Asian Cardiovasc Thorac Ann 2001;9:27-30
© 2001 Asia Publishing EXchange Pte Ltd
A 2-mm Videothoracoscopic Incision for Primary Spontaneous Pneumothorax
Kim Joung Taek, MD,
Kim Kwang Ho, MD,
Yoon Yong Han, MD,
Baek Wan Ki, MD,
Lim Hyun Kyoung, MD,1
Department of Thoracic and Cardiovascular Surgery
1 Department of Anesthesiology Inha University Hospital Inchon, Korea
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For reprint information contact: Kim Joung Taek, MD Tel: 82 32 890 2280 Fax: 82 32 890 3099 email: jtkim{at}inha.ac.kr Department of Thoracic and Cardiovascular Surgery, Inha University Hospital, 7-206 Shinheung-Dong 3 Ga, Jung Gu, Inchon 400-103, Korea.
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Abstract
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This study was designed to evaluate a recently developed 2-mm video-thoracoscope and instruments for primary spontaneous pneumothorax. Between January 1998 and June 1999, 62 consecutive patients were studied. The 2-mm video-thoracoscope was used in 30 patients (group 1), and a conventional video-thoracoscope was used in 32 (group 2). There was no significant difference in operation time, number of staples, or duration of chest tube drainage between the 2 groups. The need for parenteral analgesic (ketoprofen) postoperatively was less in group 1 (56%) than group 2 (72%), but this was not statistically significant. During a mean follow-up of 15 months, there was 1 readmission for recurrent pneumothorax in each group. It was concluded that the 2-mm video-thoracoscope and instruments can be used successfully to manage primary spontaneous pneumothorax with cosmetically excellent results.
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Introduction
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Video-assisted thoracoscopic surgery (VATS) is now accepted by many as the procedure of choice for surgical treatment of primary spontaneous pneumothorax (PSP).1,2 Video-assisted thoracoscopic bullectomy or lobectomy causes less postoperative pain and disability than the open procedure, which permits earlier discharge from hospital and a more rapid return to work.2 However, postoperative chest pain after VATS has not been resolved completely and the surgical wounds of VATS have not shown cosmetically excellent results because 2 or more wounds on the chest wall are required for thoracic ports. Thoracic ports or trocars larger than 7 mm were used in conventional VATS for spontaneous pneumothorax up to now. Recently, the video-thoracoscope has been effec-tively miniaturized and widely applied for thoracic sympathectomy with excellent results. We used a newly developed 2-mm thorascope and instruments for VATS in PSP and compared the surgical results with those of conventional VATS.
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Patients and Methods
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From January 1998 to June 1999, 62 patients requiring VATS for PSP were studied. Indications for surgery included recurrence, persistent air leakage (> 5 days), contralateral pneumothorax, and visible bulla on chest radiography. The patients were divided into 2 groups and all received information regarding the differences between 2-mm VATS (group 1) and conventional VATS (group 2) before undergoing surgery, to make their own choice of procedure. The male to female ratio was 27:3 in group 1, and 29:3 in group 2. Preoperative examination in all patients included chest radiography and chest-computed tomography for patients who were suspected of having secondary pneumothorax.
The operating time, number of staples used, duration of chest tube drainage, postoperative chest pain, and rate of recurrence were assessed. The percentage of patients needing parenteral analgesic (100 mg ketoprofen) in the first postoperative day was compared for evaluation of postoperative chest pain. Follow-up chest radiographs were carried out in the outpatient department after discharge at intervals of 1 week and 4 weeks. The patients were evaluated for development of recurrence by telephone communication and checks at outpatient clinics from 6 to 24 months postoperatively. Recurrence was confirmed by chest radiography.
All operations were performed under general anesthesia with a double-lumen endotracheal tube to allow selective single-lung ventilation. The patients were placed in the lateral decubitus position and prepared as for a standard thoracotomy. The ipsilateral lung was collapsed to obtain maximal visualization of the lung and allow adequate space for VATS. The table was flexed to open up the intercostal spaces. In group 1, two 2-mm ports were made in the third or fourth intercostal space by puncture, for insertion of the mini-telescope and mini-Endo-grasper (Minisite; United States Surgical Corporation, Norwalk, CT, USA). A 15-mm port for insertion of an Endo-GIA stapling device (United States Surgical Corporation, Norwalk, CT, USA) was made in the previous chest tube insertion hole. Pleural adhesions were completely freed using electrocautery under video vision. The bulla or bleb was inspected and grasped with the mini-Endo-grasper. The Endo-GIA stapling device was inserted and the bulla was resected. In group 2, two 1-cm incisions were made on the chest in a triangular configuration to allow the introduction of conventional thoracic instruments. The surface of the lung was identified with a 5-mm videothoracoscope. The previous chest-tube insertion hole was used for the Endo-GIA stapling device. Frequently, mechanical pleurodesis was performed on the apical pleura using dry gauze in both groups. On completion of the intrathoracic procedures, a chest tube was placed through the previous tube insertion site. The puncture sites in group 1 were closed with strip bands without suturing. The incision sites in group 2 were closed with interrupted stitches.
All patients were extubated in the operating room and transferred to the general ward. Antibiotics were ad-ministered in all cases. Oral analgesics (etodolac 200 mg) were routinely administered 3 times a day. Ketoprofen (a non-opioid, nonsteroidal analgesic) was administered intramuscularly at the patient's request. The chest tube was usually connected to a low-pressure suction system until air bubbling ceased. The criteria for removal of the chest tube was no air leakage through the tube, no evidence of collapse of the lung on chest radiography, and less than 100 mL of drainage through the chest tube for 24 hours. All patients were discharged on the day after removal of the chest tube.
Student's t test and the chi-squared test were used for statistical analysis. The statistical significance of differences between two groups was accepted for p values less than 0.05.
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Results
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Of the 62 patients, 30 (mean age, 22.7 ± 7.1 years) chose to undergo 2-mm VATS (group 1) and 32 (mean age, 22.4 ± 5.8 years) had conventional VATS (group 2). The indications in group 1 were ipsilateral recurrent pneumothorax in 12 (40%), persistent air leak in 15 (50%), visible bulla in 2 (6%), and contralateral pneumothorax in 1 patient (3%). The indications in group 2 were ipsilateral recurrent pneumothorax in 19 (59%), persistent air leak in 10 (31%), visible bulla in 2 (6%), and contralateral pneumothorax in 1 patient (3%). There was no significant difference in mean age, indications for operation, or sex distribution. There were no significant differences between the 2 groups in terms of operation time, mean number of staples used, need for parenteral analgesic, or duration of chest tube drainage (Table 1
). There was no complication during the perioperative period. The mean follow-up period was 10.5 ± 4.9 months in group 1 and 19.2 ± 8.7 months in group 2. Although the follow-up period of group 2 is twice that of group 1, there was only 1 recurrence in each group. The recurrence rate was 3.3% in group 1, and 3.1% in group 2. The patients who suffered recurrence were treated by conservative management.
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Discussion
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Primary spontaneous pneumothorax is a common condition with an estimated annual incidence of 7.9 new cases per 100,000 population in North America.2 There is a tall, thin, and young male predominance, with 6 or 10 times less occurrence in females.1 PSP refers to patients in whom a pneumothorax develops without previous underlying lung disease.3 Although the exact etiology of PSP is unknown, the goals of treatment are to rapidly and fully expand the lung, restore pulmonary function, and prevent recurrence of pneumothorax. Historically, many therapeutic approaches have been advocated. Close observation can be used for a small asymptomatic pneumothorax. It has been estimated that 1.25% of the lung volume expands spontaneously per day.4 Tube thoracostomy has been the gold standard for treating PSP of more than 25% in magnitude.4 Before the appearance of the video-thoracoscope, the standard surgical intervention was a lateral or axillary thoracotomy, through which bleb or bulla removal or pleurodesis was performed.5,6 VATS has been introduced in many thoracic disorders, and it has become the routine procedure in many hospitals for treatment of PSP.1,3-6 Video-assisted thoracoscopic ablation of the bleb or bulla causes less postoperative pain than the open procedure, and permits faster recovery.7 However, VATS for pulmonary resection may be associated with significant local trauma to the chest wall structures, which can result in chronic postoperative pain.8,9 Excessive torquing of the thoraco-scope and endosurgical instruments against the ribs at the intercostal access site can result in local rib bruising and intercostal nerve injuries. Furthermore, direct injury to the intercostal structures can occur during introduction of the thoracoscopic trocars or instruments through con-ventional access sites. Landreneau and colleagues9 suggested that the use of smaller-diameter thoracoscopes and instruments might reduce these injuries. We thought that use of a smaller-diameter thoracoscope and instru-ments could also improve cosmetic results.
Recently, a miniaturized laparoscope and instruments have been developed. Microlaparoscopy, as it is known, has been used successfully in laparoscopic cholecystectomy as well as other laparoscopic procedures such as appen-dectomy, herniorrhaphy, and colon resection.10 VATS sympathectomy for hyperhidrosis and preoperative diagnostic work-up in general thoracic surgery fields using mini-videothoracoscopy also showed cosmetically excellent results with less postoperative pain.11,12 To this end, we used 2-mm mini-videothoracoscopy to resect blebs or bulla in the management of PSP in selected cases. Visualization through the 2-mm thoracoscope was possible, and we identified blebs or bulla in all patients. Handling blebs or bulla with mini-grasping forceps via a 2-mm port was as good as with conventional grasping forceps, and satisfactory results were obtained. Further-more, there was only a chest tube site in the chest wall in the 2-mm videothoracoscopy group, whereas there were one or two other trocar wounds and a chest tube site in the conventional VATS group.
Naunheim and colleagues13 reported that most recurrences were detected within 13 months after a VATS procedure. Although the period of observation in group 1 (10.5 months) is too short to establish firm conclusions, we could expect similar long-term rates of recurrence in the 2 groups. These early results of 2-mm video-thoracoscopic management of PSP are encouraging. We recognize that this technology represents an important advance in minimally invasive thoracic surgery. The 2-mm introducer made the trocar insertion easy. Postoperative pain was minimal and hospital stay was as short as with conventional VATS. Complications have been few, and the cosmetic results compare favorably with conventional VATS. Thus, the classical indication of recurrent PSP might be extended to include first attack PSP. However, 2-mm video-thoracoscopy has a limitation: patient selection is important to minimize risk. For example, patients with secondary pneumothorax, severe pleural adhesion, and obesity are not good candidates for 2-mm videothoracoscopy. These preliminary results suggest that a 2-mm videothoracoscope can be used successfully for the surgical management of PSP in selected cases.
Presented at the 10th World Congress of the World Society of Cardiothoracic Surgeons, Vancouver, Canada, August 12–16, 2000.
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Acknowledgments
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This study was supported by Research Awards from Inha University granted to the authors in 1999.
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References
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Yim APC, Lai CKW, Ho JKS, Chan HS. Primary spontaneous pneumothorax treated by video-assisted thoracoscopic surgery. Aust NZ J Med 1995;25:146–50.[Medline]
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Liu HP, Lin PJ, Hsieh MJ, Chang JP, Chang CH. Thoracoscopic surgery as a routine procedure for spontaneous pneumothorax. Chest 1995;107:559–62.[Abstract/Free Full Text]
-
Hazelrigg SR, Landreneau RJ, Mack M, Acuff T, Seifert PE, Auer JE, et al. Thoracoscopic stapled resection for spontaneous pneumothorax. J Thorac Cardiovasc Surg 1993;105:389–93.[Abstract]
-
Liu HP, Yim APC, Izzat MB, Lin PJ, Chang CH. Thoracoscopic surgery for spontaneous pneumothorax. World J Surg 1999;23:1133–6.[Medline]
-
Yim APC, Ho JKS. One hundred consecutive cases of video-assisted thoracoscopic surgery for primary spontaneous pneumothorax. Surg Endosc 1995;9:332–6.[Medline]
-
Horio H, Nmori H, Fuyuno G, Kobayashi R, Suemasu K. Limited axillary thoracostomy versus video-assisted thoracoscopic surgery for spontaneous pneumothorax. Surg Endosc 1998;12:1155–8.[Medline]
-
Melton LJ, Hepper NGG, Offord KP. Incidence of spontaneous pneumothorax in Olmstead County, Minn, 1950–74. Am Rev Respir Dis 1979;120:1379–82.[Medline]
-
Kim KH, Kim HK, Han JY, Kim JT, Won YS, Choi SS. Transaxillary mini-thoracostomy versus video-assisted thoracoscopic surgery for spontaneous pneumothorax. Ann Thorac Surg 1996;61:1510–2.[Abstract/Free Full Text]
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Landreneau RJ, Mack MJ, Hazelrigg SR, Naunheim K, Dowling RD, Ritter P, et al. Prevalence of chronic pain after pulmonary resection by thoracotomy or video-assisted thoracic surgery. J Thorac Cardiovasc Surg 1994;107: 1079–86.[Abstract/Free Full Text]
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Somerfeld B. Microlaparoscopy in general surgery. Laparosc Focus 1996;4:1–7.
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Lee DY, Yoon YH, Hong YJ, Moon DS. Needle thoracoscopic sympathectomy for essential hyperhidrosis. Korean J Thorac Cardiovasc Surg 1998;31:598–603.
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Nakamoto K, Maeda M, Okamoto T, Kameyama K, Sugita A, Hayashi E. Preoperative diagnosis with video-assisted thoracoscopy with miniaturized endoscopes in general thoracic surgery: a preliminary study. Chest 1998; 114:1749–55.[Abstract/Free Full Text]
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Naunheim KS, Mack MJ, Hazelrigg SR, Ferguson MK, Ferson PF, Boley TM, et al. Safety and efficacy of video-assisted thoracoscopic surgical techniques for the treatment of spontaneous pneumothorax. J Thorac Cardiovasc Surg 1995;109:1198–204.
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Abstract
Introduction
