Eur J Cardiothorac Surg 2008;34:212-213. doi:10.1016/j.ejcts.2008.03.066
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Novel method for bulla detection with video-assisted thoracoscopic surgery in patients with spontaneous pneumothorax
Riken Kawachi*,
Hidefumi Takei,
Yoshihiko Koshi-ishi,
Tomoyuki Goya
Department of Surgery (Thoracic Surgery Division), Kyorin University, 20-2, Shinkawa 6-chome, Mitaka-shi, Tokyo, 181-8611, Japan
Received 18 December 2007;
received in revised form 26 March 2008;
accepted 31 March 2008.
* Corresponding author. Tel.: +81 422 47 5511; fax: +81 422 44 3576. (Email: rkawachi{at}kpe.biglobe.ne.jp).
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Abstract
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Detection of bullae is usually performed during lung inflation with an inspiratory hold in collaboration with anesthetists (conventional method). One cause leading to recurrent pneumothorax is failure to detect the position and extent of bullae under the conventional method. We herein present a novel method for detecting bullae under negative intrathoracic pressure, enabling exploration in the narrow cupola space without lung inflation.
Key Words: Device • Emphysema/bullae • Pleural space • Pneumothorax • Thoracoscopy/VATS
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1. Introduction
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Detection of bullae is performed by lung inflation and water submersion test during an inspiratory hold by collaboration between surgeons and anesthetists (conventional method). This procedure is sometimes difficult for surgeons. We describe a novel method for the detection of bullae. The concept of this method is based on differences in compliance between bullae and normal lung parenchyma; namely, a bulla is more likely to inflate than normal lung under appropriate negative intrathoracic pressure (NIP) (Fig. 1a and b).
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Fig. 1. Schematic and demonstration of using the NIP method on the lung surface showing status before NIP (a, c) and inflation of bullae by the NIP method (b, d).
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2. Technique
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We used Endopath XCEL® bladeless trocars (ETHICON Endo-Surgery, Cincinnati, OH). Characteristic features of these trocars are air-tightness and easy control of intrathoracic air pressure. All procedures were performed under general anesthesia and single-lung ventilation. The patient is placed in the lateral position with the inferior arm outstretched. Three trocars are positioned along the anterior axillary line at the third intercostal space (ICS), along the posterior axillary line at the fifth ICS and along middle axillary line at the seventh ICS. One trocar is connected to a suction unit. Intrathoracic air pressure is regulated by opening the stopcock on the trocar (Fig. 2
). The surface of the lung is explored while controlling intrathoracic air pressure, identifying bullae by expansion in response to NIP. Fig. 1 demonstrates the NIP method; Fig. 1c shows the status of the lung surface prior to NIP, and Fig. 1d shows the inflation of bullae by the NIP method.
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Fig. 2. Three trocars are inserted, with one connected to a suction tube (a). Intrathoracic pressure is controlled by turning the stopcock (b). Bullae inflate under appropriate negative pressure.
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Detection of bullae using the NIP method was performed in 22 patients, and no bullae were found in 2 patients. Both patients had severe pulmonary emphysema. Air leakage points were identified in four patients using this method. Recurrence was observed in one patient. No bullae were found in this patient, who had complications of pulmonary emphysema.
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3. Comment
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Video-assisted thoracoscopic surgery (VATS) is usually performed for spontaneous pneumothorax. The incidence of recurrence after VATS is 5–10% according to the literature [1,2], higher than that for thoracotomy procedures [3,4]. Recurrences are more frequent in patients in whom no bullae are identified intraoperatively [5–7]. Detection of bullae is usually performed by inflation of the lung during an inspiratory hold in conventional VATS procedures [8]. In this method, bulla may be missed, or the extent of bulla may not be perceived in the narrow space. We have devised a novel method of detecting bullae under NIP. The characteristic features of this method are, first, ease of exploration in a wide space, as the lung does not inflate. Second, visualization of bullae ballooning up under NIP is easy.
This method also has limitations. First, keeping a space for exploration is difficult in patients with pulmonary emphysema, as the emphysematous lung is likely to inflate. Second, detection of a leakage point is difficult with this method in cases of temporary closure of a leakage point or minimal leakage because the airway pressure is almost the same as atmospheric pressure.
In summary, we presented herein a novel method for detecting bullae without lung inflation during an inspiratory hold. Combination of this new method with the conventional method should improve the recurrence rate.
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References
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Abstract
1. Introduction
