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J Thorac Cardiovasc Surg 1995;110:547-548
© 1995 Mosby, Inc.

BRIEF COMMUNICATIONS

A TECHNIQUE TO MINIMIZE AIR LEAKAGE AFTER EXCISION OF EMPHYSEMATOUS BULLA OF THE LUNGS

Iwao Takanami, MD, Yasuki Yamamoto, MD, Tatsuya Yamamoto, MD, Susumu Kodaira, MD


Tokyo, Japan

From the First Department of Surgery, Teikyo University of School of Medicine, 2-11-1 Kaga Itabashi-Ku, Tokyo 173, Japan.

If pulmonary plication is done to treat an emphysematous bulla, pulmonary fistulae are sometimes formed and persist for long periodsGo 1 We recently established a technique to easily reduce postoperative air leakage with the use of bioabsorbable polyglactin 910 (Vicryl mesh; Johnson & Johnson Cardiovascular, King of Prussia, Pa.), a GIA 8 cm linear stapling device (United States Surgical Corporation, Auto Suture Company Division, Norwalk, Conn.), and fibrin glue (Bolheal; Teijin, Inc., Tokyo, Japan).

Several strips of absorbable polyglactin 910 (1 cm wide and 8 cm long) were prepared. One of these strips was bonded by fibrin glue onto both sides of the GIA linear stapling device (the cartridge side and the front side) (Fig. 1). The bulla was lifted by pulmonary forceps until it had a tentlike appearance. The stapling device to which strips of polyglactin 910 had been bonded was applied across the pulmonary base that was to be resected. The stapler was then used to resect the target tissue. In cases in which the tissue to be resected was longer than 8 cm, the portion of the target tissue that remained unresected was resected with the use of another stapler to which strips of polyglactin 910 had been bonded. The unconsumed portion of the fibrin glue was applied to the resected area.



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  		Fig. 1. Polyglactin 910 bonded by fibrin glue to linear stapling device.

 
Emphysematous bullae often affect the entire lungs. For this reason, the percentage of patients with this condition who are eligible for operation is relatively low. However, lung plication is needed in cases in which a giant bulla compresses the normal area of the lung, causing dyspnea, or in cases of intractable bullae in which a thoracic drain needs to be used for long periods because of pneumothorax.Go Go 1,2 When plication is performed or a stapling device is applied for cases of pulmonary bulla, air leakage through the needle holes often occurs, leading to persistent pulmonary fistulas. Various techniques to avoid this problem have been reported. Juettner and associatesGo 3 used absorbable polydioxanone ribbons and a stapling device to avoid air leakage. According to our experience, their technique involves two problems: (1) it is difficult to manipulate the stapling device while keeping the ribbon on the excision line of the lung and (2) the excessive portion of the ribbon needs to be cut with scissors. CooperGo 4 reported a technique that uses bovine pericardial strips and a GIA stapling device (United States Surgical Corporation, Auto Suture Company Division, Norwalk, Conn.). With his technique, bovine pericardial strips are first placed on the stapling device. They are then tied with a catgut thread. The bulla is resected with the stapler and the catgut thread is removed. Connolly and WilsonGo 1 reported a technique by which a Teflon felt piece is placed on the stapling device and fixed with adhesive strips. Our technique uses absorbable polyglactin 910 strips to avoid pulmonary fistulas. The strips are bonded by fibrin glue to a stapling device.

If absorbable polyglactin 910 can be preoperatively cut into strips and if these strips can be preoperatively bonded by glue to a disposable sheath for subsequent sterilization, the operation will be simpler. Our technique is also applicable to thoracoscopic partial resection of emphysematous lung tissue. For lung operations under thoracoscopic guidance, it is desirable to minimize manipulations within the thoracic cavity. In this respect, our technique, which requires less manipulation within the thoracic cavity, seems to be more useful for thoracoscopic lung operations in comparison with the techniques reported by others.

Footnotes

J THORAC CARDIOVASC SURG 1995; 110:547-8 Back

References

  1. Connolly JE, Wilson A. The current status of surgery for bullous emphysema. J THORAC CARDIOVASC SURG 1989;97:351-61.[Abstract]
  2. Fitzgerald MX, Keelan PJ, Cugell DW, Gaensler EA. Long-term results of surgery for bullous emphysema. J THORAC CARDIOVASC SURG 1974;68:566.[Medline]
  3. Juettner FM, Kohek P, Pinter H, Kepp G, Frieks G. Reinforced staple line in severely emphysematous lungs. J THORAC CARDIOVASC SURG 1989;97:362-3.[Abstract]
  4. Cooper JD. Technique to reduce air leaks after resection of emphysematous lung. Ann Thorac Surg 1994;57:1038-9.[Abstract]




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