Thomas K. Varghese Jr.
Introduction
Among the 17 participating centers in the National Emphysema Treatment Trial (NETT) lung volume reduction surgery (LVRS) was performed by median sternotomy only at eight centers and VATS only at three. There were six centers that randomized the approach to LVRS, and among this subgroup results were comparable with respect to morbidity, mortality, and functional results. Costs were less for the VATS group as the median hospital length of stay was 1 day shorter (9 vs. 10 days). Further large-scale randomized clinical trials (RCTs) have not been performed directly comparing the two techniques, and hence surgeon expertise has become the major factor in use of VATS.
INDICATIONS/CONTRAINDICATIONS/PREOPERATIVE PLANNING
Indications, contraindications, and preoperative planning are the same as for transsternal LVRS and are detailed in the previous chapter.
SURGERY
Working IV lines, an arterial line, and a thoracic epidural are often placed at the beginning of the procedure. A working thoracic epidural is used to ensure adequate pain control thus allowing for adequate pulmonary toilet in the immediate postoperative period.
After induction of general anesthesia, the patient is first intubated with a single-lumen endotracheal tube to allow for bronchoscopy. Bronchoscopy in these cases can be used for pulmonary toilet, to assess airway anatomy and rule out any endoluminal abnormalities. The single-lumen endotracheal tube is then exchanged for a left-sided double-lumen endotracheal tube, with bronchoscopic confirmation of its position. Single-lung ventilation is a necessity for VATS approach. Both sides are operated upon sequentially under the same anesthetic.
Positioning
The traditional bilateral VATS approach consists of positioning the patient in either the right or left lateral decubitus position, performance of the procedure, and then repositioning for the contralateral side. Advantage to this method is clear visualization of the target areas, while the disadvantage is time needed for repositioning, re-prepping, and draping for the contralateral side.
The alternative approach is to position the patient supine on a bean bag rolled under the back and arms that are tucked at its side, and then having the table roll to one side for performance of the procedure, and then rolling to the other. Advantage to this method is access to both sides of the chest without changing position. Disadvantages to this method include the need for larger working incisions, and possible diminished view as flexion of the bed is not used to open up the intercostal spaces. Our preference is bilateral positioning, but either method can be used.
The patient is positioned in the full left lateral decubitus position with full flexion of the operating table to 30 degrees between the nipples and anterior-inferior iliac spine, to open up the intercostal spaces for introduction of thoracoscopic instruments and the thoracoscope.
Technique
Thoracoscopic Port Placement
The chest is prepped and draped in standard surgical fashion. Strategies in VATS cases that can assist in minimizing chest wall trauma and postoperative pain are utilized, including:
Avoiding use of trocar ports (except for the camera) by introducing instruments directly through the wound to avoid intercostal nerve compression.
Utilizing an angled 30-degree scope for visualization to avoid torque in the inferior port site.
Using smaller telescopes (5 mm) when possible.
Intercostal nerve blocks in addition to infiltration with local anesthetic at planned areas of port sites.
Delivering specimen through the anterior port as the anterior intercostal spaces are wider.
Soft tissues of the incision can be spread with a Weitlaner retractor, but rib spreading is avoided during the VATS approach.
One-lung ventilation is initiated. The anesthesia team if at all possible should avoid using PEEP on the down lung if desaturation occurs during the procedure, as this can worsen ventilation-perfusion mismatch, subject hyperinflated lungs on the down side to barotrauma with risk of pneumothorax, and obscure view with shift in mediastinum into the field. Ideally discussion of strategies to deal with desaturation should be done with the anesthesia team before the start of the procedure.
The anterior port site is placed in the fifth or sixth intercostal space at the anterior axillary line. A 2 to 3 cm incision is made after infiltration of local anesthetic and intercostal nerve block. The incision is deepened through the soft tissue and muscle layers, and controlled entry into the thoracic cavity is made. A gentle sweep is made to confirm absence of any adhesions in the area. Either the thoracoscope can be inserted at this time to place the inferior port site under direct vision, or if adequately free, the inferior port can be placed in similar fashion. Placing a plastic Yankeur through the anterior port site to assess the location of the diaphragm can help with placement of the inferior port site. Depending on the size of the 30-degree angled scope used, either a 5 mm or 1 cm incision is made. The inferior port site is placed in the seventh or eighth intercostal space at the midaxillary line. An additional posterior port site is placed a fingerbreadth below the tip of the scapula (Fig. 7.1). Additional ports may be placed if needed for lung retraction, but are rarely necessary. Thoracoscopic port sites should be at a suitable distance from the target lung area (most often the apex) to provide space for manipulation. Visualizing a baseball diamond can help—anterior and posterior ports at “first” and “third base” with the camera port at “home plate” and the target area of the lung at “second base.” In female patients, an attempt should be made to strategically place the ports away from breast tissue to improve cosmesis.
Figure 7.1 VATS LVRS port placement.
Exploration and Mobilization of the Lung
After introduction of the thoracoscopic port and thoracoscope through the inferior port site, the entire hemithorax is visualized and the target region of emphysematous lung is visualized. Thoracoscopic ring forceps (Forresters) are introduced to help mobilize the lung. Adhesions between the lung and adjacent chest wall and mediastinum are carefully lysed with a combination of sharp and electrocautery dissection. Careful mobilization is performed to minimize lung injury and subsequent air leak. Larger bulla in target areas that are obscuring the view can be punctured and collapsed to improve the thoracoscopic view. Care should be done in these situations if diathermy is utilized for puncturing, to make sure that oxygen is not being passively introduced into the deflated lung by the anesthesia team to counteract any desaturation episode.
The inferior pulmonary ligament can be taken down to the level of the inferior pulmonary vein to help with re-expansion of the lung after resection and filling up of the intrathoracic cavity.
Resection of the Target Lung Area
Goals of intervention are to remove areas of lung that are especially damaged by emphysema, allowing the remaining good lung to expand and work better. When using devices such as surgical staplers, it is important to always keep in mind the principles of surgery—importance of hemostasis, gentle handling of tissue, and application of appropriate tissue compression. Thoracoscopic forceps can help precompress the lung at the area of planned stapler resection line (Fig. 7.2). As described in the previous chapter, for upper lobe predominant disease, about 70% of the right upper lobe, and 2/3 of the left upper lobe are removed during the procedure.
The endoscopic stapler is introduced through the anterior port site (Fig. 7.3). Endoscopic stapler options include use of staplers with buttress reinforcement (such as bovine pericardial strips), or utilization of staplers adapted for use with thick tissues such as the Endo GIA Tri-Staple and Echelon Endopath staplers. Staple lengths encompassing 4.8 mm thickness are used for lung resection. (Black load [4 to 4.5 to 5 mm] for the Endo GIA Tri-Staple and Green load [4.8 mm] for Echelon Endopath staplers.) Care should be taken to not cross staple lines, as this will lead to staple malfunctioning and air leaks. For the right lung, multiple firings of the stapler are performed, typically straight across the upper lobe beginning medially above the hilum and ending just above the upper extent of the oblique fissure. Care is taken not to cross the staple lines so as to avoid compromise of the remaining middle and lower lobes.
Figure 7.2 Compression of the lung along the planned resection line with the aid of thoracoscopic ring forceps.
Inspection of Staple Lines and Completion of Procedure
Staple lines, areas where adhesiolysis were performed and port sites are inspected for hemostasis. Some have advocated for the use of biologic sealants over the staple lines, but this should not be an attempt to make up for poor surgical technique or technical failure. The thoracoscope is removed from the inferior port site and introduced through the posterior port. An anterior apical chest tube (24 or 28 French) is introduced through the anterior port and directed anteriorly and apically. A 28-French chest tube is introduced through the old inferior port and directed posteriorly and apically. Chest tubes are secured to the chest wall, and connected to Pleur-Evacs. The lung is re-expanded under direct vision confirming adequate re-expansion of the remaining lobes. The thoracoscope is removed. Remaining thoracoscopic port sites are closed in layers, sterile dressings are placed.
Figure 7.3 Right VATS LVRS. Endoscopic stapler is introduced through the anterior port site.
Figure 7.4 Left VATS LVRS.
The patient is then repositioned in the contralateral right lateral decubitus position, taking care to appropriately pad all the pressure points. The chest is prepped and draped, and the procedure is repeated on the contralateral side in the same manner as described above. For upper lobe predominant disease of the left lung, the lingula is spared, and the upper 2/3 of the lung is resected with the line of excision parallel to the oblique fissure (Fig. 7.4). Care is taken to avoid crossing the fissure into the superior segment of the lower lobe, as this will lead to compromise in ability to re-expand at the completion of the procedure.
After completion of bilateral LVRS, the patient is returned to the supine position. A chest x-ray can be performed prior to extubation, or shortly after arrival to the recovery room. If postop chest x-ray demonstrates full re-expansion, the chest tubes can be put on water seal.
POSTOPERATIVE MANAGEMENT
Principles of standard thoracic postoperative management are followed including:
Early ambulation.
Transition from epidural analgesia to oral pain medications in 48 to 72 hours that provide adequate analgesia.
Pulmonary toilet measures (which had begun preoperatively) such as deep breathing, coughing, use of incentive spirometry, and handling of secretions.
Nebulized bronchodilator therapy is initiated in the early postoperative period to minimize airway reactivity, and transitioned to inhalers as needed.
Nutritional assessment and intervention is important, as it aids in healing.
Systemic steroids may be needed in the perioperative period.
Unlike other thoracic surgical procedures, early water seal is the norm, and can be started with expansion of the lung even in the presence of an air leak. Chest tubes are removed once air leaks resolve and output has minimized, in the standard fashion. Those with persistent air leaks in the postoperative period may be transitioned to Heimlich valve as long as the lung remains expanded on water seal, output is minimal, and the patient is able to care for the drain in the postdischarge setting.
COMPLICATIONS
Complications are similar for both transsternal and VATS LVRS, and are described in the previous chapter.
RESULTS
Mid-term and long-term results of NETT demonstrated clinically significant improvements in spirometry, lung volumes, diffusing parameters, oxygenation, quality of life, dyspnea, exercise capacity, and long-term survival. Results are similar for both the VATS and Transsternal techniques, and are detailed in the previous chapter.
CONCLUSIONS
LVRS is a surgical technique that involves selective reduction of lung volume by excision of tissue in areas where the emphysematous changes are pronounced. The choice between transsternal and VATS approaches is most commonly a result of surgeon expertise and patient preference. For both techniques a thoracic epidural is placed to enable adequate postoperative analgesia, thus facilitating deep breathing, coughing, early mobilization, and adequate pulmonary toilet.
The amount of tissue resected is 20% to 35% of each lung, which for upper lobe predominant disease is 75% of the right upper lobe, and 2/3 of the left upper lobe.
LVRS can lead to modest improvement in spirometry, lung volumes, diffusing parameters, oxygenation, quality of life, dyspnea, exercise capacity, and long-term survival. Key to success is strict patient selection criteria, optimizing patients preoperatively, and aggressive postoperative management to minimize the occurrence of complications.
Complications postoperatively include persistent air leak, reintubation, prolonged mechanical ventilation, pneumonia, wound infection, arrhythmias, and less commonly myocardial infarction, DVT, PE, and death.
Majority of patients are extubated in the operating room. Effective management of pain, pulmonary toilet, early ambulation, and management of secretions are key steps in minimizing complications.
Recommended References and Readings
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Cetinag IB, Boley TM, Magee MJ, et al. Postoperative gastrointestinal complications after lung volume reduction operations. Ann Thorac Surg. 1999;68:1029–1033.
Ciccone AM, Meyers BM, Guthrie TJ, et al. Long-term outcome of bilateral lung volume reduction in 250 consecutive patients with emphysema. J Thorac Cardiovasc Surg. 2003;125:513–525.
Joint Commission Lung Volume Reduction Surgery (LVRS). Certification http://www.jointcommission.org/assets/1/18/LVRS_final_addendum%20.pdf
McKenna RJ Jr, Brenner M, Fischel RJ, et al. Patient selection criteria for lung volume reduction surgery. J Thorac Cardiovasc Surg. 1997;114:957–964.
National Emphysema Treatment Trial Research Group. A randomized trial comparing lung-volume-reduction surgery with medical therapy for severe emphysema. N Engl J Med. 2003; 348:2059–2073.
National Emphysema Treatment Trial Research Group. Patients at high risk of death after lung-volume-reduction surgery. N Engl J Med. 2001;345:1075–1083.
Naunheim KS. Chapter 20: For whom is lung volume reduction surgery effective? In: Ferguson M, ed. Difficult Decisions in Thoracic Surgery. 2nd ed. New York, NY: Springer; 2011:179–186.
Naunheim KS, Kaiser LR, Bavaria JE, et al. Long-term survival after thoracoscopic lung volume reduction: A multi-institutional review. Ann Thorac Surg. 1999;68:2026–2031.
Naunheim KS, Wood DE, Mohsenifar Z, et al. Long-term follow-up of patients receiving lung-volume-reduction surgery versus medical therapy for severe emphysema by the National Emphysema Treatment Trial Research Group. Ann Thorac Surg. 2006; 82:431–443.