It is recognized that the ideal surgical field for videoassisted

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1 Selective Lobar Collapse for Video-Assisted Thoracic Surgery Alan D. L. Sihoe, MB, BChir, Kin Ming Ho, MBBS, Tak Suen Sze, MBChB, Tak Wai Lee, MBChB, and Anthony P. C. Yim, MD Division of Cardiothoracic Surgery, Chinese University of Hong Kong, and Department of Anesthesiology, North District Hospital, Hong Kong, China Background. Video-assisted thoracic surgery (VATS) is conventionally performed under single-lung ventilation. A small proportion of patients are often excluded from undergoing VATS because of their inability to tolerate single-lung ventilation. We describe a simple technique of selective lobar lung collapse that may help to recruit additional, selected patients for VATS. Methods. We use a standard suction catheter placed under bronchoscopic guidance to the target lobar bronchus through a single-lumen endotracheal tube. The catheter is left open to air, or suction can be applied to facilitate lobar collapse. The remaining lobe of the same lung can be ventilated throughout surgery. Surgery is performed using standard VATS techniques. Results. Using this technique we have successfully performed VATS on 63 chest sides in 35 patients. The procedures performed included thoracodorsal sympathectomies (n 28), mechanical pleurodesis procedures (n 3), mediastinal and pleural biopsies (n 2), and lung wedge resections (n 2). We encountered no mortality or morbidity in all cases. Conclusions. This technique is simple and safe and requires no expensive disposable devices. Although not essential for most patients undergoing VATS, it deserves to be in the armamentarium of the thoracic surgeon. Further studies will be required to better define its application in clinical practice. (Ann Thorac Surg 2004;77:278 83) 2004 by The Society of Thoracic Surgeons It is recognized that the ideal surgical field for videoassisted thoracic surgery (VATS) is achieved by the use of endobronchial intubation and single-lung ventilation, with the resulting lung collapse on the operation side allowing visualization of all the intrathoracic structures [1]. The mainstay technique today is the use of a double-lumen tube for endotracheal intubation, although lung isolation using a bronchial blocker is an alternative [2]. Some centers use carbon dioxide insufflation through a Veress needle to expedite and maintain lung collapse [3]. However, single-lung ventilation while effective in most instances is not without complications. These include cardiovascular instability, hypoxemia (due to shunting), bronchopleural fistulation, and persistent pneumothorax [1]. Patients with poor cardiopulmonary reserve are often unable to tolerate one lung ventilation. That may also true in small children [4]. Even for otherwise healthy adult patients it is intuitive that reducing the degree of shunting may be desirable. We describe here a novel method of achieving highly selective lobar collapse for VATS that forgoes the need for special devices. Our initial experience with this technique forms the basis of this paper. Accepted for publication Aug 1, Address reprint requests to Prof Yim, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong SAR, China; yimap@cuhk.edu.hk. Patients and Methods Patients who are medically fit for general anesthesia and who have had no previous thoracic surgery on the operation side are eligible for this technique. Clear definition of the target (namely, not generalized exploration) is a prerequisite for consideration of this technique of highly selective ventilation so that the lung lobe containing or adjacent to the lesion can be targeted for collapse. Examples would include resection of a pleural or lung lesion (for which the lobe opposite or containing the lesion is deflated) or sympathectomy for palmar hyperhidrosis (with selective deflation of the upper lobe to expose the second and third thoracodorsal sympathetic ganglia). We have thus far excluded patients for whom controlled, sustained, or prolonged lung collapse is critical for the VATS procedures such as major lung resections or thymectomies. We employ standard regimes for the induction and maintenance of general anesthesia. The patient s trachea is intubated with a standard cuffed single-lumen endotracheal tube. For most adult Chinese patients size 8 and 9 endotracheal tubes are usually suitable. The ventilator is connected to the endotracheal tube through a swivel connector. We insert a fine 3-mm diameter fiberoptic bronchoscope through the lumen of a standard end-hole plastic suction catheter. We find that catheters sized 14F to 16F are usually appropriate for most of our patients. The bronchoscope with the suction catheter sheathing it is 2004 by The Society of Thoracic Surgeons /04/$30.00 Published by Elsevier Inc doi: /s (03)01498-x

2 Ann Thorac Surg SIHOE ET AL 2004;77: SELECTIVE LOBAR COLLAPSE 279 Fig 1. Correctly positioned suction catheter placed through the endotracheal tube. A simple clip (arrow) can delay lobar collapse until required. then inserted through the swivel connector into the endotracheal tube and its tip guided into the bronchus of the lobe to be deflated. The suction catheter is then railroaded forward on the bronchoscope until its tip is firmly wedged into the target lobar bronchus. The bronchoscope is withdrawn, leaving the suction catheter in place (Fig 1). Ventilation is continued throughout the operation through the single-lumen endotracheal tube. This ensures ventilation of both lungs except for the single lobe selectively cannulated by the suction catheter (which effectively acts as a bronchial blocker). The catheter is left open to air and the targeted nonventilated lobe should deflate readily. We occasionally place a simple clip on the suction catheter, delaying the lobar collapse until required by the operation (Fig 1). That may potentially shorten the period of shunting or build up of bronchial secretions in the target lobe when it is collapsed. Lobar collapse can be expedited by intermittent suction applied through the catheter or by carbon dioxide insufflation to the pleural space on the operation side. When using the latter we begin with a low initial insufflation pressure (typically 2 mm Hg) and titrate the pressure upward very gradually to achieve the desired level of lobar collapse. We have employed this technique of highly selective single lobe collapse in a variety of VATS procedures using standard VATS surgical techniques. Standard port placements are used although particular care is used when inserting trocars and instruments, bearing in mind the potential for puncture of the noncollapsed lung lobes. When creating the first port, ventilation is temporarily stopped to minimize the chance of lung puncture. For sympathectomies, we employ a standard threeport technique using 3.5-mm ports and a 20- to 30-degree semisitting position. The patient s arms are abducted to 80 to 90 degrees in a crucifix position. The port strategy we use is the same as that for surgery under conventional one lung ventilation. The first camera port is placed in the midaxillary line in the fifth or sixth intercostal space with the ventilation temporarily stopped during insertion. The camera is inserted for initial inspection to confirm that the port has entered the pleural space and carbon dioxide insufflation is given if necessary to further enhance the collapse of the target lobe. The instrument ports can then be placed under guidance with the videothoracoscope. We place an axillary port in the midaxillary line in the third or fourth intercostals space. Another port anterior and one rib space above this at the lateral border of the pectoralis major muscle is then made when the port is skirting behind rather than through that muscle. Endoscopic forceps are inserted through the latter to grasp the sympathetic trunk while resection is performed with a diathermy hook inserted through the former port. Complete resection of the second and third thoracic sympathetic ganglia is performed using a combination of gentle diathermy and blunt dissection. When switching from operating on one side to the other the suction catheter must be removed and replaced to the other side using the bronchoscope. For VATS mechanical pleurodeses, lung wedge resections, and mediastinal or pleural biopsies, we perform the surgery in the same way as when using conventional one-lung ventilation. We place the patient in a lateral position with the table flexed to spread the rib spaces on the operation side. We use 10-mm ports placed in the same positions as for a conventional single lung ventilation operation. Lung resections (including bullectomies) are performed using mechanical staple gun devices. Mechanical pleurodesis is achieved by parietal pleural abrasion with an abrasive mesh while the lung is gently paddled away from the chest wall with a pair of spongeholding forceps. At the end of the procedure the suction catheter is removed. By continuing normal ventilation through the single-lumen tube the collapsed lobe readily reinflates. The reexpansion is monitored using the videothoracoscope to ensure complete reexpansion. Once the lung is reexpanded we sustain positive pressure inspiratory hold through the endotracheal tube together with suction applied through a catheter to the pleural space for 30 to 60 seconds to reduce residual pleural air and postoperative atelectasis. For our sympathectomies a chest tube is

3 280 SIHOE ET AL Ann Thorac Surg SELECTIVE LOBAR COLLAPSE 2004;77: not routinely placed at the end of the procedure but we employ an on-table water seal maneuver to confirm complete lung reinflation [12]. We do place a 24F chest tube to facilitate lung reexpansion after a pleurodesis, a lung wedge resection, or a mediastinal or pleural biopsy. Results A summary of the details of the VATS procedures we have performed during the period of August 1, 2002, to January 31, 2003, using this technique is presented below Table 1. In total we have successfully performed VATS operations on 63 chest sides in 35 patients including 21 male and 14 female patients (two sides per bilateral sympathectomy procedure). The average age was years (range, 19 to 73). The VATS operations performed included bilateral thoracodorsal sympathectomy for palmar hyperhidrosis (n 28), mechanical pleurodesis for recurrent spontaneous pneumothorax (n 3), lung wedge resection for indeterminate solitary lung nodules (n 2), biopsy of indeterminate mediastinal mass (n 1), and pleural biopsy for indeterminate pleural effusion (n 1). As this is a feasibility study the majority of operations performed using this technique were bilateral VATS thoracodorsal sympathectomies for palmar hyperhidrosis, a relatively simple operation. We have successfully performed 28 sympathectomies using this technique. The patients included 16 male and 12 female patients and the mean age was years (range, 19 to 49). The mean anesthesia induction time from the time of the patient being positioned on the operating table to the time when the patient was ready for draping was 17.4 minutes (range, 8 to 29 minutes). Carbon dioxide insufflation to assist lung collapse was used in 25 patients (89.3%). The intrathoracic exposure using this technique was generally excellent, with selective collapse of the target lobe allowing good access to the thoracodorsal sympathetic trunk while ventilation of the remaining lobes of the same lung is maintained (Fig 2). The mean operating time from first incision to final skin closure was 48.1 minutes (range, 20 to 135). The one case requiring 135 minutes to Fig 2. Intraoperative view through the videothoracoscope during video-assisted thoracic sympathectomy using highly selective lobar collapse. (A) The right hemithorax is shown, with the site of resection of the sympathetic trunk well exposed. (B) The right upper lobe of lung is well collapsed. (C) The rest of the right lung is still ventilated. perform was a patient with dense pleural symphysis not detected preoperatively that required extensive adhesiolysis. Nonetheless despite this unforeseen intraoperative challenge we did not require conversion of our highly selective single lobe collapse technique to a conventional double-lumen tube technique. Excluding this case the mean operating time would have be 44.9 minutes (range, 20 to 75). Discharge on the first postoperative day was possible for 25 patients although 1 elected to stay 1 extra day for personal reasons. Three patients elected to be discharged home on the same day as their surgery after resting for 8 hours. On follow-up of 3 to 8 months Table 1. VATS Operations Performed With the Selective Lobar Collapse Technique Operation n Male/Female Age [Years] Anesthesia Preparation Time a [Minutes] CO 2 Insufflation Required Operation Time b [Minutes] Postoperative Stay [Days] Bilateral thoracodorsal sympathectomy 28 16/ (mean 32.25) Pleurodesis 3 3/ (mean 21.0) Lung wedge resection 2 1/ (mean 49.0) 8 29 (mean 17.36) 5 34 (mean 18.33) (mean 18) 25 (89.3%) (mean 48.07) 3 (100%) (mean 41) 2 (100%) (mean 43.5) 0 2 (mean 0.93) Mediastinal biopsy 1 0/ (100%) 78 3 Pleural biopsy 1 1/ (100%) (mean 4) 2 4 (mean 3) a Induction of general anesthesia to patient being declared ready for surgery. b Skin-to-skin time.

4 Ann Thorac Surg SIHOE ET AL 2004;77: SELECTIVE LOBAR COLLAPSE 281 after surgery there have been no recurrences of palmar hyperhidrosis or of Horner s syndrome in any of the patients. For the other procedures, or any other complications, carbon dioxide insufflation was required in all cases. In all 3 cases of mechanical pleurodesis no postoperative air leak and no recurrence of pneumothorax was encountered on follow-up for 3 months. For the 2 lung wedge resections, 1 involved the resection of a 1-cm nodule in the right middle lobe and 1 involved a 1.5-cm nodule in the right lower lobe. Although the majority of the lobes collapsed were the upper lobes (for sympathectomy and pleurodesis procedures), collapse of the middle and lower lobes in these cases was performed in the same manner without added difficulty. A positive histologic diagnosis was obtained in all the cases of lung, mediastinal, and pleural biopsies. We encountered no operative mortalities or notable morbidities in all 35 cases. In none of the cases have we required conversion from our highly selective lobar collapse technique to a conventional single lung ventilation technique. There was no incidence of dislodging of the suction catheter causing disruption of the surgery in all cases. No lung trauma on port placement occurred in any case. No complications relating to intubation, anesthesia, ventilation, hypoxia or any nonsurgical aspect have been encountered in the perioperative period and on follow-up for between 3 and 8 months. The only sequel noted was persistent mild postoperative back or chest pain in 5 patients (17.9%) who had received sympathectomies. Comment Conventional single-lung ventilation for VATS requires complete collapse of one lung. Although this is effective and safe for the vast majority of patients there is still the potential for possible harmful physiologic changes. In particular the shunting of blood through the unventilated lung may cause hypoxemia during the operation [1]. Furthermore, some patients with diminished lung function may simply not be able to tolerate single-lung ventilation. Such considerations have hitherto prompted hesitation on the part of some clinicians to offer VATS to patients with poor cardiopulmonary function or to younger children [6]. In addition, single-lung ventilation most often requires the use of double-lumen tube endotracheal intubation, which not only places greater demands on the anesthetist s skills but also may involve a risk of trachea injury. Such injuries are in many cases attributable to inappropriate sizing of the endotracheal tube in respect to the patient s trachea [7]. Double-lumen tubes are typically wider and longer than corresponding single-lumen tubes and indeed double-lumen intubations are known to be associated with a risk of tracheobronchial lacerations or rupture [8]. It is now recognized that complete collapse of the entire lung may not be necessary in all VATS procedures. In recent years attempts have been made to reduce the above problems by foregoing traditional techniques of one-lung ventilation during VATS. In 1996, Rozenberg and colleagues [9] described a method of partial collapse of one lung while maintaining ventilation through a standard single-lumen endotracheal tube. By insufflating carbon dioxide at a positive pressure through a Veress needle they could induce an artificial pneumothorax, giving adequate exposure of the thoracodorsal sympathetic trunks for VATS sympathectomy. Exposure is improved by sitting the patient up 60 to 70 degrees. However, the near-sitting position is not a particularly ergonomic one for the surgeon to operate on. More importantly, considerable insufflation pressures may be required because the carbon dioxide must work against the mechanical ventilation to achieve lung collapse. It has already been eloquently demonstrated by Hill and coworkers [10] that increasing positive pressure pleural insufflation can result in adverse hemodynamic compromises. Our technique is similar to that of Rozenberg in that a single-lumen endotracheal tube is used to ventilate lobes in both lungs continuously [9] but only one lobe is completely collapsed rather than having all the lobes on the operation side partially collapsed throughout. Although carbon dioxide insufflation is used, by leaving the suction catheter open to air the target lobe can be deflated with lower insufflation pressures. In our early experience we occasionally noted transient hypotensive episodes in some patients during rapid carbon dioxide insufflation. However, by titrating the insufflation pressures very gradually as described above we now infrequently encounter significant hemodynamic compromise during the procedure. We have not encountered significant problems related to hemodynamic compromise. The technique appears useful in minimizing insufflation pressures in needlescopic VATS procedures where carbon dioxide insufflation is frequently required. We also find that we do not require the near-upright patient position used by Rozenberg and coworkers in order to get adequate exposure for a sympathectomy. In an alternative method to avoid conventional onelung ventilation, Takahashi and coworkers [6] have described a technique of highly selective blockade of a lobar bronchus with a Fogarty balloon catheter placed through a single-lumen endotracheal tube. This technique allows for single lobe collapse rather than entire lung collapse thereby reducing the degree of intrapulmonary blood shunting. Using this technique they have successfully performed VATS for pectus excavatum correction, posterior mediastinal mass resection, and thoracic duct ligation [11]. Using a similar technique Morikawa and associates [12] have performed VATS bullectomies and lung segmentectomy in adult patients. However these authors have acknowledged that the use of a Fogarty catheter is not ideal. The lack of a suction port means that the deflation of the target lobe is very slow, taking place by absorption atelectasis. Insertion of the Fogarty catheter using a guidewire technique also carries the potential for airway trauma or perforation. Maintenance of balloon inflation throughout the VATS

5 282 SIHOE ET AL Ann Thorac Surg SELECTIVE LOBAR COLLAPSE 2004;77: procedure can potentially cause pressure-related damage to the bronchus, especially in children. It was also noted by these authors that the Fogarty catheter is a relatively expensive device. In comparison our technique employs a simple, inexpensive suction catheter in place of the Fogarty balloon catheter. The suction catheter allows for intermittent gentle suction to rapidly deflate the target lobe. Our results indicate that anesthesia and operating times have not been notably lengthened using our technique. The lack of an inflatable balloon obviates the potential for bronchial wall barotrauma. Compared with the placement of a Fogarty catheter using a relatively stiff guidewire our insertion technique using direct vision throughout, with a fine bronchoscope may allow more accurate placement with a lower risk of airway trauma. We have found that no modifications of standard VATS surgical techniques are required when using this selective lobar collapse technique. In our initial experience, we have found that the whole lung is usually shifted in response to the collapse of the target lobe so that the ventilated lobes are not pressed up against the chest wall. Although we still urge caution with placing ports we have thus far not encountered lung trauma as a complication of using our technique. Similarly, because of the relative shifting of the lung away from the chest wall in response to the collapse of the target lobe, we have found adequate space for the safe abrasion of the parietal pleura when performing mechanical pleurodesis. Our results have indicated the anesthetic and operating times achieved with this technique are generally comparable with those achieved by conventional onelung ventilation for VATS, suggesting that major adjustments in standard anesthetic and surgical practices are not required to master it. We do not require expensive disposable devices when using this technique. In our institute the cost of a standard adult double-lumen tube is approximately US$55 and the cost of a Fogarty catheter as used in the Takahashi technique is approximately US$75. In comparison the disposable elements using our technique consist of only a standard single-lumen endotracheal tube and a suction catheter costing approximately US$7 and US$2 respectively in our institute. At the end of a standard VATS procedure using traditional single lung ventilation, the collapsed lung is usually reinflated by selectively ventilating that side of a double-lumen tube. Using a single-lumen tube in our technique it is less easy to achieve targeted reinflation especially if the target lobe has been collapsed for an extended time. As previously noted, we sustain a positive pressure inspiratory hold through the endotracheal tube to both lungs after each procedure to reduce residual pleural air and postoperative atelectasis. We have thus far not explored the possibility of introducing air or oxygen through our suction catheter at positive pressures to selectively reexpand the target lobe although a similar selective intrabronchial air insufflation procedure has been previously reported to reduce pulmonary lobar collapse after chest trauma or surgery [13]. A potential pitfall of our technique is that the suction catheter does not necessarily achieve an airtight occlusion of the target lobar bronchus (compared for example with the Fogarty balloon technique). Gas from the ventilator may leak around the catheter and then through it to the outside atmosphere. Therefore a higher fresh gas flow and greater amount of anesthetic may be required from the ventilation to compensate for this loss. The potential for spread of air- or droplet-borne microbes in the leaking gas also exists. We would advise against using this technique in patients suspected or known to have active, contagious respiratory tract infections. For the future, studies are warranted to demonstrate if our technique of highly selective lobar collapse can reduce the physiologic harm associated with single-lung collapse for VATS. One preliminary study of 30 patients undergoing lung lobectomy surgery has found that arterial blood oxygenation following selective lobar collapse is improved compared with conventional single lung ventilation [14]. Further studies are also warranted to demonstrate whether patients unsuitable for conventional single-lung ventilation may instead tolerate our selective lobar collapse technique. If so, such patients normally excluded from VATS may be recruited for minimal access surgery by using our technique. In conclusion, we have found that our technique of single lobar collapse using a suction catheter placed through a standard single-lumen endotracheal tube is a safe and effective method of achieving highly selective single lung lobe collapse for VATS. No expensive disposable devices or major modifications of surgical technique are required. Although this technique of selective lobar collapse is not meant to replace conventional single lung ventilation, our results suggest that it deserves to be part of the armamentarium of any VATS team. References 1. Low JM. Anesthesia for video-assisted thoracic surgery. In: Yim APC, Hazelrigg SR, Izzat MB, et al, eds. Minimal access cardiothoracic surgery. Philadelphia: WB Saunders, 2000: Hannallah M. The Univent tube: bronchial cuff inflation. Anesthesiology 1995;75: Wolfer RS, Krasna MJ, Hasnain JU, McLaughlin JS. Hemodynamic effects of carbon dioxide insufflation during thoracoscopy. Ann Thorac Surg 1994;58: Tonz M, Bachmann D, Mettler D, Kaiser G. Pulmonary function after one-lung ventilation in newborns: the basis for neonatal thoracoscopy. Ann Thorac Surg 1998;66: Yim APC, Sihoe ADL, Lee TW, Arifi AA. A simple maneuver to detect air leaks on the operating table after needlescopic video-assisted thoracic surgery. J Thorac Cardiovasc Surg 2002;124: Takahashi M, Yamada M, Honda I, et al. Selective lobarbronchial blocking for pediatric video-assisted thoracic surgery. Anesthesiology 2001;94: Chen EH, Logman ZM, Glass PSA, Bilfinger TV. A case of tracheal injury after emergent endotracheal intubation: a review of the literature and causalities. Anesth Analg 2001; 93: Massard G, Rouge C, Dabbagh A, et al. Tracheobronchial lacerations after intubation and tracheostomy. Ann Thorac Surg 1996;61:

6 Ann Thorac Surg SIHOE ET AL 2004;77: SELECTIVE LOBAR COLLAPSE Rozenberg B, Katz Y, Isserles SA, et al. Near-sitting position and two-lung ventilation for endoscopic transthoracic sympathectomy. J Cardiothorac Vasc Anesth 1996;10: Hill RC, Jones DR, Vance RA, Kalantarian B. Selective lung ventilation during thoracoscopy: effects of insufflation on hemodynamics. Ann Thorac Surg 1996;61: Takahashi M, Kurokawa Y, Toyama H, et al. The successful management of thoracoscopic thoracic duct ligation in a compromised infant with targeted lobar deflation. Anesth Analg 2001;93:96 7. INVITED COMMENTARY This paper describes a technique that has worked well for the authors in a small subset of cases that allows partial lung collapse for thoracoscopic procedures. The technique itself appears fairly simple, but in the majority of cases did require the use of carbon dioxide insufflation. This method is designed to replace the need for double lumen endotracheal tubes and single lung ventilation. Our experience has been very good with the use of double lumen endotracheal tubes. They provide optimal visualization of the surgical field for thoracoscopic procedures and, as such, expedite the rapid performance of these procedures. Although the authors suggest no delays in their surgical times by using this technique, I believe it is quite possible, particularly with more advanced surgical procedures, that using this method will increase the operative time, thereby offsetting any cost advantage from avoiding the double lumen endotracheal tubes. In addition, in the last 10 years with over 3,000 procedures using double lumen endotracheal tubes, we have had only one significant airway injury. I believe that this attests to the general safety of the placement of double lumen endotracheal tubes in experienced hands. The need for carbon dioxide insufflation changes the flow of the procedure as we perform it today. In fact, we often do not use trocars at our access sites. Instead, we 12. Morikawa T, Sugiura H, Kaji M, et al. Availability of lobeselective bronchial blockade for video-assisted thoracic surgery: an initial experience with three cases. Surg Endosc 2002;16: Haenel JB, Moore FA, Moore EE, Read RA. Efficacy of selective intrabronchial air insufflation in acute lobar collapse. Am J Surg 1992;164: Campos JH. Effects of oxygenation during selective lobar versus total lung collapse with or without continuous positive airway pressure. Anesth Analg 1997;85: use a simple skin incision with an incision between the intercostal space and then use standard instruments. Adding the need for CO 2 requires keeping seals, and can be cumbersome, while making it difficult to use some of the instrumentation that we normally use. In summary, I believe that for simple procedures this technique can be utilized. However, for the majority, I am doubtful that there is any clinically significant benefit. There may be a small subset where this technique may have a role, such as those that have severely compromised pulmonary function or where the use of a double lumen endotracheal tube is not possible. For the vast majority of cases, I personally will accept the cost of a double lumen endotracheal tube so that I can achieve optimal visualization. Stephen R. Hazelrigg, MD Department of Cardiothoracic Surgery Southern Illinois University School of Medicine PO Box N Rutledge, Room D319 Springfield, IL shazelrigg@siumed.edu 2004 by The Society of Thoracic Surgeons /04/$30.00 Published by Elsevier Inc doi: /j.athoracsur