A novel approach to the lung apex avoiding dissection of severe pleural adhesions

A 70-year-old man was incidentally diagnosed with left pneumothorax. Primary surgery via the caudal thoracic cavity found severe pleural adhesions causing narrowing of the tunnel leading to the lung apex. The point of air leakage was located at the lung apex beyond the tunnel. To stop the air leakage, fibrin glue was injected to the apex via the tunnel; however, leakage reoccurred postoperatively. Considering the lung injury, a novel approach for lung apex without adhesion dissection was chosen for secondary surgery. An axillary skin incision was made at the 2nd intercostal space, and extrapleural dissection proceeded toward the apex. After the pleural space was confirmed by the movement of pleural effusion, the parietal pleura was incised, and a bulla was exposed and resected. The presented procedure to reach the apex of the lung without adhesion dissection could be an option in cases with dense and extensive pleural adhesions.