Each in turn consists of two similar pieces that are assembled to prepare the tissue for suturing, and then deassembled on copleting the procedure. Each piece presents a flat rectangular head unit out of which a thin metal rod some 12 cm long emerges. At the other end of the same face of the head unit there is a deep, dead-end orifice into which the rod of the opposing head unit is introduced. Each head unit in turn possesses two transverse orifices for manipulating the units during the assembly process. One of the rods ends in a point, while the tip of the other is rounded and is a few millimeters shorter, to facilitate coupling.

The lobe to be remodeled is exteriorized and insuflated. The most damaged section is easily distended.A small incision is made at the most distal point (Fig. 2).

The cortical zone with destructive emphysema rapidly collapses, clearly delimiting the line bordering with less damaged tissue. At this point we temporarily apply a straight clamp to block air escape (Fig. 3).

The blocked zone is divided into two flaps down to the clamp; care is taken to not perforate them. The needle point rod is then inserted along the full length of the free margin of one of the flaps (Fig. 4), followed by assembly with the complementing head unit and blunt rod.

Following assembly, the flap is rolled up (Fig. 5).

The resulting flap roll lies parallel to the blocking clamp and is fixed by two forceps through one of the lateral orifices of each head unid (Fig. 5). The same procedure is repeated with the other parenchymnal flap. The clamp and forceps are removed, and the instruments are given a final twist to superficialize the deepest zone of the incision. The head units of both instruments are precisely opposed and fixed in position by two forceps through the deepest transverse orifices of the head units (Fig. 6).

Thus, by using the fragile emphysematous lung tissue, a firm plane is created on which to support suturing. At each of the incision comissures (critical suture points) we apply two silk x-sutures (Fig. 6). A horizontal "shoemaker's"surget is performed (thus termed in being similar to that used in sewing soles to shoes)(Fig. 7); multifilament 2-0 polyglactine lubricatet with silicone is employed to this effect.

Suturing begins at a point passing below the comissure. The free end of the filament (that without the needle) is deliberately left long and parallel to the suture trajectory. the needle advances as shown in Figure 7, and includes the free end at each turn. The needle end of the filament should be kept tense, so that at each turn it drags the free end of the filament into the tissue. The needle should pass through the planes perpendicularly, advancing only on the side opposite to the free end of the filament, to secure full tissue inclusion in the surget.

Having completed the trajectory, and always keeping the needle end of the filament firm, traction is exerted upon the free end so that the tissue becomes firmly trapped between the two threads. Both are then knotted, including the comissure. The instruments are deassembled and removed. The knot is tightened and reinforced by several more, superimposed upon each other.

This procedure thus affords an effective hemo- and pneumostatic suture. The few leakages left by the passage of the filament through the visceral pleura are covered by an extensive tissue flap that simultaneously facilitates cicatrization (Fig. 8).

The procedure is repeated as often as required until the lung presents a volume appropriate to the thoracic capacity. This aspect is of fundamental importance. An excessively voluminous lung will be unable to secure an optimal functional recovery of the recycled tissue, while too small a lung will be unable to expand sufficiently. This inconvenience is avoided by correctly evaluating the collapsed sector via selective pulmonary cineangiography.

The cases of prolonged air leakage encountered in our series of 76 patients were not caused by the suturing but by lung tearings or lesions far removed from the operated site. In order to avoid such complication, a number of measures should be adopted:

 .The thoracotomy should be sufficiently extensive to facilitate maneuvering and avoid traction.

 .A blunt instrument should be utilized to access to the pleural cavity.

 .In sectioning the visceral pleura, care should be taken to not depress the lung with instruments, but protect it with the flexed index finger.

 .Care must be taken to carefully debride the lung prior to exteriorization, to avoid the risk of tearing the organ. Such a tear would cause air leakage of difficult management. The emphysematous lesions are a constant presence at source bronchial level. In order to avoid possible tearing of the latter on exerting traction to expose the lung, the mediastinal pleura around the bronchus should be sectioned (Fig. 9).

Fig. 9. The source bronchus is always surrounded by small vauoles that frequently tear on exerting traction on the lung, which in turn leads to air leakages that are difficult to resolve. In order to avoid this problem, the mediastinal pleura surrounding the source bronchus is sectioned before surgical manipulation of the lung.

 .Care should be exerted to avoid rib fracture with the separators; the ribs of these patients tend to be fragile.

 .The lung should be handled in a semi-insuflated state.

 .Both the lung and hands of the surgeon should be kept permanently humid. Exposure to the air and the heat of the overhead illumination tnd to dry the visceral pleura of the emphysematous lung, which becomes even more fragile to contact with dry gloves.

 . Metal instruments should be avoided in rib joining; the pericostal x-sutures effectively compensate them.

 .Two-way sondes should be employed in anesthesia, to avoid excessive distension of the destructive emphysema zones of the contralateral lung during insuflation maneuvers to detect lung leakage.

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