A 40-year-old man with chronic obstructive pulmonary disease underwent a right upper lobectomy for infection. At the completion of the operation, there are multiple air leaks from the cut surface of the remaining lower and middle lobes, and the lung does not appear to be capable of filling the hemithorax. Which of the following is the best option?

A. phrenic nerve crush
B. laser scarification of the lung surface
C. apical pleural tent
D. talc pleurodesis
E. pneumoperitoneum 

Answer C

The successful completion of any pulmonary resection requires that the pleural space is controlled at the completion of the operation. All attempts should be made to obtain pleural apposition when the chest is closed. Normally, space is obliterated by elevation of the hemidiaphragm, hyperexpansion of the remaining lung, shifting of the mediastinum toward the operated side and decreases in the intercostal spaces on the ipsilateral side. When these "natural" mechanisms fail to obliterate the space, other techniques can be used to reduce the pleural space. For upper lobe resections, a pleural tent is an excellent way to control air leaks. The parietal pleura is removed intact from the upper chest wall and draped onto the resected surface of the lung. This will help seal any small air leaks from the lung. For lower lobe resections, induced pneumoperitoneum will elevate the diaphragm, providing pleural symphysis and sealing small air leaks. Talc pleurodesis or laser scarification will not be effective in the patient described since the pleural surfaces are not in apposition. Phrenic nerve crush is a possibility, but it is not the best choice as it will further limit this patient's pulmonary function postoperatively.