HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS		QUICK SEARCH:   [advanced] Author: Keyword(s): Year:  Vol:  Page:

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Wickii T. Vigneswaran Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Vigneswaran, W. T. Articles by Podbielski, F. J. Search for Related Content PubMed PubMed Citation Articles by Vigneswaran, W. T. Articles by Podbielski, F. J.

Ann Thorac Surg 1997;63:1807-1809
© 1997 The Society of Thoracic Surgeons

---

How To Do It

Single-Stage Bilateral, Video-Assisted Thoracoscopic Lung Volume Reduction Operation

Division of Cardiothoracic Surgery, University of Illinois at Chicago, Chicago, Illinois

Accepted for publication January 13, 1997.

	Abstract

Top Footnotes Abstract Introduction Technique Operative Technique Results Comment References

 
Lung volume reduction (LVR) produces significant clinical and objective improvement in selected patients with diffuse emphysema. Unilateral and bilateral approaches have been successfully employed. A median sternotomy approach is the standard for bilateral LVR, whereas video-assisted thoracoscopy has been used to perform unilateral LVR. Encouraging video-assisted thoracoscopic results with sequential, staged, bilateral LVR have been shown. This report describes an alternate technique of single-stage, bilateral LVR for end-stage emphysema.

	Introduction

Top Footnotes Abstract Introduction Technique Operative Technique Results Comment References

 
In 1957 Brantigan and Mueller [1] reported a procedure by which excision of multiple wedges of emphysematous lung via a lateral thoracotomy reduced the overall lung volume and improved the patient's respiratory status. A high early mortality and lack of objective evidence, however, kept the operation from gaining wide acceptance. In the early 1990s Cooper and colleagues [2] reported bilateral excision of emphysematous lung via a median sternotomy with objective improvements in pulmonary function and a low mortality in end-stage emphysema patients.

Unilateral video-assisted thoracoscopic (VATS) lung volume reduction (LVR) with improvement in respiratory function and acceptable morbidity and mortality has also been reported [3–6]. Cumulative data from these reports suggest that bilateral versus unilateral lung resection provides greater improvement in pulmonary function and respiratory mechanics. As early ambulation and aggressive pulmonary toilet are an essential part of successful recovery in patients undergoing a volume reduction operation, the concept of VATS LVR is attractive to patients and physicians. Two groups [7, 8] have reported application of the bilateral VATS technique for LVR using a lateral approach with short-term functional improvement comparable with the open technique. This report describes an alternate VATS technique with the patient supine and a single-stage, bilateral LVR procedure.

	Technique

Top Footnotes Abstract Introduction Technique Operative Technique Results Comment References

 
Patient Selection
Patients selected for LVR are significantly incapacitated due to respiratory insufficiency resulting from chronic obstructive airway disease. Patients with cardiac failure, cerebrovascular disease, or significant hepatic or renal dysfunction are excluded. Patients are started on a monitored rehabilitation program for a 4- to 8-week period before the operation. Computed tomography of the chest and lung perfusion scans are performed to focus the operative resection. Right heart catheterization is performed in all patients; those with a mean pulmonary artery pressure greater than 45 mm Hg are excluded from operation.

	Operative Technique

Top Footnotes Abstract Introduction Technique Operative Technique Results Comment References

 
Patients are admitted the day of the operation, and a radiopaque thoracic epidural catheter is placed at the fourth to fifth thoracic vertebral level while the patient is awake. After induction of anesthesia, patients are intubated with a left-sided double-lumen endotracheal tube for lung separation. The position of the bronchial tube is verified by fiberoptic bronchoscopy. Patients are positioned supine with both arms extended over the head (Fig 1). The shoulders and upper arms are protected by placement of pillows. Inflatable bags are placed longitudinally under the scapulae on each side to be inflated by the anesthesia team for optimal body positioning during the procedure. The skin is prepared from chin to umbilicus and laterally to the posterior axillary line. This position offers satisfactory exposure for not only VATS but median sternotomy, as well as anterior/lateral thoracotomy on both sides. The shoulder bag on the initial operative side is inflated and the table rotated toward the opposite side. The bronchial tube is then clamped and the lung allowed to deflate. The first thoracoscopic port is placed anteriorly at the submammary level. Perfect hemostasis is ensured during entry to the thorax. After thoracoscopic inspection of the lung, additional ports are placed anteriorly at the level of the diaphragm, allowing passage of the stapling device through a larger intercostal space, with a third port laterally at the level of the submammary line. This port placement configuration allows for electrocautery division of adhesions at the apex and posteriorly without significant difficulty.

View larger version (20K): [in this window] [in a new window]   Fig 1. . Schematic diagram of intraoperative patient positioning for bilateral video-assisted thoracoscopic lung volume reduction procedure.

View larger version (33K): [in this window] [in a new window]   Fig 2. . Excision of lung tissue proceeds as indicated using an Endopath 45 stapling device (Ethicon Endo-Surgery, Cincinnati, OH). (A = thoracoscope; B = Endopath 45 stapler; C = lung clamp.)

At the conclusion of the procedure a 1.5-cm incision and two chest tubes are present on each side. Thoracostomy tubes are placed to water seal to limit the air leak. Patients are extubated in the operating room and transferred to the recovery area.

	Results

Top Footnotes Abstract Introduction Technique Operative Technique Results Comment References

 
Between July 1995 and October 1996, nine patients have undergone single-stage, bilateral, VATS LVR at our institution. There was no in-hospital mortality, and morbidity included prolonged air leak (>7 days) in 3 patients and refractory supraventricular tachyarrythmia in 1. Median hospital length of stay for the VATS LVR group was 11.0 days (range, 5 to 24 days). All patients were subjectively improved at 8 weeks postoperatively with a significant improvement in the forced expiratory volume in 1 second compared with preoperative values.

	Comment

Top Footnotes Abstract Introduction Technique Operative Technique Results Comment References

 
The Barnes Hospital experience with end-stage emphysema has generated renewed interest in surgical treatment of this disease. The standard median sternotomy technique for bilateral "target area" resection is most commonly used, whereas other investigators have proposed a minimally invasive approach with a potential benefit of less pulmonary morbidity in a fragile patient population. A great deal of controversy exists as to the optimal approach and best method of removal of emphysematous lung. Current reports supporting either the median sternotomy or a VATS approach to LVR exist in the literature. Proponents of the minimally invasive technique have demonstrated that unilateral LVR can be performed using the VATS technique with minimal mortality and morbidity.

Improvements observed in forced expiratory volume in 1 second, dyspnea index, and 6-minute walk test, however, have shown less improvement in unilateral VATS versus bilateral resection via median sternotomy. McKenna and associates [7] performed a retrospective analysis comparing patients undergoing bilateral and unilateral VATS LVR. Their group confirmed the superiority of the bilateral procedure in improving spirometry, relief of dyspnea, and the ability to wean from supplemental oxygen. Their technique entails sequential resection using a VATS approach in the lateral decubitus position. This method requires turning the patient intraoperatively after completion of the first side. The single-stage, bilateral VATS approach eliminates this additional time and allows for easy access to the initial operative side should urgent reexploration be necessary during work on the contralateral side, whereas lateral decubitus positioning would again require turning the patient.

We describe the technique of a single-stage, bilateral LVR performed in the supine position. The approach saves time in preparation and provides more versatile positioning for emergent thoracoscopic exploration or conversion to an open procedure. One of our patients required a muscle-sparing anterior thoracotomy due to significant adhesions that was easily accomplished with the patient in the supine position.

In our experience the anterior approach to single-stage bilateral LVR can be performed safely and efficiently using the VATS technique, with minimal morbidity and significant improvement in respiratory status.

	Footnotes

Top Footnotes Abstract Introduction Technique Operative Technique Results Comment References

 
Presented at the Movie Session of the Thirty-third Annual Meeting of The Society of Thoracic Surgeons, San Diego, CA, Feb 3-5, 1997.

Address reprint requests to Dr Vigneswaran, Division of Cardiothoracic Surgery, University of Illinois at Chicago, 840 S Wood St, M/C 958, Chicago, IL 60612.

	References

Top Footnotes Abstract Introduction Technique Operative Technique Results Comment References

 

1. Brantigan OC, Mueller E. Surgical treatment of pulmonary emphysema. Am Surg 1957;23:789–804.[Medline]
2. Cooper JD, Trulock EP, Trantafillou AN, et al. Bilateral pneumonectomy (volume reduction) for chronic obstructive pulmonary disease. J Thorac Cardiovasc Surg 1995;109:106–19.[Abstract/Free Full Text]
3. Wakabayashi A. Thoracoscopic laser pneumoplasty in the treatment of diffuse bullous emphysema. Ann Thorac Surg 1995;60:936–42.[Abstract/Free Full Text]
4. Lewis RJ, Caccavale RJ, Soser GE. VATS argon beam coagulator treatment of diffuse end-stage bilateral bullous disease of the lung. Ann Thorac Surg 1993;55:1394–9.[Abstract/Free Full Text]
5. McKenna RJ Jr, Brenner M, Gelb AF, et al. A randomized, prospective trial of stapled lung volume reduction versus laser bullectomy for diffuse emphysema. J Thorac Cardiovasc Surg 1996;111:317–22.[Abstract/Free Full Text]
6. Naunheim KS, Keller CA, Krucylak PE, et al. Unilateral VATS lung volume reduction. Ann Thorac Surg 1996;61:1092–8.[Abstract/Free Full Text]
7. McKenna RJ Jr, Brenner M, Fischel FJ, et al. Should lung reduction surgery for emphysema be unilateral or bilateral? J Thorac Cardiovasc Surg 1996;112:1331–9.[Abstract/Free Full Text]
8. Bingisser R, Zollinger A, Hauser M, et al. Bilateral volume reduction surgery for diffuse pulmonary emphysema by video-assisted thoracoscopy. J Thorac Cardiovasc Surg 1996;112:875–82.[Abstract/Free Full Text]

This article has been cited by other articles:

				M. M. DeCamp Jr., R. J. McKenna Jr., C. C. Deschamps, and M. J. Krasna Lung Volume Reduction Surgery: Technique, Operative Mortality, and Morbidity Proceedings of the ATS, May 1, 2008; 5(4): 442 - 446. [Abstract] [Full Text] [PDF]

				M. Brenner, N. M. Hanna, R. Mina-Araghi, A. F. Gelb, R. J. McKenna Jr, and H. Colt Innovative Approaches to Lung Volume Reduction for Emphysema Chest, July 1, 2004; 126(1): 238 - 248. [Abstract] [Full Text] [PDF]

				W. T Vigneswaran, E. V Chomka, V. Jelnin, M J. Hernan, and F. J Podbielski Cardiac Morphology in Lung Volume Reduction Surgery for Endstage Emphysema Asian Cardiovasc Thorac Ann, March 1, 2003; 11(1): 48 - 51. [Abstract] [Full Text] [PDF]

				M. A. de Castro Current Controversies in Surgical Therapy for Emphysema Seminars in Cardiothoracic and Vascular Anesthesia, March 1, 2000; 4(1): 26 - 30. [Abstract] [PDF]

				M. de Perrot, M. Licker, and A. Spiliopoulos Muscle-sparing anterior thoracotomy for one-stage bilateral lung volume reduction operation Ann. Thorac. Surg., August 1, 1998; 66(2): 582 - 584. [Abstract] [Full Text] [PDF]

This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Wickii T. Vigneswaran Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Vigneswaran, W. T. Articles by Podbielski, F. J. Search for Related Content PubMed PubMed Citation Articles by Vigneswaran, W. T. Articles by Podbielski, F. J.