Use of autologous pleural flap buttress in thoracoscopic lung volume reduction surgery

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staple line after resection of the emphysematous lung has been a major complication after LVRS. 1 Several techniques, with fibrin glue, bovine pericardial strip buttressing, 3 fold plication, 4 or polyglycolic acid felt buttressing, 5 have been developed to prevent this postoperative air leakage. Although these techniques substantially reduce major, prolonged, or both air leakages, disadvantages include incorporation of foreign materials and cost. We have recently developed a new technique using an autologous pleural flap to buttress the staple line. The new procedure is simple, effective, and cost free, and it might enhance pleural adhesion after surgical intervention. Clinical Summary A 62-year-old man who had been a heavy smoker (one pack per day for 50 years) had progressive exertional dyspnea for 5 years before admission. Chronic obstructive pulmonary disease was diagnosed on the basis of chest radiography and spirometry examination. Despite regular use of oral and inhalational bronchodilators and oral prednisolone at the outpatient clinic, the dyspnea symptoms had worsened. After admission, the functional class was assessed as World Health Organization class III, and the patient was mostly confined to bed with nasal oxygen support. The spirometry study revealed a forced vital capacity of 2.52 L (82.3%), a forced expiratory volume in 1 second (FEV1.0) of 0.69 L (28.3%), a percent FEV1.0 of 27.4%, a residual volume of 3.7 L (236.3%), a total lung capacity of 6.4 L (137.4%), and a maximum voluntary ventilation of 17.9 L/min (22.8%). Diffusion capacity was 8.7 mL · min 1 ·m m Hg 1 (47.6%). The pulmonary exercise maximum oxygen consumption was 13.1 mL · min 1 kg 1 (43.3%). Chest computed tomography showed diffuse emphysematous changes with bulla formation, which was more severe on the bilateral upper lobes. Ventilation scans revealed heterogenous tracer ventilation in bilateral lung fields, and arterial blood gas on room air was pH 7.39, PaO2 was 78.5 mm Hg, PaCO2 was 38.5 mm Hg, and HCO3 was 22.8 mEq/L. The patient was deemed a good candidate for LVRS, with the new technique subsequently used during the operation. LVRS was performed by the bilateral thoracoscopic approach. First, a left-sided double-lumen tube was inserted to provide unilateral lung collapse during the thoracoscopic procedure. The patient was placed in the true lateral position, with his right side upward. A camera port (1 cm) was first made in the ninth intercostal space (ICS) along the midaxillar line. After inspection of lung pathology, a 3-cm working port was made in the third ICS in the midsubaxillar area, without entrance into the parietal pleura. Another 1-cm working port was made subsequently in the fifth ICS along the anterior-axillar line. Blunt dissection was commenced on the first working port, with the dissection plane between the parietal pleura and chest wall. Dissection of a large flap of parietal pleura was very simple because the interior between the parietal pleura and chest wall consisted only of areolar tissue (Figure 1, a). The area of dissection was anterior to the mediastinum, posterior to the paraspinal area, and extended downward to the fifth ICS, which was carefully preceded to avoid injury to the sympathetic trunk and intercostal vessels. Subsequently, a pleural flap