Figure 98-1 illustrates possible port placement for patients presenting with spontaneous pneumothorax. Note that the “operative triangle” is placed in the anterior axillary region; the largest stapling port is placed in the anterior position. Exploration is begun with a 5-mm, 30-degree scope. The posterior axillary port may either be a 5-mm port or an incision to place a curved sponge stick. This access port is used to manipulate the lung for exploration. Examination of the entire lung parenchyma is undertaken with explicit attention to the apical segment of the upper lobe and the superior segment of the lower lobe. Identified blebs are stapled using a 35-mm device with 3.5-mm “blue” stapler loads and with resection of minimal lung tissue.
Port placement for spontaneous pneumothorax. The operative triangle is located in the anterior axillary region, with largest stapling port in the anterior position.
In a multi-institutional study reported by Naunheim et al.,10 blebs were identified in more than one lobe in 10% of the patients, and in 9% of patients, no bleb could be identified. When no discrete bleb is identified, great care should be taken to look for areas of scarring or visceral pleural changes on the lung that could represent changes from a decompressed bleb. Even if no abnormalities are found, apical stapling of the upper lobe still should be performed. It is important to resect as little normal lung as possible, especially taking note that in young patients the elastic recoil of the lung is so effective that seemingly small resections can result in a significant loss of lung volume. Specimens are removed from the chest either in a protected bag or within the confines of the largest port. Pleural abrasion then should be performed; my present preference is to perform an apical pleurectomy, and this can easily be performed thoracoscopically.
Mechanical abrasion with the aid of a folded Bovie scratch pad or endoscopic peanut can complete the procedure for the lower lateral chest cavity. Talc insufflation should be avoided because the long-term effects are not well defined, and the severe granulomatous reaction may impede future possible thoracic interventions. A single no. 24 chest tube is placed into the most inferior (5-mm) port; thoracoscopic visualization of the tube placement is always performed. To minimize barotrauma to the dependent lung, the contralateral “down” lung is clamped during reexpansion of the operative lung. Active expansion of the lung during ventilation is observed. The chest tube is placed on suction and kept on suction during postoperative day 1 to help promote pleural symphysis. The tube may be removed and the patient discharged on postoperative day 2, provided there are no persistent air leaks.
Resection of Bullous and Giant Bullous Disease
After initial placement of the double-lumen tube, single-lung ventilation should commence as soon as possible to avoid further hyperinflation of the bullous disease on the operative side and to facilitate decompression of the bulla. Figure 98-2 illustrates operative port placement for giant bullous disease (Fig. 98-3). Note that the “operative triangle” is shifted more caudad but still maintains an anterior orientation. If the bullous lesion is based in an inferior portion of the chest, the triangle may be shifted even lower. Again, a 5-mm, 30-degree scope is placed to explore the chest initially. Relatively normal or spared lung should become atelectatic at a faster rate than lung tissue with bullous disease, exaggerating the demarcation between the most diseased and the relatively normal lung parenchyma. The operative course is enhanced by early decompression of the giant bulla or bullous area using a long Bovie-tip electrocautery (Fig. 98-4). The now deflated bulla is grasped at its apex, and the demarcation between bullous and nonbullous disease is delineated with either a sponge stick or thoracoscopic Landreneau masher (Pilling Surgical, Teleflex, Inc., Research Triangle Park, NC) (Fig. 98-5). The base of the bulla then is plicated using a 45-mm long linear stapler with buttressed support (Fig. 98-6).
Port placement for giant bullous disease. The operative triangle is shifted caudad but still maintains an anterior orientation.
Intraoperative photograph of giant bulla.
The giant bulla or bullous area is decompressed using a long Bovie-tip electrocautery.
After deflating the bulla, it is grasped at its apex. The line between bullous and nonbullous disease is delineated with the aid of a sponge stick or Landreneau masher (latter shown in figure).
The base of the bulla then is plicated using a 45-mm long linear stapler with buttressed support.
Great care is taken to plicate the bulla completely to avoid any residuum while retaining as much normal tissue as possible. The resected bulla then is placed in an endoscopic bag and removed from the chest in a protected fashion. It is important to remove the tissue in this manner to avoid seeding the chest or chest wall in the case of occult carcinoma or infection. Pleural management with apical pleurectomy and inferior abrasion then should be performed. In patients with limited lung reexpansion, consideration may be given to the development of an apical pleural tent. One 24 chest tube is left in place; preferentially, this should be placed on water seal. Bullae present in the mid to lower lung field (Fig. 98-7) can appear to be intraparenchymal. However, the resection principle is similar to the giant bullae in the apex (Fig. 98-8).
Photograph of bulla postresection.
It is important to note that the surgical approach to recurrent pneumothorax due to catamenial pneumothorax is significantly different from a standard bleb resection. Treating these patients in the traditional manner will predictably fail. Initial consideration in these patients is ovulation suppression with hormonal therapy, such as birth control pills. I routinely refer these patients to a GYN specialist in this regard. This may be an appealing approach to patients nearing menopause. In regard to surgical therapy, although a thorough exploration of blebs and/or endometrial lung implants is performed, the primary pathology tends to be diaphragmatic fenestrations. These should be approached thoracoscopically with primary repair of any fenestrations, and then placement of biologic patch on the diaphragmatic surface. The initial ports are placed low on the chest cavity to enable better access to the diaphragm.