Historically, LVRS was accomplished via a median sternotomy. This is an approach that provides excellent exposure and a minimum of incisional morbidity. However, as comfort with thoracoscopic approaches to disease has increased, the majority of these procedures are now done via a VATS approach. We describe here a technique for performing a bilateral VATS in the supine patient, using buttressed staple lines. It is worth noting, however, that fairly uniform results have been obtained using a wide array of surgical strategies, including bilateral and unilateral approaches, open and thoracoscopic operations, and buttressed or unbuttressed staplers.
Many patients with severe emphysema have a significant element of chronic bronchitis with increased sputum production. Following induction of anesthesia, a single lumen tube is placed and flexible bronchoscopy is carried out to suction secretions and obtain a specimen for culture and for rapid gram stain to guide perioperative antibiotics. If thick, tenacious secretions are encountered, a minitracheostomy may be inserted at the end of the operative procedure to facilitate postoperative pulmonary toilet. Following bronchoscopy, the single lumen endotracheal tube is replaced with a left-sided double lumen tube.
The patient is positioned on the table with a padded roll beneath the shoulders, hips, and along the spine. The arms are then suspended, padded carefully above the patient's head, and affixed to a support bar. This position provides sufficient access to allow placement of three thoracoscopic ports; a camera port in the midaxillary line at the ninth interspace, an assistant port in the posterior axillary line at the eighth interspace, and a working port just medial to the anterior axillary line in the fifth interspace (Fig. 99-3).
A. Patient positioning for bilateral VATS LVRS. With the arms protected above the patient's head, and rolls placed beneath the patient's shoulders, hips, and spine, access to both pleural spaces can be accomplished without repositioning. B. Three thoracoscopic ports are placed; a camera port in the midaxillary line at the ninth interspace, an assistant port in the posterior axillary line at the eighth interspace, and a working port just medial to the anterior axillary line in the fifth interspace.
Most candidates for LVRS have upper lobe predominant disease. Several minutes after ventilation is suspended to the right lung, the right middle and lower lobes are usually well deflated and become progressively atelectatic. The pulmonary ligament is divided and adhesions are taken down under direct vision. Dense adhesions are not common but may be encountered if there have been prior episodes of pneumonia. We, very rarely, might use an extrapleural dissection adjacent to adhesions to avoid injuring the fragile lung parenchyma.
For upper lobe disease, 70% to 80% of the right upper lobe is excised with multiple applications of a linear stapler buttressed with strips of bovine pericardium. It is often easier to apply the stapler to the deflated lung and this can rapidly be accomplished by using the cautery to fenestrate the apex of the right upper lobe (Fig. 99-4). The marked collateral ventilation leads to prompt collapse. A long, straight intestinal clamp can be applied to the lung to create a linear “crush” mark before application of the linear stapler (Fig. 99-5). We currently staple straight across the upper lobe beginning medially above the hilum and ending up just above the upper extent of the oblique fissure. Care should be taken to avoid crossing the fissure as this may damage the superior segment of the lower lobe (Fig. 99-6). In addition, stapling across the fissure may tether the superior segment of the lower lobe to the remaining upper lobe and prevent the superior segment from fully expanding and filling the apex of the chest. It is important to remember that the goal is to adequately reduce volume, not to remove all of the diseased lung.
Cautery can be used to facilitate deflation of the upper lobe. This is performed on an area that will be excised and makes it easier to apply mechanical staplers.
The lung is marked with an atraumatic clamp to guide the generous wedge resection.
The wedge is performed with a buttressed stapler with all due care to avoid injury of the superior segment of the lower lobe.
Occasionally, the apex of the upper lobe will be densely adherent to the apex of the chest and to the superior mediastinum. In such cases, it may be easier to first transect the upper lobe as described above before attempting to dissect the apical and mediastinal adhesions (Fig. 99-7). Once the transection has been accomplished, the specimen can be more easily detached from the chest wall and mediastinum using blunt or sharp dissection, cautery, or even a linear stapler leaving a small remnant of the lung attached to the mediastinum if necessary. It is imperative to avoid injury to the phrenic nerves—a complication that will severely compromise postoperative recovery.
It is sometimes easier to perform the wedge resection before separating the pleural adhesions. If there are dense mediastinal adhesions, the phrenic nerve must be identified and protected. A paralyzed diaphragm is catastrophic in these patients. If the adhesions are so dense that the phrenic nerve is not well identified, it is better to leave a little lung parenchyma attached to the mediastinal pleura.
Following the upper lobe resection, the chest is partially filled with warm saline and the lung is gently inflated. Air leaks at this time are unusual but the reexpanded, remaining lung often does not completely fill the apex of the chest. We have explored the use of a pleural tent in this situation but now reserve it for rare instances, in particular when the remaining lung remains tethered in the chest by virtue of adhesions to the chest wall or diaphragm. It has not been our practice to perform mechanical or talc pleurodesis, even if the patient is not a potential candidate for subsequent lung transplantation. The efficacy of pleurodesis is questionable and the morbidity can be burdensome.
Two chest tubes are placed in the pleural space via the anterior and middle axillary port sites (Fig. 99-8). The posterior tube is brought across the dome of the diaphragm and halfway up the posterior chest. The anterior tube is brought to the apex of the chest near the mediastinum. Recently, the authors have been using a single chest tube after a straightforward resection with no intraoperative air leaks identified.
Chest tube position at the completion of the procedure.
Ventilation is shifted from the left lung to the right lung and similar port sites are placed on the left side. With upper lobe predominant disease, the goal is to excise the superior subdivision of the left upper lobe leaving the lingula intact, as this is usually much less diseased. The left pulmonary ligament is usually divided but this requires displacement of the heart. If exposure is limited, the ligament is left intact and adhesions between the left lower lobe and the diaphragm are taken down. Unlike the anatomic situation on the right side, the superior segment of the left lower lobe usually reaches easily to the apex of the chest even without division of the pulmonary ligament.
The upper half to two-thirds of the left upper lobe is excised with multiple applications of the linear stapler. This is facilitated by deflating the apex of the upper lobe with cautery puncture. The long, straight intestinal clamp is often useful in helping to identify and demarcate the proposed line of excision. The line of excision is nearly parallel to the oblique fissure separating the upper and lower lobes. Similar to the right side, care is taken to avoid stapling across the fissure into the superior segment of the left upper lobe (Fig. 99-9).
A generous left upper lobe wedge is shown. Most of the lingula is left in place.
Following left upper lobe excision, the lung is reinflated and inspected for air leaks. Two chest tubes are placed in a similar manner to the right-sided tubes. Virtually all patients are extubated in the operating room. If excessive secretions are present following the procedure or during the initial bronchoscopy, a 4-mm diameter minitracheostomy is inserted at the time of extubation to facilitate aggressive pulmonary toilet.