Asian Cardiovasc Thorac Ann 2006;14:472-475
© 2006 Asia Publishing EXchange Ltd
Modification of Thoracoscopic Surgery for Spontaneous Pneumothorax
Kyu-Do Cho, MD,
Chan-Beom Park, MD1,
Min-Seob Cho, MD,
Ung Jin, MD1,
Deog-Gon Cho, MD,
Chi-Kyeong Kim, MD1
Department of Thoracic and Cardiovascular Surgery, St. Vincent’s Hospital,
1 Department of Thoracic and Cardiovascular Surgery, St. Paul’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, South Korea
For reprint information contact: Chan-Beom Park, MD, Tel: 82 2 958 2477, Fax: 82 2 958 2477, Email: drcs5223{at}daum.net, Departments of Thoracic and Cardiovascular Surgery, St. Paul’s Hospital, College of Medicine, The Catholic University of Korea, 620-56 Jeonnong-dong, Dongdaemoon-gu, Seoul 130-709, South Korea.
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ABSTRACT
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Morbidity, use of analgesics, postoperative drainage, and hospital stay are reduced after video-assisted thoracoscopic surgery for pneumothorax. However, some surgeons prefer a minithoracotomy because the rate of recurrence after thoracoscopic surgery is 5%–10%. A modified thoracoscopic bullectomy is described, which has the advantages of both conventional video-assisted thoracoscopic surgery and a minithoracotomy. Of 69 patients who underwent surgery for pneumothorax from January 2002 to February 2003, 13 were treated by conventional video-assisted thoracoscopic surgery and 21 by the modified thoracoscopic bullectomy. The mean ages were 20.6 years in the conventional group and 23.0 years in the modified group, with follow-up of 25.8 ± 1.8 months in the conventional group and 20.6 ± 1.3 months in the modified group. The duration of operation was similar in both groups (49.3 ± 16.0 vs. 44.2 ± 19.2 min). Significantly fewer staples were used in the modified group (1.62 ± 0.74 vs. 2.92 ± 1.19). The duration of chest tube drainage and postoperative hospital stay were significantly reduced in the modified group. The modified thoracoscopic bullectomy is an effective procedure for the treatment of primary spontaneous pneumothorax.
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INTRODUCTION
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After the initial use of thoracoscopy in the surgical treatment of pneumothorax by Levi and colleagues1 in 1990, thoracoscopy has become the major treatment modality for spontaneous pneumothorax. Surgery for pneumothorax using a thoracoscope gives superior cosmetic results and has the advantages of decreased morbidity, postoperative pain, drainage, cost, and hospital stay, as well as a more rapid return to everyday life.2 However, a recurrence rate of 5%–10% has highlighted the necessity for changes in the current surgical techniques.3 Kim and colleagues4 found no difference between surgical treatment of pneumothorax by a transaxillary minithoracotomy and video-assisted thoracoscopic surgery (VATS). However, a transaxillary minithoracotomy necessitates a larger incision than conventional VATS, and is thus cosmetically inferior.5 Postoperative pain due to traction on the intercostal space during surgery is another disadvantage of the transaxillary minithoracotomy.6 Therefore, we developed a modified thoracoscopic bullectomy and compared this with the conventional method.
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PATIENTS AND METHODS
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There were 69 cases of primary spontaneous pneumothorax treated in St. Vincent’s Hospital from January 2002 through February 2003. Of these, 13 were treated by conventional VATS (group C) and 21 by the modified thoracoscopic bullectomy (group M). The remaining 35 patients included 27 who underwent an axillary minithoracotomy, 7 who were predicted to have severe pleural adhesions and thus a posterolateral thoracotomy was performed, and one in whom a thoracoscope was used to resect bullae and a small nodule. The characteristics of both study groups are given in Table 1
. The criterion for postoperative chest tube removal was daily drainage < 100 mL with no air leakage and fixed water levels.
Surgery was performed under general anesthesia using a double-lumen endotracheal tube. The patient was placed in the right or left down decubitus position. An incision was made along the 7th intercostal space, and a 10.5-mm trocar was inserted. When a chest tube was inserted preoperatively, a 10.5-mm trocar was inserted into that site and a 10-mm thoracoscope was introduced via the trocar. The pleural cavity was examined initially for existing adhesions or effusion, and the locations of the bullae were sought, especially in the apex. An incision was made along the anterior margin of the axillary fold in the 3rd intercostal space, large enough so that a 11.5-mm trocar could be inserted, but the trocar was not inserted. The intercostal muscles were dissected, and an incision larger than the skin incision (approximately 2–2.5 cm) was made in the intercostal muscles and the pleural area, so that the bullae could be easily extracted. Through the two incision sites, the location and size of the bullae were examined repeatedly, and a sponge forceps was introduced through the superior incision site. Under thoracoscopic vision, the bullae were clamped and extracted, and excised using a stapler (Figure 1). The cut margin was sutured using black silk for reinforcement, and the outer margins were sutured more steadfastly and with greater care. After the reinforcing suture, the surrounding area of the cut margin was carefully examined, and when subpleural bullae were located, bulla plication was performed using either suturing or a stapler. A chest tube was inserted, and the operation was concluded.
SPSS version 10.0 software (SPSS, Inc., Chicago, IL, USA) was used for statistical analysis. Depending on the variables, parametric data were assessed using one-way analysis of variance. For nonparametric data, the Kruskal-Wallis test was performed, and the Scheffe test was used as a post-hoc test. Statistical significance was defined as a p value < 0.05.
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RESULTS
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There was no difference in the mean duration of operation in the two groups (Table 2). The number of staples used and the duration of indwelling chest tube drainage were less in group M than group C. Group M had a much shorter hospital stay than group C. There was no difference in postoperative analgesic use, so it was concluded that there was no substantial difference in postoperative pain between the two groups.
There were 6 cases of perioperative complications: 5 in group C (38.5%) and 1 in group M (4.8%). After conventional VATS, 4 patients suffered either recurrent or persistent air leakage, and another patient had to be converted to a transaxillary minithoracotomy after the stapled suture site reopened. Pleurodesis was performed using talc in 1 case of persistent postoperative air leakage. In two cases, a small degree of recurrent pneumothorax was discovered during follow-up, which subsequently resolved spontaneously. The other patient was discharged when the collapse that had occurred after chest tube removal resolved with reinsertion. In this patient, pneumothorax recurred after discharge, and chest tube insertion was performed in another hospital. After the modified VATS, a small degree of pneumothorax recurred in one patient (4.8%) during follow-up, which subsequently resolved spontaneously.
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DISCUSSION
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There have been numerous reports on the advantages and efficacy of thoracoscopic surgery, indicating lower morbidity rates, decreased postoperative pain, reduced drainage, less postoperative pulmonary function impairment, and shorter hospital stay.2,7,8 However, Hatz and colleagues9 in 2000 reported a 4.7% recurrence rate among 109 patients who had undergone thoracoscopic surgery. The etiology of recurrence includes undiscovered bullae, inadequate resection margins that fail to include healthy lung tissue, and coexisting severe emphysema.9 Some prolonged air leaks and early recurrences are most likely due to missed bullae, technical problems in the use of the endoscopic stapler, applying the stapler too close to the bulla, or excessive tension on the lung (due to improper angles) resulting in unrecognized lacerations near the staple line.10
Video-assisted thoracoscopic surgery has been reported to increase the cost of treatment because of the use of Endostaplers, double-lumen endotracheal tubes, disposable materials, and video equipment.3 Thus, although the use of a thoracoscope is preferred by some surgeons, others avoid it because of the high recurrence rate. To compensate for these disadvantages, a transaxillary minithoracotomy has been used. Kim and colleagues4 reported no differences in operation time, analgesic use, and indwelling chest tube duration between the transaxillary minithoracotomy and VATS. In addition, unlike their experience with VATS, there was no recurrence after treatment through a transaxillary minithoracotomy. Although the 3-port method of conventional VATS in bullectomy includes advantages of less pain, improved postoperative cosmesis, and decreased hospital stay, the 5%–10% recurrence rate remains a problem. To prevent such recurrences, pleurectomy, mechanical pleurodesis, chemical pleurodesis using tetracycline or talc, use of cellulose mesh and fibrin glue to cover the sites of bullectomy, and other methods have been tried.1,11,12
Our method of modified thoracoscopic bullectomy uses only 2 ports, so we obtained better cosmetic results. Furthermore, additional supportive sutures after bullectomy using the stapler can prevent recurrence, and suturing in cases of dehiscence of stapler closure sites can be attempted. Recurrence can also be prevented by attempting plication using either sutures or staples in areas of subpleural bullous lesions. Although not statistically proven, omission of a traction device for opening the intercostal space is expected to improve postoperative pain and hasten chest tube removal compared to conventional VATS. All these advantages combine to shorten hospital stay. An additional advantage is that an incision larger than the skin incision can be made in the pleural wall, thus recurrence can be prevented by creating pleurodesis. There was some difficulty in comparing recurrence rates because the follow-up period for each group differed. However, considering the fact that recurrence after pneumothorax surgery is noted within 6 months, the modified thoracoscopic bullectomy is effective in preventing recurrence.
Our experience with this modified thoracoscopic bullectomy indicates that it is an effective procedure in the treatment of primary spontaneous pneumothorax, with some advantages over conventional VATS.
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REFERENCES
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- Levi JF, Kleinmann P, Riquet M, Debesse B. Percutaneous parietal pleurectomy for recurrent spontaneous pneumothorax. Lancet 1990;336(8730):1577–8.[Medline]
- Freixinet J, Canalis E, Rivas JJ, Rodriguez de Castro F, Torres J, Gimferrer JM, et al. Surgical treatment of primary spontaneous pneumothorax with video-assisted thoracic surgery. Eur Respir J 1997;10:409–11.[Abstract]
- Massard G, Thomas P, Wihlm JM. Minimally invasive management for first and recurrent pneumothorax [Review]. Ann Thorac Surg 1998;66:592–9.[Abstract/Free Full Text]
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- Olsen PS, Andersen HO. Long-term result after tetracycline pleurodesis in spontaneous pneumothorax. Ann Thorac Surg 1992;53:1015–7.[Abstract]
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ABSTRACT
INTRODUCTION
