then reinflated under direct vision, and layered closure of the stab wounds complete the operation. The drains are connected to low suction (10 cm H2O). If postoperative chest radiograph shows full lung expansion, the drains are then put on waterseal only (Photo 5).
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Video 7 The staple line, areas of adhesiolysis and port sites are inspected for bleeding and hemostasis secured.
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Technical aspects
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Complications associated with the technique include air leak from the staple line, especially in emphysematous patients [11], which can be greatly reduced by pericardial buttress reinforcement [12]. Gentle handling of the lung tissue, ensuring the staple line isover healthy lung tissue, and avoiding crossing of staple lines are all important in reducing post-operative air leak, which can carry significant morbidity especially in patients with poor pre-morbid status. Occasionally, the staple lines may need fibrin glue reinforcement. Furthermore, we have previously reported endoscopic staple cutter malfunctioning as a potential hazard [11]. Careful haemostasis is also paramount in reducing morbidity, as these patients usually have a low functional reserve, therefore prolong chest tube drainage, re-operation for haemostasis, and clot retention with empyema is best avoided.
Additional side holes may be cut into the more proximal part of the chest tube to facilitate effective air and fluid drainage. We do not advocate high suction to the chest drain because it may propagate any air leak, particularly in patients with emphysematous lungs.
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Results
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The pre-operative and post-operative pulmonary function test results are summarized in Table 1. The patient describes improvement in exercise tolerance from 1 flight of stairs prior to VATS bullectomy to 3 flights of stairs at 9 months post-operatively.
There are no major studies in the English literature describing the results and complication rates following VATS bullectomy for emphysematous/bullous lung disease. However, the results for VATS bullectomy in the management of primary spontaneous pneumothorax are summarized in the table in Ng CSH, Rocco G, Yim APC. Videoendoscopic treatment of pneumothorax – doi:10.1510/mmcts.2004.000349.
In a retrospective series by De Giacomo et al., VATS bullectomy for select patients with emphysematous bullous disease resulted in similar pulmonary functional improvements when compared with comparable group undergoing lung volume reduction surgery [13]. At 6 months following VATS bullectomy, significant improvements in FEV1, FVC, TLC, RV, DLCO, PaO2, PaCO2 and 6 min walking test were seen compared with pre-operative values [13]. These findings compliment those of O'Donnell et al., who also found symptom of chronic breathlessness improved significantly following bullectomy [14]. Furthermore, no mortality was recorded in this small selected group undergoing VATS bullectomy for end-stage emphysema [13]. The two most common complications include prolonged air leak of more than 7 days reported in 46%, and subcutaneous emphysema in 53% of VATS bullectomy patients. It is important to note that the pre-operative size of bullae is a significant predictor of expected increase of postoperative FEV1 and improvement in ventilatory capacity following bullectomy [15]. Potential complications of buttressing with pericardial strips include local inflammation and infection leading to delayed erosion into the airways, which rarely can present with metalloptysis [16].
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References
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- Ng CSH, Sihoe ADL, Wan S, Lee TW, Arifi AA, Yim APC. Giant pulmonary bulla. Can Respir J 2001;8:369–371.[Medline]
- Nathanson LK, Shimi SM, Wood RA, Cuschieri A. Videothoracoscopic ligation of bulla and pleurectomy for spontaneous pneumothorax. Ann Thorac Surg 1991;52:316–319.[Abstract]
- Urschel JD, Dickout WJ. Thoracoscopic intracavitary drainage for pneumothorax secondary to bullous emphysema. Can J Surg 1993;36:548–550.[Medline]
- Brenner M, Kayaleh RA, Milne EN, Della Bella L, Osann K, Tadir Y, Berns MW, Wilson AF. Thoracoscopic laser ablation of pulmonary bullae. Radiographic selection and treatment response. J Thorac Cardiovasc Surg 1994;107:883–890.[Abstract/Free Full Text]
- Hillerdal G, Gustafsson G, Wegenius G, Englesson S, Hedenstrom H, Hedenstierna G. Large emphysematous bullae. Successful treatment with thoracoscopic technique using fibrin glue in poor-risk patients. Chest 1995;107:1450–1453.[Abstract/Free Full Text]
- Yim APC, Ng CSH. Thoracoscopic management of spontaneous pneumothorax. Curr Opin Pulm Med 2001;7:210–214.[Medline]
- Ng CS, Wan S, Lee TW, Wan IY, Arifi AA, Yim AP. Video-assisted thoracic surgery in spontaneous pneumothorax. Can Respir J 2002;9:122–127.[Medline]
- Brock H, Rieger R, Gabriel C, Polz W, Moosbauer W, Necek S. Haemodynamic changes during thoracoscopic surgery the effects of one-lung ventilation compared with carbon dioxide insufflation. Anaesthesia 2000;55:10–16.[CrossRef][Medline]
- Yim AP. Minimizing chest wall trauma in video assisted thoracic surgery. J Thorac Cardiovasc Surg 1995;109:1255–1256.
- Yim APC. Cost containment strategies in video assisted thoracoscopic surgery – An Asian perspective. Surg Endosc 1996;10:1198–1200.[CrossRef][Medline]
- Yim APC, Liu HP. Complications and failures of video-assisted thoracic surgery: experience from two centres in Asia. Ann Thorac Surg 1996;61:538–541.[Abstract/Free Full Text]
- Hazelrigg SR, Boley TM, Naunheim KS, Magee MJ, Lawyer C, Henkle JQ, Keller CN. Effect of bovine pericardial strips on air leak after stapled pulmonary resection. Ann Thorac Surg 1997;63:1573–1575.[Abstract/Free Full Text]
- De Giacomo T, Rendina EA, Venuta F, Moretti M, Mercadante E, Mohsen I, Filice MJ, Coloni GF. Bullectomy is comparable to lung volume reduction in patients with end-stage emphysema. Eur J Cardiothorac Surg 2002;22:357–362.[Abstract/Free Full Text]
- O'Donnell DE, Webb KA, Bertley JC, Chau LK, Conlan AA. Mechanisms of relief of exertional breathlessness following unilateral bullectomy and lung volume reduction surgery in emphysema. Chest 1996;110:18–27.[Abstract/Free Full Text]
- Baldi S, Palla A, Mussi A, Falaschi F, Carrozzi L, Giuntini C, Angeletti CA. Influence of bulla volume on postbullectomy outcome. Can Respir J 2001;8:233–238.[Medline]
- Shamji MF, Maziak DE, Shamji FM, Matzinger FR, Perkins DG. Surgical staple metalloptysis after apical bullectomy: a reaction to bovine pericardium? Ann Thorac Surg 2002;74:258–261.[Abstract/Free Full Text]
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Summary
Introduction