Ann Thorac Surg 1998;66:1833-1834
© 1998 The Society of Thoracic Surgeons
How to Do It
Thoracoscopic pleural tent
Federico Venuta, MDa,
Tiziano De Giacomo, MDa,
Erino A. Rendina, MDa,
Costante Ricci, MDa,
Giorgio Furio Coloni, MDa
a Department of Thoracic Surgery, University of Rome "La Sapienza", Rome, Italy
Accepted for publication June 11, 1998.
Address reprint requests to Dr Venuta, Cattedra di Chirurgia Toracica, Policlinico Umberto I, University of Rome "La Sapienza", V.le del Policlinico, 00100 Rome, Italy
e-mail: (fevenuta{at}tin.it)
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Abstract
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Lung volume reduction has been performed in patients with advanced emphysema to relieve dyspnea and improve exercise tolerance. Median sternotomy and video-assisted thoracoscopy have been proposed as equally adequate approaches; however, prolonged postoperative air leakage is the most prevalent complication in all series. For this reason, on the basis of the experience achieved with the median sternotomy approach, buttressing of the suture line with different materials and techniques for space reduction have been proposed. We describe a technique to create a pleural tent after thoracoscopic volume reduction. The thoracoscopic creation of a pleural tent is feasible and results in a duration of postoperative air leaks and hospital stays similar to that achieved with stapler line buttressing.
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Introduction
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Lung volume reduction by means of automatic staplers is currently performed in patients with advanced emphysema to reduce the thoracic volume, improve exercise tolerance, and relieve dyspnea. However, emphysematous lungs are particularly prone to tearing, and these procedures may be associated with prolonged postoperative air leaks [1]. Ideally, treatment begins with prevention: because airtight sealing of the suture line is virtually impossible, it is important that the residual lung parenchyma completely fills the pleural cavity. The use of different materials to buttress the suture line [1–5] and alternative techniques to reduce the pleural space have been proposed. In particular, the creation of a pleural tent, along with buttressing using bovine pericardial strips, has been demonstrated to be effective during lung volume reduction through a median sternotomy [1, 5]. We describe a technique to create a pleural tent to reduce air leaks after thoracoscopic lung volume reduction.
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Technique and results
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Thoracoscopic lung volume reduction was performed through three ports. The Endo GIA 45 (Ethicon Endosurgery, Cincinnati, OH) was used to resect 20% to 30% of the lung parenchyma. After completion of lung volume reduction we created thoracoscopically an extended pleural tent to reduce the pleural space, cover and protect the suture line immediately after the resection, and attempt to reduce postoperative air leaks. Blind finger dissection of the extrapleural space was started at the level of the lower insertion port. As soon as an extrapleural pocket was created, a traction clamp was placed on the parietal pleura from inside the thoracic cavity under visual control and the thoracoscope was then inserted inside the extrapleural space. A thoracoscope with an operative channel facilitates dissection of the extrapleural space; swabs and cherry dissectors also can be inserted parallel to the thoracoscope through the same port. The parietal pleura is easily dissected from the chest wall, and tough adhesions can be coagulated and sectioned with scissors under direct control, reducing the chances of bleeding. Once the level of the other ports is reached, the surgeon can carefully insert additional dissecting tools in the extrapleural space, paying attention not to enlarge the pleural incisions. The apical pleura is completely freed from the chest wall and the dissection is completed on the mediastinal side, tailoring a cap for the residual lung. Before the chest tubes are inserted, the parietal pleura incision at the level of the superior port is closed from the inside with clips; the lower ports are used to insert two chest drainage tubes inside the chest cavity (inside the intrapleural space). At this level, the upper part of the pleural incision is secured to the chest wall with clips, and the extrapleural space is closed, leaving inferiorly a tunnel for the chest tubes. This strategy does not ensure a complete sealing of the extrapleural space; however, blood quickly coagulates in the lower part of the extrapleural space and closes any small hole left. In this way, the extrapleural pocket is quickly filled with fluid (Fig 1). The creation of a thoracoscopic pleural tent in 10 consecutive patients undergoing lung volume reduction (9 unilateral and 1 bilateral) led to a reduction in both postoperative air leaks and hospital stay (6.1 ± 2.1 and 9.8 ± 1.6 days, respectively).
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Fig 1. Postoperative chest radiograph after right unilateral thoracoscopic lung volume reduction for emphysema showing the extrapleural cap designed by the pleural tent (arrows) and fluid accumulated outside it.
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Comment
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Emphysematous lungs pose a number of problems when a pulmonary resection is planned. Even when a lobectomy or a wedge resection for lung cancer is performed, air leaks from the interlobar fissures or the stapler line are frequent. Incomplete lung reexpansion may require prolonged hospitalization and increase the risk of complications. Lung volume reduction, in particular when performed thoracoscopically, may pose additional problems. The lung parenchyma has to be completely deflated to allow gentle and atraumatic manipulation of the surface without injuring the visceral pleura; coagulation and section of adhesions may result in air leaks. Furthermore, video-assisted techniques have the potential for more manipulation of the lung. The staple line is usually long and an interruption between two subsequent firing lines is possible. Thoracoscopic staplers are shorter than standard GIA staplers, and more cartridges are usually fired. The staple lines have been buttressed or protected in many different ways to reduce air leaks and allow immediate and complete filling of the pleural cavity. Several materials have been used for reinforcement: fibrin glue [2], polydioxanone ribbons [6], Teflon felts [7], a nonwoven fabric of polyglycolic acid as a patch [8], and expanded polytetrafluoroethylene [3]. The use of bovine pericardial sleeves has gained popularity in lung volume reduction [2, 4, 5, 9], improving postoperative outcome without causing complications. However, the cost of this material is still high, particularly when the sleeves have to be used to reinforce numerous stapler lines for bilateral lung volume reduction. In our experience, preoperative work-up and pulmonary rehabilitation absorb most of the costs of this operation.
The creation of a pleural tent has been added to staple line buttressing by Cooper and associates [1, 5] while performing the procedure via median sternotomy, to reduce postoperative air leaks. This technique has been described in open lung operations [10–13] to prevent postoperative spaces after resection for pulmonary tuberculosis, and more recently it has been proposed after upper lobectomy for lung cancer (Robinson LA, personal communication, 1997), proving to be an excellent tool.
We have demonstrated that thoracoscopic procedures also may benefit from this excellent means of prevention of air leaks. Technical details have been devised to obtain morphologic and functional results similar to those described in open operations. We have employed this technique in 10 patients undergoing thoracoscopic lung volume reduction and 1 patient undergoing thoracoscopic left upper lobectomy for lung cancer. In emphysema patients the duration of postoperative air leaks and hospitalization was comparable with that obtained by other groups with stapler line buttressing, but the cost of the procedure was obviously lower. Further randomized studies are required to assess the real effectiveness of this technique, alone or associated with other measures of prevention of air leaks. However, we have demonstrated that it is technically feasible with a thoracoscopic approach and it may be a useful tool to reduce postoperative air spaces and leaks.
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References
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Abstract
Introduction
