Where should the incision be made for a bulectomy?

Optimal Incision Placement for Bullectomy

For bullectomy, the incision should be placed directly over the bulla, typically through a lateral thoracotomy approach at the level of the hilum in the fourth intercostal space, extending from the midclavicular line to the anterior axillary line. 1

Anatomical Considerations for Bullectomy Incision

• The primary incision should be placed at the level of the hilum, usually in the fourth intercostal space, starting at the midclavicular line and extending laterally to the anterior axillary line 1
• The patient should be positioned supine with the affected side slightly elevated by placing a small pillow or IV bag inferior to the scapula to open up the axillary space 1
• The incision should be large enough to allow for adequate light to reach the surgical field, with the size potentially decreasing with greater surgical experience 1
• A soft tissue retractor should be placed, and slight rib spreading may be required for adequate exposure 1

Technical Approach to Bullectomy

• For optimal exposure, the patient should be positioned all the way to the affected side of the table, with the arm fully supported and slightly flexed to improve access to the anterior axillary line 1
• The head should remain in the midline and should be supported to minimize risk of brachial plexus injury 1
• Placement of defibrillator pads across the chest wall is recommended, as access to the ventricles is limited during the procedure 1
• Carbon dioxide insufflation at 2 to 3 L/min is beneficial in minimizing air in the surgical field 1

Patient Selection Considerations

• Bullectomy is most effective when the bulla occupies at least 50% of the hemithorax and shows definite displacement of adjacent lung tissue 2, 3
• The procedure is indicated for large-sized, compressive bullae with normal or near-normal underlying lung parenchyma 4
• For successful outcomes, there should be radiologic evidence of compressed lung tissue that can be re-expanded by removal of the bulla 2
• Patients with diffuse, noncompressive bullous disease are less likely to benefit from standard bullectomy approaches 4

Alternative Approaches

• For primary spontaneous pneumothorax, a transareolar approach using a 5-mm thoracoscope has shown promising results with excellent cosmetic outcomes 5
• Video-assisted thoracoscopic surgery (VATS) approaches may be considered for smaller bullae or when minimizing chest wall trauma is a priority 5
• When using alternative approaches, the principle of placing the incision directly over the lesion rather than at a distance still applies 1, 6

Surgical Technique Considerations

• Meticulous hemostasis is critically important to prevent hematoma formation, which can complicate postoperative evaluation 1
• The specimen should be examined for determination of clear margins, with reexcision performed if necessary 1
• For image-guided approaches, triangulation based on position and depth is essential for proper incision placement 1
• Tunneling should be avoided, and the surgeon should attempt to make the skin incision as close to the lesion as possible 1, 6