Apical Bleb Resection

Apical bleb resection is the simplest procedure, and is as suited to thoraco-scopic intervention as cholelithiasis is suited to laparoscopic intervention. Apical blebs are identified thoracoscopically by placing the camera in the sixth intercostal space in the midaxillary line. The grasper and the stapler are positioned at the first base and third base positions as discussed previously. Figure 25.2 describes the positions.

Sometimes the apical bleb is very difficult to identify and a 30° scope may be useful instead of the 0° scope in going up above the apex in the lung to identify the lesion. It may be helpful to instill some saline in cases in which no bleb is identified and try to inflate the lung to see if there is any air coming out of the apical bleb. After the bleb has been resected, a pleural abrasion procedure should be done. This is accomplished by taking a piece of cautery scratch pad and inserting it through the stapler trocar site using a grasper and rubbing the apical parietal surface of the pleural space to produce ultimate fusion of the visceral and parietal areas.

Fig 25.2. Video thoracoscopy for apical bleb resection and abrasion pleurodesis. The camera is inserted into the sixth interspace in the midaxillary line. The grasper and stapler are on either side. Abrasion pleurodesis is performed using a cautery scratch pad inserted through the stapler part. Reprinted with permission from Ann Thoracic Surg 1992; 54:800-807.

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