Eur J Cardiothorac Surg 1999;16:480-481
© 1999 Elsevier Science NL
Easy pleurectomy with winding up of pleural flaps
Leif Dernevik,
Göran Rådberg,
Ali Belboul
Department of Thoracic and Cardiovascular Surgery, Sahlgrenska University Hospital, S-413 45 Gothenburg, Sweden
Corresponding author. Fax: +46-31-417-991
e-mail: leif.dernevik{at}sahlgrenska.se
 |
Abstract
|
|---|
The authors describe an effective method of performing apical pleurectomy by winding up large pleural flaps on the thoracoscopic forceps after delineating the borders of the pleurectomy with electrocautery. The method is preferred by the authors compared to abrasio of the parietal pleura or stripping the pleura in small pieces and is in their hands easier and quicker than the other methods.
Key Words: Pneumothorax • Pleurectomy • Pleurodesis • Thoracoscopy
|
Introduction
|
|---|
Thoracoscopy has proved to be a suitable method for surgical treatment of recurrent pneumothorax [1,2]. Pulmonary blebs can easily be resected with the aid of staplers and the pleura may either be abrased or resected [3,4]. We prefer doing an apical pleurectomy as the results seem to be better with pleurectomy than with simple abrasio [5]. Sometimes it may by difficult to perform the pleurectomy without breaking the pleura into small pieces that are difficult and time-consuming to resect.
We are using a variation of pleural mobilisation techniques that preserves the integrity of the pleura until we have dissected large flaps that can easily and quickly be removed. This technical variation must certainly already be used by experienced surgeons, but we have never seen any written description, so we hope that this report might be of use to younger surgeons testing different techniques.
We use a standard three port technique where we place the first port in the axially line above the eighth rib for the camera. Two other ports are placed widely apart in the fourth or fifth intersperse.
With electrocautery we delineate the borders of the intended pleurectomy with one resection line parallel to the sympathetic chain posteriorly and the mammary vessels anteriorly. Those lines are carried from the first rib as far down as to cover the uppermost part of the lower lobe. At the top and bottom of these resection lines two additional lines are made following the first rib and a lower rib as far as the space permits. Where the lines meet we have two corners anteriorly and posteriorly.
With the long thoracoscopy forceps the corners are dissected free first. One forceps grabs the corner and lifts it gently while the other undermines the pleura thus creating a flap. Now with the forceps that is tangential to the flap, the corner is grasped in such a way that with rotation of the forceps, the whole pleural flap is curled up on the shaft of the instrument (Fig. 1). A large flap can now be resected in one piece both anteriorly and posteriorly. The pleura becomes tightly wound up on the instrument and must be cut loose with a knife until the forceps is free to wind up the remaining pieces of pleura.
View larger version (65K):
[in this window]
[in a new window]
|
Fig. 1. In the centre the thoracoscopy forceps is seen covered with the curled-up parietal pleura. The denuded thoracic cavity is seen to the right of the forceps as the winding up of the pleura is begun. The sharp pleural edge to the far right was developed by electrocautery.
|
|
With some practice it becomes natural to see how the diathermy lines shall be placed and where the instruments must be inserted to comfortably resect most of the apical pleura in just a couple of minutes. The traction force is spread out over a large pleural surface which ensures the integrity of the thin pleura and makes it come loose with very little bleeding from the surface under it. Without having performed any formal comparative studies, we quite subjectively find this technique far easier and quicker than every abrasive technique or other pleural stripping technique that we have tested, and the amount of bleeding seems to be the same, or more often less, than other techniques.
|
References
|
|---|
-
Celik M., Helzeroglu S., Senol C., Keles M., Yalcin Z., Urek S., Kiral H., Arman B. Video-assisted thoracoscopic surgery: experience with 341 cases. Eur J Cardio-thoracic Surg 1998;14:113-116.[Abstract/Free Full Text]
-
Gossot D., Kleinmann P., Levi J.-F. Thoracoscopy. France: Springer Verlag, 1992:61-69.
-
Inderbizi R.G.C., Leiser A., Furrer M., Althaus U. Three years experience in video-assisted thoracic surgery (VATS) for spontaneous pleumothorax. J Thorac Cardiovasc Surg 1994;107:1410-1415.[Abstract/Free Full Text]
-
Massard G., Thomas P., Wihlm J.M. Minimally invasive management for first and recurrent pneumothorax. Ann Thorac Surg 1998;66:592-599.[Abstract/Free Full Text]
-
Rådberg G., Dernevik L., Svanvik J., Thune A. A comparative retrospective study of thoracoscopy versus thoracotomy for the treatment of spontaneous pneumothorax. Surg Laparosc Endosc 1995;5:90-93.[Medline]
Received December 21, 1998;
received in revised form June 14, 1999;
accepted June 29, 1999.
Top
Abstract
Introduction
