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Lung Ventilation with Carbon Dioxide Insufflation

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Lung Ventilation with Carbon Dioxide Insufflation Original Article Single-port thoracoscopic surgery for pneumothorax under two- lung ventilation with carbon dioxide insufflation Kook Nam Han1, Hyun Koo Kim1, Hyun Joo Lee1, Dong Kyu Lee2, Heezoo Kim2, Sang Ho Lim2, Young Ho Choi1 1Department of Thoracic and Cardiovascular Surgery, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea; 2Department of Anesthesiology and Pain Medicine, Korea University College of Medicine, Seoul, Republic of Korea Contributions: (I) Conception and design: HK Kim; (II) Administrative support: HK Kim; (III) Provision of study materials or patients: HK Kim, YH Choi, DK Lee, H Kim, SH Lim; (IV) Collection and assembly of data: HK Kim, KN Han, HJ Lee; (V) Data analysis and interpretation: KN Han, HJ Lee; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Hyun Koo Kim, MD, PhD. 97 Guro-donggil, Guro-gu, Seoul 152-703, Republic of Korea. Email: [email protected]. Background: The development of single-port thoracoscopic surgery and two-lung ventilation reduced the invasiveness of minor thoracic surgery. This study aimed to evaluate the feasibility and safety of single-port thoracoscopic bleb resection for primary spontaneous pneumothorax using two-lung ventilation with carbon dioxide insufflation. Methods: Between February 2009 and May 2014, 130 patients underwent single-port thoracoscopic bleb resection under two-lung ventilation with carbon dioxide insufflation. Access was gained using a commercial multiple-access single port through a 2.5-cm incision; carbon dioxide gas was insufflated through a port channel. A 5-mm thoracoscope, articulating endoscopic devices, and flexible endoscopic staplers were introduced through a multiple-access single port for bulla resection. Results: The mean time from endotracheal intubation to incision was 29.2±7.8 minutes, the mean operative time was 30.9±8.2 minutes, and the mean total anesthetic time was 75.5±14.4 minutes. There were no anesthesia-related complications or wound problems. The chest drain was removed after a mean of 3.7±1.4 days and patients were discharged without complications 4.8±1.5 days from the operative day. During a mean 7.5±10.1 months of follow-up, there were five recurrences (3.8%) in operated thorax. Conclusions: The anesthetic strategy of single-lumen intubation with carbon dioxide gas insufflation can be a safe and feasible option for single-port thoracoscopic bulla resection as it represents the least invasive surgical option with the potential advantages of reducing operative time and one-lung ventilation-related complications without diminishing surgical outcomes. Keywords: Pneumothorax; thoracoscopy/video-assisted thoracoscopic surgery (VATS); minimally invasive surgery; anesthesia; ventilation Submitted Feb 04, 2016. Accepted for publication Mar 10, 2016. doi: 10.21037/jtd.2016.03.95 View this article at: http://dx.doi.org/10.21037/jtd.2016.03.95 Introduction lung (1,2). The goal of surgical therapy is to reduce the likelihood of a recurrence, which can exceed 50% if not A pneumothorax is a collection of air in the pleural space between the lung and chest wall. Primary spontaneous managed appropriately (3). Video-assisted thoracoscopic pneumothorax is a common disease that usually occurs surgery (VATS) is the preferred surgical method of resecting in tall, thin young men as a result of the rupture of bullae or blebs and creating a pleurodesis (4,5). emphysematous subpleural bullae or blebs in the apical Recently, the surgical technique for VATS has evolved © Journal of Thoracic Disease. All rights reserved. jtd.amegroups.com J Thorac Dis 2016;8(6):1080-1086 Journal of Thoracic Disease, Vol 8, No 6 June 2016 1081 into single incisional thoracoscopic surgery (SITS) Table 1 Characteristics of the study population (N=130) performed through 2- to 3-cm incisions (6,7). In addition, Characteristics Value some groups, including ours, reported on the feasibility and Sex, n (%) safety of SITS for minor to major lung resection in benign Male 121 (93.1) or malignant thoracic disease (8-11). The potential benefits Female 9 (6.9) of SITS in thoracic surgery reportedly include reduced Age, mean ± SD* (years) 22.6±8.3 intercostal pain (12,13), reduced surgical trauma (14), and surgeon hand-eye coordination similar to that of open Laterality, n (%) thoracotomy (15). The single-port approach also promises Right 58 (44.6) improved ergonomics through the development of SITS Left 54 (41.5) endoscopic devices and their combination with robotics (16). Bilateral 18 (13.9) Despite recent improvements in surgical technique, *SD, standard deviation. one-lung ventilation anesthesia (OLVA) is still indicated in most thoracic surgeries and can be performed with double-lumen endotracheal intubation or with bronchial Methods blockers through single lumen endotracheal intubation (17). During VATS for pneumothorax, OLVA is used for Patients the identification and resection of bullous lesions in a A consecutive series of 130 patients with primary non-ventilated state since bullae are most commonly treated spontaneous pneumothorax underwent single-port with endoscopic stapling. Many physiological disadvantages thoracoscopic bleb resection using a SILS port under TLVA of OLVA have been reported including overventilation of a non-collapsed lung resulting in a postoperative ventilation/ with CO2 gas insufflation between February 2009 and perfusion mismatch, hypoxemia, sputum retention, May 2014 at our institution. The study was approved by consolidation, and edema in the operative lung (18,19). our institution’s Ethics Committee, and written informed Moreover, fiberoptic bronchoscopy is essential for confirming consent was obtained from all patients in accordance with the proper location of the endotracheal tube or blocker (20). the Declaration of Helsinki (institutional review board no. These OLVA-related problems can be minimized with KUGH14263-001). Initially, all patients were managed adequate intraoperative management and postoperative with a tube thoracostomy. Chest computed tomography care. However, even minor adverse events after VATS for was performed to identify subpleural bullae or blebs. Our pneumothorax in patients with poor pulmonary function and hospital’s surgical indications were reported previously (22). lung manipulation during surgery can increase postoperative Patients with a first episode of bullae or blebs on chest lung problems such as pulmonary edema or atelectasis, computed tomography, combined hemothorax, an air leak resulting in prolonged hospital stays (21). lasting more than 5 days, an unexpanded lung, bilateral Since 2007, we have been using a two-lung ventilation pneumothorax, tension pneumothorax, or recurrent anesthesia (TLVA) strategy with low tidal volume during attack were included in our study. Patients with secondary VATS for pneumothorax (22). We previously reported pneumothorax with severely emphysematous lungs or that TLVA was cost-effective and time-saving compared pneumothorax caused by traumatic injury and moderate- with OLVA (23). In 2009, we started performing SITS for to-severe adhesions on computed tomography scans were pneumothorax under TLVA with carbon dioxide (CO2) excluded (Table 1). gas insufflation using a special multiple-access single port (SILSTM port, Covidien, Mansfield, MA). The SILS port Anesthesia has multiple channels including a three-way stopcock for gas infusion, which enabled the performance of SITS The TLVA protocol used during single-port surgery was under TLVA with gas infusion to achieve acceptable the same as that described in our previous report (24). After surgical views. To our knowledge, there are no reports on general anesthesia induction, patients were intubated with SITS under TLVA. This was the first study to evaluate the a single-lumen endotracheal tube (Sheridan/CF Tracheal feasibility and safety of SITS performed using a SILS port Tubes, ID 7.0 for women and ID 8.0 for men; Hudson RCI, under TLVA with CO2 gas insufflation for pneumothorax. Durham, NC) and ventilated with a volume of 10 mL/kg, © Journal of Thoracic Disease. All rights reserved. jtd.amegroups.com J Thorac Dis 2016;8(6):1080-1086 1082 Han et al. Single-port VATS for pneumothorax under two-lung ventilation Single lumen intubation Bullectomy Ventilator setting: Tidal volume 5 mL/kg Respiratory rate 15-22/min I:E ratio =1:2 Carbon dioxide insufflation Instruments on SILS port Figure 1 Operative setting and procedures for single-port thoracoscopic bleb resection through a multiple-access single port under two-lung anesthesia with carbon dioxide insufflation. a respiratory rate of 12 breaths/min at a 0.5 fraction of prevent instrumental conflicts was introduced to identify inspired oxygen, a 1:2 inspiratory-to-expiratory ratio, and pleural adhesions and bullae or blebs. After inspecting a 1.5 L/min flow rate for oxygen and nitrous oxide without the location and extent of bullae or blebs, we used one or positive end-expiratory pressure. Immediately before two flexible endoscopic staplers to resect the apical lung surgical incision, the tidal volume was reduced to 5 mL/kg lesion along with an articulating Endo Grasper. Finally, the and the respiratory rate was increased to 15 breaths/min CO2 gas insufflation was stopped and the SILS port was (Figure 1). CO2 retention and intrinsic positive end-expiratory removed; a resected lung specimen was retrieved through pressure were monitored using end-tidal CO2 and a the incision. The
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