Advertisement

Thoracoscopic Lung Volume Reduction Surgery

  • Robert J. McKenna Jr
    Correspondence
    Address reprint requests to Robert J. McKenna, Jr, MD, Cedars Sinai Medical Center, Department of Thoracic Surgery, 8635 West Third 975W, Los Angeles, CA 90048.
    Affiliations
    Cedars Sinai Medical Center, Department of Thoracic Surgery, Los Angeles, California.
    Search for articles by this author
      Surgery has been proven to be beneficial for selected patients with severe emphysema. Compared with medical management, lung volume reduction surgery (LVRS) significantly improves pulmonary function, exercise tolerance, quality of life, and even survival for selected patients.
      The National Emphysema Treatment Trial Research Group
      Effects of lung volume reduction surgery versus medical therapy: results from the National Emphysema Treatment Trial.
      It is also cost effective.
      • McKenna Jr, R.J.
      • Benditt J.O.
      • DeCamp M.
      • et al.
      Safety and efficacy of median sternotomy versus video-assisted thoracic surgery for lung volume reduction surgery.
      The results of the procedure are comparable, whether LVRS is performed through a median sternotomy or by video-assisted thoracic surgery (VATS).
      The National Emphysema Treatment Trial Research Group
      Cost effectiveness of lung volume reduction surgery versus medical therapy: results from the National Emphysema Treatment Trial.
      The National Emphysema Treatment Trial (NETT) showed that the VATS approach was less costly and provided earlier recovery compared with the median sternotomy.
      • McKenna Jr, R.J.
      • Benditt J.O.
      • DeCamp M.
      • et al.
      Safety and efficacy of median sternotomy versus video-assisted thoracic surgery for lung volume reduction surgery.
      This article will describe the technique for LVRS by VATS.

      Indications for LVRS

      The indications for LVRS are the same, whether the procedure is performed with VATS or a median sternotomy. Candidates have severe emphysema and are symptomatic despite maximal medical management. Maximal medical management includes medicines, inhalers, steroids, oxygen, and pulmonary rehabilitation. These patients have difficulties with simple activities of daily living, such as taking a shower, doing household chores, bending, and carrying anything. They can walk only short distances. If oxygen saturations regularly drop below 90%, randomized trials have shown that oxygen therapy prolongs survival. Pulmonary function tests for candidates include the following: forced expiratory volume 1 < 45% predicted, mean total lung capacity = 140% predicted, and mean residual volume = 250% predicted. Rehabilitation does improve quality of life, lead to better exercise tolerance, and reduce hospitalizations, but it does not impact survival, does not improve pulmonary function, and really provides only minor benefit. Therefore, there is a need for either better medical treatment or an operation to improve the plight of the patient with severe emphysema.
      The most important selection factor for LVRS is the presence of a heterogeneous pattern of emphysema. Only about 20% of patients with severe emphysema have a heterogeneous pattern of emphysema. The basic concept behind LVRS is resection of nonfunctional areas of lung to allow the better areas work more effectively. Patients usually have severe destruction of the parenchyma in the upper lobes bilaterally. Patients with severe destruction in the lower lobes (related both to smoking and to alpha-1 antitrypsin deficiency) are potentially candidates. There is little evidence that LVRS benefits patients with a homogeneous pattern of emphysema.

      Position of the Patient

      Although a few surgeons place the patient supine for VATS LVRS, most surgeons perform the procedure with the patient in the lateral decubitus position. This means two separate preps, but this allows the best exposure for the procedure. Repeated episodes of bronchitis and pneumonia may lead to pleural adhesions. If these adhesions are located posteriorly, lysis of those adhesions is performed better and more safely from a lateral approach.

      VATS Technique

      VATS LVRS is usually a bilateral staple procedure that is performed under general anesthesia utilizing selective lung ventilation. As soon as the patient is placed in the lateral decubitus position, one-lung ventilation is instituted because the poor elastic recoil of emphysematous lung causes it to decompress very slowly. Target areas for resection often remain expanded, whereas the better areas become atelectatic. Bronchoscopy with suctioning through the double lumen endotracheal tube helps to collapse the lung for LVRS.

      Operative Technique

      Figure thumbnail gr1
      Figure 1The surgeon stands in front of the patient, who is in a full lateral decubitus position. The 5-mm trocar and 30° thoracoscope are placed through the 9th or 10th intercostal space in the mid-axillary line. The incision is low to allow the maximal panoramic view of the chest and because the lungs are so hyperinflated that the diaphragm is very depressed. Because the lungs are so hyperinflated, the incision can be placed lower than for other VATS procedures. A 2-cm incision is made in the 6th intercostal space in the mid-clavicular line. This incision is made as far anteriorly and inferiorly as possible. This should be one space below the mammary crease because an incision in the mammary crease is uncomfortable for women.
      Figure thumbnail gr2
      Figure 2The stapler passes through the 6th intercostal incision for the pulmonary resection. A 1-cm incision is made in the 4th intercostal space in the mid-axillary line. A ring forceps passes through this incision to hold the lung for the stapler.
      Figure thumbnail gr3
      Figure 3The exact location of the tissue to be resected depends on the preoperative computed tomographic (CT) scan and ventilation perfusion scans. This is usually at the apex of both upper lobes. LVRS generally involves resection of about 30% of each lung (60-70% of the upper three segments of each lung). Because emphysematous tissue does not hold sutures or staples well, the staple lines are usually buttressed with bovine pericardium (Synovis, St. Paul, MN) or Gore-Tex (Gore, Newark, DE). These buttresses do not eliminate air leaks, but they do reduce the incidence of air leaks. In the NETT, 90% of patients developed an air leak postoperatively, and 50% of the leaks lasted for at least 1 week. We measure the title volume in and out to determine if there is a leak. If there is a leak, water is placed into the chest to help find the leak.
      Figure thumbnail gr4
      Figure 4For upper lobe emphysema, the resection usually starts medially at the junction of the anterior segment of upper lobe with the middle lobe on the right or the anterior segment and the lingula on the left. The resection proceeds from anterior to posterior, over the top of the lobe. On the right, the resection parallels the minor and then the major fissure.
      Figure thumbnail gr5
      Figure 5The resection generally removes about 60% of the volume of the right upper lobe or the upper division of the left upper lobe. The staple line does not go into the fissure because, when the subpleural emphysema in the fissure is stapled, significant air leaks may result. Rarely, the entire upper lobe is resected. If the CT and perfusion scans show that the anterior segment of the upper lobe is not destroyed by emphysema, then it is preserved. In that case, the staple line begins in the mid-axillary line and proceeds from lateral to medial over the top of the lung.
      Figure thumbnail gr6
      Figure 6The procedure is performed with two staplers so the surgeon can be firing one stapler as the scrub nurse prepares the other stapler. The procedure can be performed quickly if the lung is held properly so that the stapler easily slides across the lung. There should be little manipulation of the lung as the procedure progresses. The resected portion of lung is then generally brought out of the port site originally made for the stapler.
      Figure thumbnail gr7
      Figure 7This drawing illustrates what is typically left of the upper lobe following LVRS with the buttressed staple line parallel to the oblique fissure and relatively sparing of the posterior segment of the lobe. On the left, LVRS is a mirror image of the procedure on the right. For lower lobe emphysema, the stapler is fired on the lower lobe tissue, parallel to and 1 cm away from the major fissure. If the preoperative CT and perfusion scans show that the entire lobe has been destroyed by emphysema, then the entire lobe is resected. Sometimes the superior segment of the lower lobe is still functional. In that case, the superior segment is preserved. The staple line follows the fissure superiorly to the level of the superior segment. The staple line then turns transversely at the junction of the superior segment and the basilar segments.

      LVRS: Sternotomy or VATS?

      Most surgeons perform LVRS by a median sternotomy because they are more comfortable with that approach. The NETT, a randomized prospective trial comparing medical management with and without LVRS, showed that LVRS provided better pulmonary function, exercise tolerance, quality of life, and survival for properly selected patients. A substudy of the NETT compared LVRS by VATS versus median sternotomy. The two approaches showed comparable morbidity, mortality (4% for VATS and 4.6% for median sternotomy, P = 1.0), and functional improvement. The length of stay (median, nine for MS and eight for VATS, P = 0.001), costs of hospital care and also all medical care for 6 months following LVRS, and return to independent activities favor the VATS approach.

      Conclusions

      LVRS has been shown to provide benefit over medical management whether it is performed with a median sternotomy or VATS. Although the functional benefits are the same for the two approaches, the VATS approach does offer some advantages that are statistically significant.

      References

        • The National Emphysema Treatment Trial Research Group
        Effects of lung volume reduction surgery versus medical therapy: results from the National Emphysema Treatment Trial.
        New Engl J Med. 2003; 348: 2059-2073
        • McKenna Jr, R.J.
        • Benditt J.O.
        • DeCamp M.
        • et al.
        Safety and efficacy of median sternotomy versus video-assisted thoracic surgery for lung volume reduction surgery.
        J Thorac Cardiovasc Surg. 2004; 127: 1350-1360
        • The National Emphysema Treatment Trial Research Group
        Cost effectiveness of lung volume reduction surgery versus medical therapy: results from the National Emphysema Treatment Trial.
        New Engl J Med. 2003; 348: 2092-2102