All the procedures were performed under general anaesthesia, single lung ventilation with double-lumen endotracheal tube or spontaneously breathing laryngeal mask anaesthesia and in the lateral decubitus position. Two or 3 sub-centimetric incisions were performed in the axillary triangle. After the chest exploration, apical blebs or small bullae (stage III according to Vanderschueren’s classification) were sealed via the CC as described previously [9 (link), 10 (link)]. The endoscopic instrument adopted was the Endo-Floating Ball and consists in a 5-mm monopolar electrocautery with a steel floating sphere on the tip from which it spills saline solution drop by drop (Fig. 1). This instrument allows transcollation of blebs or bullae without charring and burning. Saline irrigation keeps cooled down the temperature of the tip that contacts the lung surface, avoiding eschars formation. Instrument was placed for few seconds over the apical blebs or bulla until they shrink over to their basis by sealing the lung parenchyma (Fig. 2).
Eventual residual air leak was tested by inflating the lung under saline solution and then sealed with a floating ball second pass.
Finally, we block the saline solution spilling, and we use the instrument as a common electrocautery to induce a mechanical pleurodesis by patchy cauterization of the parietal pleura until its interruption (Fig. 3). At the end of the procedure 1 or 2 pleural drainages (according to the surgeon’s choice) are placed in the chest through the operative incisions. Chest drains were connected to a suction system at −15 cm H2O for at least 2 days.
Mechanical pleurodesis was similarly induced in all patients of the study. In both groups, pleural irritation was obtained by a patchy cauterization of parietal pleural with Floating Ball (CC group) or long-bladed monopolar electrocautery (SA group).