How is bullectomy performed?

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

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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