Managing Adhesions and Air Leaks in Lung Volume Reduction Surgery

This instructional video demonstrates techniques for managing adhesions and preventing air leaks during right upper lobe lung volume reduction surgery (LVRS) in patients with severe emphysema.

In Case 1, a 79-year-old patient with significant comorbidities presented with extensive adhesions between the right upper lobe and the chest wall. Careful adhesiolysis was performed using cauterization while staying close to the parietal pleura to protect the visceral pleura. Additional adhesions at the apex and around the azygos vein were released, ensuring clear visualization and safe continuation of the procedure.

Case 2 highlights a 65-year-old patient with persistent hyperinflation despite prior endobronchial valve therapy. Adhesions within the fissure were dissected using scissors to minimize tissue damage and reduce the risk of postoperative air leaks. Dense adhesions unsuitable for dissection were managed with reinforced stapling. In the anterior mediastinum, dissection techniques such as the “blunt drilling technique” and suction-assisted release were used effectively. Critical anatomical landmarks, including the azygos vein, superior vena cava, and phrenic nerve, were clearly identified and preserved.

A key technical point emphasized is the complete release of adhesions between the azygos vein and the bronchus. Failure to do so may result in traction injury during stapling and lead to severe, irreparable air leaks.

The video also outlines a structured approach to perioperative air leak management. After lung reinflation, air leaks are assessed by comparing inspired and expired tidal volumes, with up to a 10 percent difference considered acceptable. When a significant leak is detected, underwater testing is used to localize the source. Once identified, air leaks are addressed with reinforced stapling and reassessed iteratively. Sealant sheets can be applied to strengthen staple lines.

The key take-home messages are to handle lung tissue with minimal touch, dissect chest wall adhesions close to the parietal pleura, avoid cautery in fissures, and use stapling when necessary. It is essential to ensure that critical anatomical spaces are fully cleared and to systematically evaluate and treat air leaks in collaboration with anesthesia.

The guiding principle throughout is clear: avoid, do not accept, and reintervene.

Disclosure

Professor Dr. Laurens J. Ceulemans is a consultant for Medtronic.

This video submission is from the 2026 CTSNet Instructional Video Competition. Stay tuned to CTSNet.org and the CTSNet YouTube channel in the coming weeks to watch all entries from the competition, including the winning videos.  

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