The experience gained with the use of mechanical sutures in the resection of emphysematous blebs and bullae in open operations can readily be transferred to thoracoscopic procedures. Since this approach does not create a painful thoracotomy incision, the postoperative course is much easier for both patient and surgeon alike, to the point where bilateral lesions can be addressed during the same hospitalization, in a second stage, as described below. Similarly, the lung volume reduction for emphysema (Figure II-4, A to E) can be performed as a two-stage thoracoscopic procedure with a much easier postoperative course than a one-stage operation through a median sternotomy. Since the ENDO GIA™ instruments place three staggered rows of staples on each side of the cutting blade, the use of pericardial strips may not be required so rigorously if the tissue to be stapled and transected is sufficiently competent in preventing airleaks, after testing in one corner of the area to be excised with an application of the ENDO GIA™ 30.
In a 42-year-old man with bilateral giant bullae, which occupied over half of both hemithoraces and reduced the patient to a pulmonary cripple, we left two small, benign-appearing blebs in place, using a judgment derived from the "open" era. The resection of three giant bullae on the left required 10 applications of the ENDO GIA™ 60 instrument. Postoperatively, over a 1-week period, while the patient was breathing room air through his normal upper airways, the two small and thick-walled fibrotic blebs expanded into the newly available space, faster than the remaining lung. However, it was a simple technical matter to reoperate through the same thoracoport sites and remove these two recalcitrant blebs that had expanded into bullae.
The second side (right) was operated on a week later and all giant bullae and blebs were removed with 14 applications of the ENDO GIA™ 60 and ENDO GIA™ 30 instruments, depending on maneuverability within the chest cavity. The patient returned to his regular employment as a laborer and was able to climb two floors of steps briskly without any shortness of breath.