VATS

BULLECTOMY

Initial shillong Experience

Dr L.M.Darlong
Asst Prof Surgery
NEIGRIHMS Shillong
lmdarlong@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 Therapeutic
• Pleurodesis/Empyema
• Pleura • Mediastinal mass
• Bullous lung disease
• Lung parenchyma • Lobectomy/ wedge ex /
pneumonectomy
• Mediastinum
• 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 Experience
Case Age Indication Intraop Vats OT Postop Duration Postop Follow-
/ sex procedure time compli of chest stay up
(mins) drain (days ) (months )
cation (days )
1 32/M Chest pain, Left apical Stappled 150 4 5 5
dyspnoea bullae bullectomy
pnx Mech pld
Persistent
pnx air leak
2 32/M Contra lateral Rt apical Stappled 120 Cathete 3 4 4
bulla bullae bullectomy r
Mech pld related
prepuc
e
edema
3 42/M Chest pain , Rt apical Stappled 180 3 5 5
apical bulla bulla with bullectomy
sub Endoloop
pleural ligation.
blebs

NO BLOOD TRANSFUSION
 VATS - WHY
Access procedure

Benefits
•Postop Pain Cellular level
•Postop stay •Cytokine activation
•Acceptance
•Cosmetic •Immune function
•Cost benefit
•Long term benefits
Instrumentation
Author No
Review of literature
O.T Indications Postop Chest Postop Follow
of time Complication drain Hospital up
case (mins) Removal Stay (days) (mths)
s (days)
Akio 16 Dyspnoea(10) Air leak(3-62 36
w.etal Spontaneous days)
pneumothorax(6)
Infection(1)
Teriyashi 50 147.8 Giant bulla(6) 5.2(bulla) 11.3(bulla)
etal (bulla) Spontaneous 1.2(bleb) 4.7(bleb)
45.9 pneumothorax(44)
(bleb)
H.P.Liu 79 70 Symptomatic Subcutaneous 6 9.6 21
etal Bullous emphysema(3)- (4-16) (5-26) (5-37)
(40- emphysema 3.8%
110) Air leak>10
days(7)-8.9%
Localized
empyema(2)
Wound
infection(3)
Gian 29 Spontaneous Reoperation for 5 6 16
franco pneumothorax(23) persistent air (3-14) (3-16) (1-36)
etal Choice(6) leak(2)
Respiratory
failure(2)-6.9%
Tiziano 25 107=25 Complication of Air leak>7 8=4.13 11=5.76
etal bulla(9) days(12)-48%
Dyspnoea(12)
Asymptomatic
giant bulla(4)
 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