Case video report on uniportal VATS for giant bullous emphysema (GBE) with wide resection of a giant bulla in the right upper lobe

Introduction

Giant bullous emphysema (GBE), also known as vanishing lung syndrome, is a rare and severe manifestation of chronic obstructive pulmonary disease (COPD). It is characterized by the presence of large bullae, typically occupying more than one-third of the hemithorax, which compress surrounding lung parenchyma and impair respiratory function. These bullae are prone to rupture, leading to life-threatening complications such as spontaneous pneumothorax, or in other cases, they can be completely asymptomatic (1,2).

The optimal management of GBE involves careful patient selection and, in suitable cases, surgical intervention to restore lung function and prevent recurrent complications. The formation of bullae in GBE is associated with alveolar wall destruction due to chronic inflammation, often linked to smoking or environmental exposure to toxins. Over time, these bullae expand, replacing functional lung tissue and resulting in severe dyspnea, reduced exercise tolerance, and recurrent infections. The compression of adjacent lung tissue exacerbates the functional impairment. Radiologically, GBE is often diagnosed using high-resolution computed tomography (HRCT), which reveals the extent of bulla formation and its impact on surrounding structures (3). While conservative management, including smoking cessation and bronchodilator therapy, is recommended for stable patients, surgical intervention is often necessary for those with symptomatic GBE or recurrent complications. Nowadays, this type of condition is commonly treated in a minimally invasive way through video-assisted thoracoscopic surgery (VATS). There is an increasing trend toward adopting the uniportal video-assisted thoracoscopic surgery (U-VATS) technique, driven by its promising outcomes. The surgical community is increasingly focusing on minimizing surgical invasiveness, striving to offer patients less pain, faster recovery times, and better overall results. This shift reflects a broader movement in the field towards optimizing surgical approaches to improve patient care while reducing the impact of the procedure. The aim of this case report is to show how it is possible to resect a giant bulla through the minimally invasive U-VATS approach, reinforcing the stapler line by buttressed materials, to obtain optimal clinical and functional results. This case is presented in accordance with the CARE reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-38/rc).

Case presentation

A 34-year-old non-smoking male patient was admitted for progressive dyspnea and right-sided chest pain in the last 9 months. No family history for pulmonary disease. Chest computed tomography (CT) revealed a GBE in the right upper lobe (RUL), causing partial compression of the remaining lung parenchyma (Figure 1). The pulmonary bulla, as seen on the CT, originated from the RUL, in the region of segment S1–S3, compressing the lobe itself and partially affecting the middle lobe as well as the apical segment (S6) of the right lower lobe. The dimension of the larger bulla was 88.9±56.6 mm. Due to the symptoms and functional impairment, the patient was scheduled for a lung volume reduction surgery by U-VATS.

Figure 1 Computed tomography scan of right upper lobe bulla. (A) Axial scan; (B) coronal scan.

Surgery was performed in general anesthesia, with patient in lateral left decubitus and single lung ventilation. A single 3-cm incision was made in the 5th intercostal space along the middle axillary line. A wound protector (Alexis^® Small) was used to protect the intercostal space and prevent soiling of the camera (30°/10 mm) during the procedure. Dedicated long and curved instruments with double articulation (proximal and distal) were utilized to enhance maneuverability within the cavity through the single incision.

Video 1 shows the localization in the RUL of the known bulla that protrudes into the mediastinum (Figure 2). Careful lysis of pleuro-mediastinal adhesions was performed using electrocautery until complete mobilization of the lung parenchyma was achieved. As shown in the video, the main adhesions were between the RUL and the mediastinal pleura, likely due to inflammatory sequelae. Once the bulla was isolated, the location of the bulla implant was localized in the RUL within the fissure with the middle lobe. Therefore, parenchymal resection was carried using multiple loads of reinforced Gore^® Seamguard^® EndoGia sutures 45- or 60-mm cartridges, on a portion of healthy parenchyma to make the resection effective avoiding air leaks.

Figure 2 Pulmonary right upper bulla.

Subsequently, further bullectomy of a smaller mediastinal bulla was performed using a single load of mechanical stapler, which did not require a reinforced stapler due to its small size and healthy parenchyma. A bubble test was performed at the end of surgery that showed no signs of air leaks. The residual lung parenchyma was completely inflated. Time of surgery was about 67 minutes. The procedure was successfully completed without intraoperative complications. The postoperative course was uneventful. After surgery and on postoperative day 1, a chest X-ray was performed, being regular. Rapid clinical and radiological improvement was observed and the patient was discharged on postoperative day 4.

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Discussion

VATS has emerged as the gold standard for lung volume reduction surgery in GBE due to its minimally invasive nature. The U-VATS approach, in particular, has gained popularity in recent years due to its significant advantages over traditional open surgery or multiport VATS (4,5). The U-VATS technique involves a single small incision through which both the camera and surgical instruments are introduced (6). Using high-definition visualization, the surgeon identifies and resects the bullae, ensuring preservation of healthy lung parenchyma. Stapling devices, often reinforced with materials such as Gore^® Seamguard^® or bovine pericardium, have proven to be essential in cases of large bullae to minimize postoperative air leaks and ensure a durable repair (7). The main advantages of U-VATS approach are: (I) minimized surgical trauma: compared to thoracotomy, U-VATS significantly reduces postoperative pain and complications; (II) faster recovery: patients undergoing U-VATS experience shorter hospital stays, quicker returns to daily activities, and improved quality of life (8); (III) improved outcomes: the reduction in dead space and restoration of lung expansion led to enhanced pulmonary function and better exercise tolerance. The presented case underscores the efficacy of U-VATS in treating GBE in terms of outcomes. The limit of the technique is related to its learning curve; therefore, growing experience in using this technique is necessary, even for this type of disease, which, although benign, could present difficulties, i.e., it may be challenging, especially for those who are not yet experts, when mobilizing the parenchyma with a very large bulla. The use of reinforced staplers, such as Gore^® Seamguard^®, played a pivotal role in minimizing air leaks, a common challenge in patients with fragile lung parenchyma. As shown in literature (7), the use of these staplers is essential due to their coating, which varies depending on the stapler used, as it ensures a more effective healing process and helps prevent the resected lung area from giving way due to its fragility. The patient experienced significant clinical and radiological improvement, with restored lung expansion and alleviation of dyspnea. These results align with evidence from the literature, which highlights the importance of advanced surgical techniques in achieving optimal outcomes (9). Although U-VATS offers significant advantages, it requires expertise in thoracic surgery, particularly for managing large bullae. Preoperative evaluation, including pulmonary function tests and imaging, is crucial. Postoperative air leaks remain a concern, but conservative management is effective in most cases. The use of reinforced staplers provides an additional layer of security, reducing complications and enhancing long-term success.

Conclusions

The management of GBE via U-VATS represents a significant advancement in thoracic surgery. By combining minimally invasive techniques with meticulous surgical planning and the use of reinforced staplers, this approach ensures favorable patient outcomes with reduced morbidity. Continued research is needed to explore long-term outcomes and the potential of integrating emerging technologies, such as robotic-assisted thoracoscopic surgery, to further improve the treatment of this complex condition.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-38/rc

Peer Review File: Available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-38/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jovs.amegroups.com/article/view/10.21037/jovs-24-38/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent was obtained from the patient for the publication of this case report, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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