LVRS: Decreasing Lung Volume to Increase Patient Vitality

Lung volume reduction surgery (LVRS) is a surgical procedure predominantly utilized to treat patients diagnosed with a subtype of chronic obstructive pulmonary disease (COPD), severe emphysema. The condition is a progressive lung disease caused by long-term smoking or exposure to harmful environmental factors, leading to significant breathing difficulties and reduced quality of life as a result of the destruction of alveoli (the tiny air sacs responsible for gas exchange). This destruction entails the formation of large, nonfunctional air spaces called bullae, which reduce the surface area used for gas exchange and trap air, leading to hyperinflation of the lungs. The hyperinflation hence hinders the diaphragm’s ability to contract and relax, which impairs the simple mechanics of breathing, reducing the efficiency of ventilation.

LVRS involves the removal of diseased lung tissue to enhance the quality of life of the patient. It improves lung mechanics by resecting hyperinflated and thus nonfunctional tissue, allowing the remaining healthier lung tissue to expand more effectively. This reduces lung volume (hence the name!) and helps the diaphragm contract by giving it an optimal position, enhancing the once-compromised ventilatory efficiency. It also advances gas exchange by reducing the volume of dead space in the lungs, considering that the operation leads to better aeration, oxygenation, and carbon dioxide expulsion from the bloodstream. The severe hyperinflation of emphysema suppresses cardiac output by compressing the heart, but by LVRS, said compression is alleviated, granting potentially improving hemodynamics and cardiac function.

LVRS involves equipment depending on the approach used. Two surgical techniques are typically used:

1. Median/midline sternotomy

The patient is placed in supine position (laying faced upwards) and put under general anesthesia. This approach involves making a vertical incision along the chest midline to grant access to the lungs. An incision is made from the sternal notch until just above the xiphoid process; the sternum is divided longitudinally to show the thoracic cavity using a sternal saw. The sternum is held open with retractors, hence how a clear view and access to both lungs is provided. The surgeon identifies the nonfunctional areas of the lungs, typically in the upper lobes. The surgeon then resects 20-30% of this tissue. Additionally, stapling devices and electrocautery are used to ensure precise cutting and sealing of lung tissue to prevent air leaks. The lungs are then reexpanded to check for air leaks via chest tubes, which also enable postoperative drainage. The sternum is wired shut, and the incision sutured. The technique allows for a bilateral approach, which properly addresses both lungs in one operation, benefitting those affected with widespread emphysema.

2. Video-assisted thoracoscopic surgery (VATS)

   

VATS is a minimally invasive alternative to the median sternotomy for LVRS. The patient is placed under general anesthesia into a lateral decubitus position to allow access to the thoracic cavity. The surgeon creates multiple small incision sites (usually 3-4) between the ribs on one side of the chest. A thoracoscope is inserted into one of the incisions to generate a video feed to a monitor, guiding the surgeon during the procedure. Other ports are used to insert surgical instruments. Upon identifying the diseased areas of the lung, endoscopic stapling devices resect the nonfunctional tissue. The staples cut and seal the lung tissue to avoid air leaks. The resected tissue is then expelled through one of the aforementioned ports, the lung is reexpanded, and the surgeon checks for air leaks using saline. Chest tubes ensure the reexpansion and postoperative drainage. The incisions are closed with sutures. If the contralateral side also must be treated, the patient is repositioned to the other side to repeat the procedure. VATS ensures speedier recovery and less postoperative pain in comparison to the median sternotomy.

LVRS is a prime example of how removing diseased lung tissue, formerly essential for ventilation and life functions, can ironically save the life in question. It is a revolutionary surgical technique, once doubted, now thriving and granting others the comfort of breathing securely.

Written by Hana Shqairat at Incisionary

References:

Lee M, Sharma S, Mora Carpio AL. Lung Volume Reduction Surgery. [Updated 2024 Aug 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK559329/