Bullectomy Technique

Updated: Feb 21, 2019
  • Author: Neerja Gulati, MD; Chief Editor: Dale K Mueller, MD  more...
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Technique

Approach Considerations

Careful patient selection is the key to achieving good results.

Early extubation and appropriate invasive and noninvasive monitoring are needed.

Air leakage can be reduced by minimizing the duration of positive-pressure ventilation and applying a secure staple line with or without buttress material/fibrin sealants and creation of a pleural tent.

Chest tube connection to water seal/suction and monitoring for development or worsening of a pneumothorax are needed.

Postoperative pain control, bronchodilators, antibiotics, and pulmonary toileting are needed.

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Removal of Lung Bulla

Choice of approach

The choice of surgical technique depends on the size and number of bullae to be removed. The main options are video-assisted thoracic surgery (VATS) and open thoracotomy/sternotomy, with VATS being the less invasive approach. [20, 21, 22, 23, 24]

When an open thoracotomy is performed, the anterolateral or posterolateral approach is generally used for unilateral and median sternotomy for bilateral disease. [15, 25]  

VATS is the preferred approach for patients who are at excessive risk with thoracotomy. [26]  VATS also allows quicker recovery and is associated with less pain than thoracotomy and can be used for bilateral disease.26 Various single-incision thoracoscopic surgical (SITS) approaches have been described. [27, 19]

Operative details

The objectives of concern for surgeon are the following:

  • Amount of lung adjacent to the bulla that should be removed
  • Method of resection
  • Prevention of air leaks

A bulla with a broad stalk is managed with stapler excision or plication. If several bullae exist and it is hard to define healthy tissue, wedge resection is performed. If an entire lobe of lung is affected, lobectomy is performed. (See the images below.)

Flattened bulla. Image courtesy of Richard Lazzaro Flattened bulla. Image courtesy of Richard Lazzaro, MD, New York Methodist Hospital.
Surgical field showing multiple bullae. Image cour Surgical field showing multiple bullae. Image courtesy of Richard Lazzaro, MD, New York Methodist Hospital.
Surgical field showing bullae. Image courtesy of R Surgical field showing bullae. Image courtesy of Richard Lazzaro, MD, New York Methodist Hospital.

The bulla is usually excised with a rim of normal lung parenchyma to avoid leaving open bronchioles. The various techniques include stapler excision, plication, and (less commonly) laser ablation. Additional small bullae and blebs in the residual lung are often excised.

Buttressing of the suture line to prevent an air leak can be done with exogenous material, fibrin sealant, or creation of an apical postoperative pleural tent.

Bovine pericardial strips and other synthetic material (eg, polytetrafluoroethylene [PTFE]) are used to buttress fragile lung tissue. Application of fibrin glue, use of cryoprecipitate, and even reinforcement by the wall of the bulla have been performed to reduce air leaks. [28]

Another surgical technique is the creation of a pleural tent, which reduces the size of the pleural cavity and enables apposition between the sutured surface of the lung and the chest wall. [29]  This is done by dissecting parietal pleura from the chest wall and tailoring it to make a tent for the residual lung. [30, 31, 32, 5, 33, 34, 35]

After resection of the bulla, the lung is examined for air leakage and bleeding. Gentle reexpansion of the residual lung is carried out to check how it fills the pleural cavity. One or two chest tubes are left in the pleural cavity.

The management of drains and tubes is highly variable among surgeons. A retrospective analysis of 838 patients who underwent elective pulmonary resection found that chest tubes on water seal are safe for most patients with an air leak and a pneumothorax. Chest tubes were connected to the drainage system, and –20 cm H2O of suction was added on the day of surgery. The chest tubes were then placed on water seal on the morning of postoperative day 1.

Chest radiographs were obtained daily. All tubes remained on water seal unless they failed water seal. For those who failed water seal (as evidenced, for example, by development of new-onset hypoxia, enlarging pneumothorax, or development of new-onset or enlarging subcutaneous emphysema), chest tubes were then placed to –10 cm H2O of suction. If the problem continued after 24 hours, the tubes were then placed to –20 cm H2O of suction.

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Postoperative Care

Early extubation is the goal. Epidural analgesia and opioids are generally used for pain management in the postoperative period. [8]  Epidural analgesia should be used liberally to provide regional pain control and minimize postoperative narcotic use and respiratory suppression.

Early postoperative ambulation on the day of surgery is encouraged. Early ambulation is important because it drives CO2 production, forcing the patient to ventilate and thereby mitigating postoperative atelectasis.

The chest tubes are left in the thoracic cavity until the air leak is resolved and the lung is fully expanded. Patients are monitored for hypoxia and hypercarbia. Chest radiography is performed as needed for pneumothorax.

The patient should receive bronchodilators and prophylactic antibiotic coverage, along with deep venous thrombosis (DVT) prophylaxis.

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Complications

The most common pulmonary complications of bullectomy are as follows [9, 11, 34, 15, 35] :

  • Air leakage
  • Postoperative respiratory failure
  • Pneumonia
  • Bleeding

The most common cardiac complications are as follows:

Other complications include the following:

In a series of 43 patients who underwent resection of a giant bulla, prolonged air leakage lasting for more than 7 days was seen in 53%, atrial fibrillation (AF) in 12%, postoperative mechanical ventilation in 9%, and pneumonia in 5%. [11]  Another study described prolonged air leakage lasting for more than 7 days in 46% and subcutaneous emphysema in 53% of patients undergoing VATS. Better results may be expected in patients without underlying diffuse emphysema. [17]

In a series of 41 patients, mortality within the first year was 7.3%, and late mortality was 4.9%. [13]  Causes of death included postoperative pneumonia, acute and chronic respiratory failure, PE, and MI.

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