Understanding the anatomy of the thoracic cavity, particularly the lung, is important for the successful completion of a lung volume reduction surgery (LVRS). Figure 17-1 demonstrates key anatomic structures that must be considered before performing a thoracoscopic LVRS.

LVRS is a treatment option for patients suffering from moderate to end-stage emphysema and serves as a bridge toward lung transplantation by improving pulmonary function. This procedure is designed to address physiologic manifestations through palliation of the symptoms by removing or plicating damaged areas of lung tissue to permit elastic recoil improvement and a reduction in residual volume. The thoracoscopic LVRS procedure helps minimize surgical trauma and significantly decreases wound infection and breakdown.

Patient screening is paramount to optimizing the benefit of this procedure through identification of patients who have failed medical therapy and have an acceptable surgical risk.

Screening should include an extensive history and physical examination, pulmonary function tests, and imaging studies or radiographic observation (radiographs and computed tomography [CT] scans).

Distinguishing emphysema from intrinsic airway disease or chronic bronchitis is crucial in patient selection. A diagnosis of emphysema is made in patients with increased total lung capacity and residual volume, severely reduced expiratory airflow, and decreased diffusion capacity.

Surgery should be performed after the greatest benefit is obtained from preoperative therapy.

Surgical targets of the long are established preoperatively, and areas most severely affected by emphysema are identified through CT or lung scintigraphy ( Fig. 17-2 ).

The National Emphysema Treatment Trial (NETT Trial) mandated a stapled bilateral approach to LVRS unless contraindicated.

Indications for unilateral LVRS include unilateral or asymmetric emphysema, contralateral pleurodesis, or thoracotomy ( Table 17-1 ).

A thoracic epidural catheter is placed and tested before inducing general anesthesia for postoperative analgesia.

After general tracheal anesthetic, flexible bronchoscopy is performed with a single-lumen endotracheal tube, which allows for assessment, clearance, and culture of secretions and possible endobronchial malignancies.

Patient is then reintubated with a double-lumen endotracheal tube for split-lung ventilation.

Bilateral LVRS can be performed with the patient placed in a supine position with arms over head and secured to the operating table. Support may be added beneath the patient’s spine, shoulders, and hips.

Alternatively the patient can be placed in the lateral decubitus position, alternating for the bilateral procedure under one anesthetic. Ensure that the chest drains in the first pleural space remain unobstructed during contralateral procedure.

Unilateral LVRS is best performed with patient in the lateral decubitus position.

Presence of posterior pleural adhesions or resecting portions of the lower lobe requires the lateral decubitus position.

A wide area of the chest is prepped for surgical incision. For alternating bilateral procedures, the patient needs to be reprepped and draped.