Asian Cardiovasc Thorac Ann 2007;15:511-514
© 2007 Asia Publishing EXchange Ltd
Novel Method of Thoracoscopic Surgery for Giant Bulla without Residual Cavity
Tomoki Utsumi, MD,
Akinori Akashi, MD,
Soichiro Funaki, MD
Department of General Thoracic Surgery, Takarazuka Municipal Hospital Hyogo, Japan
For reprint information contact: Tomoki Utsumi, MD, Tel: 81 6 6879 3152, Fax: 81 6 6879 3163, Email: utsumi{at}surg1.med.osaka-u.ac.jp, Department of Surgery, Osaka University Graduate School of Medicine, 2-2, Yamadaoka, E-1, Suita-City, Osaka 565-0871, Japan.
 |
ABSTRACT
|
|---|
A giant bulla is generally resected by thoracoscopic surgery. Resection using an automated stapling device is popular, however, a number of cartridges may be consumed and a cavity is sometimes left remaining, especially when resecting wide-based lesions. To establish a thoracoscopic surgical procedure that results in no residual cavity, we developed a method in which the roof of the bulla is resected first, followed by resection of the pulmonary parenchyma, including the base of the bulla, using a stapling device. Exposure of the base by first removing the roof facilitates determination of the resection line. Between 2003 and 2005, the procedure was attempted in 6 patients, which included one bilateral case. Conversion to a minithoracotomy was required in one patient because of bulla thickening. The operating time ranged from 80 to 150 min (median, 135 min) in the other 6 cases. Postoperative chest drainage ranged from 2 to 13 days (median, 3 days), and postoperative hospital stay was 5 to 18 days (median, 6 days). No adverse events occurred. We found this procedure to be simple and useful for complete resection of giant bullae.
|
INTRODUCTION
|
|---|
Giant bullae are generally resected in the setting of thoracoscopic surgery. Surgical staplers are effective and can be utilized without manipulating or collapsing the lesions. However, residual cavities are frequently seen postoperatively, especially in cases with wide giant bullae. Furthermore, the cost can be significant as many cartridges may be consumed. When giant bullae are resected conventionally through a thoracotomy, the cavity is opened to determine the base, then suturing or stapling is performed, focusing on the closure of each cavity.1 With this background in mind, we considered it important to develop a thoracoscopic surgical procedure for giant bulla resection, which would minimize the risk of a residual cavity, even when applied to wide giant bullae. We report the use of a novel thoracoscopic procedure for resection of giant bullae in 6 patients, which is a modification of the usual thoracotomy-based method.
|
PATIENTS AND METHODS
|
|---|
From April 2003 to March 2005, 6 patients underwent thoracoscopic surgery for giant bullae in our hospital. Their characteristics are summarized in Table 1
. All were men who ranged in age from 31 to 54 years (mean, 46 years). The sites were on the right side in 2 cases, the left side in 3, and bilateral in one. Three patients had emphysematous changes in the pulmonary parenchyma other than giant bullae, shown by preoperative computed tomography. There were no other symptoms noted. In all patients, the Hugh-Jones dyspnea grade was I and performance status was 0. Each patient was considered for surgery because a giant bulla occupied more than one third of the hemithorax or it had shown marked enlargement in follow-up examinations.
Under general anesthesia with double-lumen endobronchial intubation, the patient was placed in the decubitus position. Three ports were placed at the intersections of the midaxillary line and the 6th intercostal space, the anterior axillary line and the 4th intercostal space, and the posterior axillary line and the 5th intercostal space. A thoracoscope was inserted through the port located at the intersection of the midaxillary line and the 6th intercostal space, while the other 2 ports were used as working ports. When located, the giant bulla was punctured and collapsed with cautery to widen the view. The wall of the bulla was incised with a Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH, USA) on a line 1-cm peripheral to the border between the bulla and pulmonary parenchyma (Figure 1A). Any trabeculae inside the bulla were resected to expose the base of the bulla. While thoracoscopically ensuring the base, the wall was resected circumferentially to de-roof the bulla (Figure 1B). The remaining wall of the bulla was held longitudinally with forceps, while the pulmonary parenchyma at the edge underneath the bulla wall was cut and closed with a surgical stapler, along with the base (Figure 1C and 1D). To ensure that no air cavity remained underneath the staple line, the base was viewed thoracoscopically while setting the stapler, as shown in Figure 1C. For bullae with an especially wide base, another port was added to allow holding the remaining wall stable and in a straight line, which allowed setting the stapler in the manner noted in the report of Cooper and colleagues.2 The staple line was not reinforced in any of our 6 patients.
View larger version (122K):
[in this window]
[in a new window]
|
Figure 1. The operative procedure; (A) The wall of the perforated bulla is cut above the border between the bulla and the parenchyma (arrows); (B) Completion of circumferential resection of the wall near the bottom of the bulla; (C) The residual wall is held linearly and the pulmonary parenchyma just beneath the border (arrows) is cut with a stapling device; (D) Completion of the procedure for 2 lesions.
|
|
|
RESULTS
|
|---|
All patients survived. Conversion to a minithoracotomy was performed in one patient (case no. 5, right side), as the bulla had become thick and adhered tightly to the chest wall. This case was excluded from the following analyses: the median operative time was 135 min (range, 80–150 min; mean, 122 min). The time was longer for those with pulmonary emphysema, as shown in Table 1
. The median postoperative drainage period was 3 days (range, 2–13 days; mean, 6 days) and median postoperative hospital stay was 6 days (range, 5–18 days; mean, 9 days). Air leakage was sustained for more than 5 days in 2 cases with pulmonary emphysema, both of which healed spontaneously. There were no adverse events, such as surgical site infection, which resulted from opening the cavity of the bulla. Pre- and postoperative chest computed tomography images of a representative case are presented in Figures 2A–D. In this patient, 2 giant bullae were located in the left upper lobe and occupied the space from the apex to below the carinal level. The rest of the left lung, which was compressed before surgery, expanded to fill the whole left thoracic cavity after surgery, without leaving any residual cavities.
View larger version (93K):
[in this window]
[in a new window]
|
Figure 2. Chest computed tomography images before and after surgery; (A, B) Before surgery, 2 giant bullae are seen in the left thorax reaching the carinal level; (C, D) After surgery, the vascular shadow in the whole left thorax has expanded.
|
|
|
DISCUSSION
|
|---|
Before thoracoscopic surgery procedures became common, resection of a giant bulla was generally performed through a thoracotomy, during which narrow lesions were sutured and ligated at the base. Wide lesions were first opened longitudinally to examine the base. Originally, after opening the bulla cavity, bronchiolar orifices seen at the base were ligated, and the wall of the bulla was sewn linearly. Later, Cooper and colleagues2 reported using a stapling device instead of ligating the orifice and sewing the wall. With this method, bullae with circular-shaped bases were held linearly with forceps to allow stapling and cutting with the device, while the residual wall was used to buttress the staple line. Care was taken in both methods not leave a residual cavity postoperatively.
Resections of giant bullae have also been performed thoracoscopically with several technical variations, a stapling device and ligation with a loop being the 2 most commonly employed as in simple bullectomy procedures.3–7 However, when treating wide lesions, these methods may lead to incomplete resection, as the base cannot be confirmed. Another technique, in which the bulla is resected or ligated after being collapsed and twisted, may better visualize the border and the parenchyma to be resected, although the border of a collapsed and twisted giant bulla usually becomes round- or oval-shaped, which is not appropriate for stapling in the case of a wide lesion.5 Ligation of a wide lesion after collapsing and twisting results in a residual cavity, because it is extremely difficult to ligate the border of a bulla and parenchyma, or parenchymal side of the border, in that situation.
With this in mind, we investigated a new thoracoscopic surgical technique for resection of a giant bulla without leaving a cavity. For complete resection, it is better to open the bulla and visualize the base before resecting the pulmonary parenchyma. However, if the procedures used in the open thoracotomy methods were to be directly transferred to a thoracoscopic setting, after opening, the bulla wall would surely interfere with vision through the scope. Therefore, we employed a new method in which the roof of the bulla is resected, except for a 1-cm margin along the bottom, which is held and resected later.
We consider that our technique is advantageous for giant bulla resection, although it may be inadequate in a number of situations. For example, in a patient with severe pulmonary emphysema, it would be quite difficult to define the base of a giant bulla, even if opened using this technique. In that case, we recommend the use of a surgical stapler to resect areas of the lung showing severe emphysematous changes, using a procedure similar to that employed in thoracoscopic lung volume reduction surgery.8 Another example is when a giant bulla extends close to the hilum. De-roofing could be performed with a thoracoscopic procedure, however, resection of the pulmonary parenchyma with a surgical stapler may injure the large vessels or bronchi. In such cases, it is advisable to suture the opened giant bulla using a thoracoscopic approach or after converting to a thoracotomy, depending on the skill of the surgeon. Also, patients with narrow giant bullae, whose bases can be discerned without de-roofing, are not recommended for this technique, because the aim of de-roofing is to ascertain the base, which in turn results in defining the line to resect the pulmonary parenchyma. Thus, when the entire base can be clearly seen without opening the bulla, resection with a surgical stapler or ligation with a loop should lead to a good result. Finally, our method is not indicated for infected bullae, as the walls and surrounding pulmonary parenchyma will have become thickened with inflammation. In that situation, our method may lead to a stapling failure, as the staple legs may not completely penetrate the thick tissue. In those situations, simple opening of the bulla may be the treatment of choice.9
We encountered prolonged postoperative air leakage in 2 of 3 patients with emphysema. As long as the procedure is properly employed, it is reasonable that leakage occurs at the staple holes after puncturing the emphysematous pulmonary parenchyma. Thus, it is necessary to consider applying techniques to minimize air leakage in these patients, such as buttressing the staple lines with a strip of bovine pericardium or polyglycolic acid felt, and applying fibrin glue to the staple lines.10,11 This novel procedure for thoracoscopic giant bulla resection was found to be effective, and no cavities remained postoperatively. This method may be especially useful in cases of wide giant bullae, whereas narrow bullae can be sufficiently managed using simple resection with a surgical stapler or loop ligation.
|
REFERENCES
|
|---|
- Deslauriers J, LeBlanc P. Bullous and bleb diseases, emphysema of the lung, and lung volume reduction operations. In: Shields TW, LoCicero J, Ponn RB, editors. General thoracic surgery. 5th ed. Philadelphia: Lippincott Williams & Wilkins, 2000:1001–38.
- Cooper JD, Nelems JM, Pearson FG. Extended indications for median sternotomy in patients requiring pulmonary resection. Annals Thorac Surgery 1978;26:413–20.
- De Giacomo T, Venuta F, Rendina EA, Della Rocca G, Ciccone AM, Ricci C, et al. Video-assisted thoracoscopic treatment of giant bullae associated with emphysema. Eur J Cardiothorac Surg 1999;15:753–7.[Abstract/Free Full Text]
- Ishida T, Kohdono S, Fukuyama Y, Hamatake M, Maruyama R, Saitoh G, et al. Video-assisted thoracoscopic surgery of bullous and bleb disorders of the lung using endoscopic stapling device. Surg Laparosc Endosc 1995;5:349–53.[Medline]
- Menconi GF, Melfi FM, Mussi A, Palla A, Ambrogi MC, Angeletti CA. Treatment by VATS of giant bullous emphysema: results. Eur J Cardiothorac Surg 1998;13:66–70.[Abstract/Free Full Text]
- Tsuchida M, Nakayama K, Shinonaga M, Tatebe S, Yamaguchi A. Video-assisted thoracic surgery for thorascopic resection of giant bulla. Surg Today 1996;26:349–52.[Medline]
- Yim AP, Ho JK. Video assisted thoracoscopic staple resection of a giant bulla. Aust N Z J Surg 1996 Jul;66:495–7.[Medline]
- Kotloff RM, Tino G, Bavaria JE, Palevsky HI, Hansen-Flaschen J, Wahl PM, et al. Bilateral lung volume reduction surgery for advanced emphysema. A comparison of median sternotomy and thoracoscopic approaches. Chest 1996;110:1399–406.[Medline]
- Nomori H, Horio H, Fuyuno G, Kobayashi R, Morinaga S, Suemasu K. Opening of infectious giant bulla with use of video-assisted thoracoscopic surgery. Chest 1997;112:1670–3.[Medline]
- Cooper JD. Technique to reduce air leaks after resection of emphysematous lung. Ann Thorac Surg 1994;57:1038–9.[Abstract]
- Kawamura M, Kase K, Sawafuji M, Watanabe M, Horinouchi H, Kobayashi K. Staple-line reinforcement with a new type of polyglycolic acid felt. Surg Laparosc Endosc Percutan Tech 2001;11:43–6.[Medline]
TOP
ABSTRACT
INTRODUCTION
