VATS Bullectomy

VATS BULLECTOMY

Initial shillong Experience Dr L.M.DarlongAsst Prof SurgeryNEIGRIHMS Shillonglmdarlong@gmail.com

VATS

• Video Assisted Thoracoscopic Surgery

• Jacobeus in 1910 ( Thoracoscopy )

• 1992 - VATS

Bullous lung disease

• Expansion of alveolar spaces• Heavy smoking• Symptomatic• Pressure effect – compress

normal functioning lung tissues , Pneumothorax

• Asymptomatic – incidental finding

Surgical indications

• Progressive respiratory insufficiency

• Recurring pneumothorax• persistent pneumothorax• Hemoptysis• Chest pain• Bulla infection

Aims of surgery

• Reduce pressure effect - Lung Parenchyma - Diaphragm - Mediastinum

• V/Q ratio Optimization

• Dead space reduction

Surgical Techniques

• Ressect bulla – Stappled - Endoloop

• Prevent recurrence – - Pleurodesis

• Preserve functioning lung tissue

Indications Diagnostic

• Pleura

• Lung parenchyma

• Mediastinum

Therapeutic• Pleurodesis/

Empyema• Mediastinal mass• Bullous lung disease• Lobectomy/ wedge

ex / pneumonectomy

• Esophagus • Thymectomy• Ectopic parathyroid• Cardiac surgery• Spine surgery

Contraindications

Inability to tolerate single lung ventilation

Case 1

• 32 yrs male , smoker • Sudden onset chest pain, dyspnoea• Cxr – Lt pneumothorax • Post ICD drainage persistant

pnx,air leak• HRCT chest – Lt apical subpleural

blebs with C/L apical bulla• 2 stage VATS done

Case 2

• 42 yrs male , smoker• Progressive dyspnoea Grd II• Chest pain• Cxr – Rt apical bulla• HRCT Chest – Rt apical bulla,

multiple septation

Imaging

Shillong ExperienceCase Age

/ sex

Indication Intraop Vats procedure

OT time (mins)

Postop compli

cation

Duration of chest drain (days )

Postop stay (days )

Follow-up (months )

1 32/M Chest pain, dyspnoea pnx

Persistent pnx air leak

Left apical bullae

Stappled bullectomy

Mech pld

150 4 5 5

2 32/M Contra lateral bulla

Rt apical bullae

Stappled bullectomy

Mech pld

120 Catheter related prepuce edema

3 4 4

3 42/M Chest pain , apical bulla

Rt apical bulla with sub pleural blebs

Stappled bullectomy Endoloop ligation.

180 3 5 5

NO BLOOD TRANSFUSION

VATS - WHY Access procedure

Benefits•Postop Pain•Postop stay•Acceptance•Cosmetic

•Cost benefit

Cellular level•Cytokine activation

•Immune function

•Long term benefits

Instrumentation

Author No of cases

O.T time(mins)

Indications PostopComplication

Chest drainRemoval (days)

PostopHospital Stay (days)

Followup(mths)

Akio w.etal

16 Dyspnoea(10)Spontaneous pneumothorax(6)Infection(1)

Air leak(3-62 days)

36

Teriyashi etal

50 147.8(bulla)45.9(bleb)

Giant bulla(6)Spontaneous pneumothorax(44)

5.2(bulla)1.2(bleb)

11.3(bulla)4.7(bleb)

H.P.Liu etal

79 70

(40-110)

Symptomatic Bullous emphysema

Subcutaneous emphysema(3)-3.8%Air leak>10 days(7)-8.9%Localized empyema(2)Wound infection(3)

6(4-16)

9.6(5-26)

21(5-37)

Gian franco etal

29 Spontaneous pneumothorax(23)Choice(6)

Reoperation for persistent air leak(2)Respiratory failure(2)-6.9%

5(3-14)

6(3-16)

16(1-36)

Tiziano etal

25 107=25

Complication of bulla(9)Dyspnoea(12)Asymptomatic giant bulla(4)

Air leak>7 days(12)-48%

8=4.13 11=5.76

Review of literature

Recurrence

• 3 – 10 % overall recurrence in lit

• 1.8 % with Apical bullectomy

• 23 % with no excision

• Recurrences more -No bleb / bullae

Conclusion

• Short term results – good• Acceptance higher• Superior in terms of

– Low Morbidity– Low invasiveness– Cosmetic

• Similar recurrence

Thank you