The outer sheath is usually inserted under local anesthesia into the anterior axillary line between the fourth and fifth intercostal space while the patient is in a lateral position with the unaffected side down in the same manner used for the insertion of a thoracic drain. After removal of the mandrin, a FB is inserted, and the thoracic cavity is observed. The FB passes smoothly through the outer sheath, and since the length of the FB protruding from the tip is freely adjustable, extensive observations are possible, including the posterior surface of the lung, as well as the interlobar surfaces.
The vertical septal surfaces were observed with the patient in a supine position. After discovering a bleb, we inserted the high-frequency coagulator through the FB channel and performed electrocoagulation. When we believed that coagulation therapy was insufficient due to giant or extensive blebs or when there were obvious punctures on blebs, we resorted to intrableb adhesion by injecting 1 ml of 4 percent fibrinogen solution (Green Cross, Japan) and 1 ml of thrombin solution (thrombin for topical use; Warner-Lambert; 1,000 units/ml) into the blebs using a FB topical injection syringe. We also attempted to stop air leaks by spraying fibrinogen and thrombin solutions onto the surface of the blebs.