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184 Videothoracoscopic bullectomy for spontaneous pneumothorax
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Spontaneous
pneumothorax
The timely selection of each particular
1
treatment varies according to different
clinical conditions, which are roughly
expressed in the algorithm.
First episode
<20%
Asymptomatic
Observation
Tube drainage
20%
Symptomatic
– tension SP
– previous
contralateral SP
– hemopneumothorax
– high risk occupation
Air leak > 72 h
Recurrence
Resolution
Recurrent
VATS
Bullectomy
High risk
COPD
Talc
1
PREOPERATIVE ASSESSMENT AND
PREPARATION
Preoperative assessment and preparation for bullectomy in
primary spontaneous pneumothorax patients usually does
not represent a problem since they are, by and large, healthy
young individuals with a good cardiorespiratory reserve. In a
second episode of pneumothorax, basic routine presurgical
tests will suffice in such patients.
Secondary pneumothorax in elderly patients represents a
great challenge. They should be drained as soon as they arrive
in the emergency room because they are at great risk of tension pneumothorax and sudden death. In fact, 5% of them
die before a chest tube is inserted. The internal diameter of
the tube should not be less than 6.88 (28 French), which is
capable of draining flows as high as 15–16 L/min when connected to a –10 cm H2O suction source. Once the patient is
stable, accurate cardiorespiratory risk can be assessed, and a
final therapeutic decision can be made. After proper preparation, the great majority of these patients tolerate a VATS procedure on one-lung ventilation. Some extremely high risk
COPD patients are not candidates for surgery. In this situation 5 g of asbestos free talc slurry introduced through the
tube thoracostomy might be an option. This therapeutic
modality should be reserved only for those patients who cannot be candidates for lung volume reduction surgery.
ANESTHESIA
These patients should be operated on under general anesthesia with a double-lumen endotracheal tube, which is a standard procedure in VATS surgery. Better control of the
respiratory function is obtained in patients under general
anesthesia than when local anesthesia is used.
A note of caution: when using double-lumen endotracheal
tubes, never ventilate the lung which is going to be operated
on, unless the hemithorax has been previously drained, and
the drainage tube system is still open. Otherwise, the risk of
tension pneumothorax is very high, and intraoperative
death may result.
Postoperative pain control is obtained by infiltrating the
corresponding intercostal nerves with bupivacaine 0.5%
before the surgical field is set and the trocars are introduced.
Intravenous and oral analgesics during the postoperative
period will suffice. Opioids are seldom needed.
OPERATION
This operation has three phases:
1 The liberation of the pleural space (if necessary) and thor-
ough lung exploration with identification of the leaking
source
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2 Resection of the bulla or bleb
3 Consolidation and drainage of the pleural space. By “con-
solidation” we mean pleural abrasion, occasionally talc
pourage, and rarely parietal pleurectomy.
For the first phase two ports are enough; in the second phase
a “holder” port (usually a 5 mm trocar) should be added
either in the axillary rim or in the auscultatory triangle, while
the other two are reserved for the camera and stapler.
For port placement, a triangular-shaped scheme is used:
2
incisions should be separated from each other for a distance of at least 10 cm in order to avoid “swording.” The first
incision is placed in the sixth or seventh intercostal space (i.s.)
at the level of the posterior axillary line (caudal port). After
digital exploration, a 5 or 11 mm diameter trocar is introduced, in order to speed up the spontaneous lung collapse.
We do not use CO
ration a 30 degree telescope is preferred – either 5 or 10 mm
in diameter – so as to rule out pleural adhesions or other
abnormal findings. The second incision, 2cm long, is made in
the periareolar line in the male while in the female patient a
similar location is placed (fourth intercostal space) in the
submammary line by retracting the breast medially (ventral
port). This incision, like any other one, should be watched
videoscopically. Its wider extension (2 cm) allows digital
palpation and easy specimen retrieval. These two incisions
are the key ones through which the endostapler and the
telescope will be introduced alternately in each phase of
the operation.
insufflation. For the initial visual explo-
2
2a
2b
3
2
10 cm
1
2c
186 Videothoracoscopic bullectomy for spontaneous pneumothorax
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Once both entries are usable, instru-
ment-driven exploration begins, look-
3
ing for pleural adhesions which, if found,
are cut and coagulated with endo-scissors.
The best instrument to manipulate the lung
is an endo-Pföerster; or when the distance
between the port and the target is adequate,
a regular curved Pföerster forceps will do.
By exchanging the location of the camera
and the endo-Pföerster, the whole pulmonary surface can be explored. Even when
obvious bullae or blebs are readily seen,
careful search for additional pathology
should always be accomplished initially.
Special attention should be paid to the dorsal aspect of the upper and lower lobes
which can be exposed by grasping the lung
in its lateral aspect and dragging it ventrally
from the periareolar entry keeping the camera in the caudal port. Interplaying with the
telescope and the grasper between these two
entries generally renders excellent results.
3
A bulla on the collapsed lung can
4
either be seen deflated as a “whitish”
plane area applied over the pulmonary surface
or as an inflated balloon. In any case, it is wise
to ventilate the lung with small tidal volumes
in order to determine the exact site of leakage
and/or to make evident any other accompanying lesion.
4
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The endograsp is removed, and an endoretractor is
5
inserted to restrain its full expansion while a sufficient
amount of saline is poured into the cavity so as to make the
leaking point evident. This maneuver should be repeated
after the bulla resection is completed in order to rule out any
leakage from the suture line and to be sure that no leaking
points are left behind.
5
188 Videothoracoscopic bullectomy for spontaneous pneumothorax
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When the leaking source has been identified, the third
6
incision is done according to its placement in the lung’s
surface. For apical lesions, a small 5 mm trocar is inserted in
the axillary rim; for more dorsal lesions, an auscultatory triangle 5 mm port will do. Sometimes this incision has to be
extended to 11 mm whenever a good alignment angle for the
endostapler cannot be acheived. Whether three or four incisions are needed is not important. The goal is to obtain a
good complementary angle with the first endostapler “firing.”
6
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In any case, 5 mm diameter holding instruments like an
7
endograsp or endoclinch are used. Sometimes during the
exploration phase an obvious leaking bulla is found at the
apex of the lung, hanging from a parietal pleural adhesion. At
this instance the surgeon can be tempted to apply the
endostapler directly onto the neck of the bulla without cut-
ting the adhesion in an attempt to avoid another incision.
Such a maneuver is to be condemned since frequently leads to
troublesome consequences, either bleeding from an unseen
vascularized pedicle or the presence of some concealed
pathology on the dorsal area of the parenchyma.
Adhesions
Inappropriate
Application
7
190 Videothoracoscopic bullectomy for spontaneous pneumothorax
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Once the lung is totally freed from the adhesions and the
8
leaking source has been truly identified, the operation
enters its second phase: resection of the compromised tissue.
The bulla is grasped by a 5 mm diameter endoclinch inserted
through the axillary port or the auscultatory triangle. The
endostapler is introduced through the periareolar entry; the
trocar is pulled back, and the stapler is progressed beyond the
target tissue to get full opening of both jaws.
The stapler is retracted a bit so as to encompass the base of
the bulla between the wide-opened jaws. Note that the bulla
has to be resected with a thin rim of normal parenchyma.
Therefore, the angle of incidence should be almost parallel to
the pulmonary surface. Avoid acute angles and thick bits of
lung tissue. Resect only the bulla and its base. It is very
important to line the stapler to the desired angulation by
exchanging ports, if necessary, in order to avoid “the banana
peel” phenomenon. The endostapler should be positioned
over the long surface close to the bulla’s base, making sure
that a rim of normal parenchyma is removed together with
the specimen. Do not place the stapler on the bulla itself.
Occasionally, in small bullae the leaking point can be
sutured only with the unbladed Endogia 30 or Endo TA 30,
leaving six rows or staples in situ without sectioning. Stapling
is a much safer method than endolooping ligation and
equally expensive. We do not recommend endoloop ligation.
When the leaking source cannot be found, it is advised to
blindly resect the apex of the lung or the most suspicious area
according to the CT scans. This situation usually occurs in
young people with primary spontaneous pneumothorax. In
elderly patients this situation should be treated by inducing
pleurodesis with talc poudrage or pleural abrasion without
resection.
8
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Once the bullae has been completely resected
9,10
within the pleural cavity, the specimen is removed through
the ventral port with a Kaiser–Pilling forceps protected by a
conventional polyethylene camera sleeve or any commercially available device and sent to pathology and bacteriology.
and it is hanging freely from the endoclinch
Thin rim of normal parenchyma
9
10
192 Videothoracoscopic bullectomy for spontaneous pneumothorax
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The pleural cavity is then filled with saline to check
11
aerostasis. The third phase or consolidation is generally carried out by abrading the apical parietal pleura with a
gauze sponge held by a Kaiser–Pilling curved ring forceps
until the pleura becomes petechyal. The visceral pleura
should also be sponged, although less vigorously. In chronic
obstructive pulmonary disease (COPD) patients with multiple blebs, 4 g of asbestos free talc are insufflated and spread
over the lung surface as a fine cloudy suspension, leaving a
thin talc film over the whole pleural surface. Avoid bulky
(gross) deposits of talc. The drainage tube is introduced
through the caudal port and inserted, piercing the immediate
cephalad “virgin” intercostal space placed under videoscopic
guidance. The port wound is closed in planes around the
tube, which is secured by a strong stitch to the surrounding
skin and connected to a water-sealed continuous suction
device.
11
POSTOPERATIVE CARE
On returning to the recovery room, an immediate postoperative chest radiograph is obtained to determine the completeness of lung expansion. Suction (–10/–15 cmH2O) should be
applied if there is any incomplete re-expansion or air leakage.
Prophylactic antibiotics are normally stopped after 24 hours.
Physiotherapy is started in the immediate postoperative
period, and prompt patient deambulation is strongly encouraged. Pain control is achieved by indicating oral analgesics
which interact with the preoperative bupivacaine intercostal
nerve blockage. Epidural analgesia is not recommended for
this type of procedure. Drainage tube removal is indicated
after any 24 hour period once air leakage ceases and full lung
expansion has been attained. A chest X-ray is obtained 12
hours after tube removal, and the patient is discharged 12
hours later.
OUTCOME
The treatment of choice for a ruptured bulla and its ensuing
pneumothorax, persistent air leak and septic complication of
the pleural cavity is surgical resection. This goal can be
accomplished by two modalities: open thoracotomy or
videothoracoscopy. Full posterolateral thoracotomy constitutes a procedure too formidable for the management of a
small offending lesion. A semiblind approach such as a 6 cm
limited thoracotomy is acceptable in terms of anatomical disarrangement but markedly reduces the field of vision, which
may result in missing other leak sources and failure of the
procedure.
In the early 1990s, several initial experiences with VAT bullectomies compared its results to the historical series of thoracotomy bullectomies. The recurrence rate for VAT
procedures was 6–8% while for thoracotomy it was much
lower, between 0 and 1%. Most of these failures were due to
inexperience, or a “learning curve.” VAT bullectomy’s failures, occurring during the first three days may be solved by
re-exploring the pleural cavity using the same incisional
ports; later than that we create new entries, in order to avoid
pleural infection. Some surgeons prefer to use an open thoracotomy to treat VATS failures, in the understanding that the
patient will be more willing to accept a procedure different
from the one which failed originally. We do not share this
policy and re-explore prolonged bullectomy leaks by VATS.
Nowadays acceptable recurrence rates should be 1–2%.
Complications are infrequent, ranging between 5% and
15%. The most frequent complication is prolonged air leakage. Localized empyema is exceptional and is usually associated with talc instillation. Chest wall bleeding and
hemorrhage after parietal pleurectomy is possible but very
rare. All these complications can be treated by VATS.
Postoperative pain is seldom a problem if intercostal nerves
have not been compressed by improper trocar insertion.
Most of these complications result from a faulty surgical technique. Mortality depends on the patient’s condition but by
proper management should be nil. Strict adhesion to the
strategic algorithm is recommended.
Our own experience comprises 472 episodes of spontaneous pneumothorax treated between February 1985 and
January 2000. Ninety-five of these cases were dealt with
before February 1992 when we incorporated VATS equipment and techniques into our practice (“pre VATS era”), and
377 were treated after that date (“VATS era”). In the “pre
VATS era” 76 cases were resolved by simple tube drainage,
and another 19 required thoracotomy and bullectomy. None
of these thoracotomy-treated cases recurred. Morbidity was
9.1% and mortality 0% in the first subset.
During the “VATS era” 234 cases were treated by tube
Further reading 193
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drainage; 126 by VATS; 10 giant bullae were resected through
axillary thoracotomy; and 15 small pneumothoraces were
managed by simple observation. In the VATS group three
recurrences (2.3%) ocurred during the first part of the experience and were probably due to faulty technique (“learning
curve”). The morbidity was 10.9% and the mortality 0%.
None of the patients required conversion into an open thoracotomy.
In summary, VAT bullectomy emerges as the gold standard procedure for the treatment of recurrent pneumothorax
during its second or subsequent episodes. It renders:
1 Excellent visualization of the entire lung and pleural cavity
2 A high rate of success
3 Little anatomical disarrangement
4 Low postoperative pain
5 Good cosmesis
6 Reduced hospital stay
7 Earlier return to work.
FURTHER READING
Baumann MH, Strange C, Heffner JE. AACP Pneumothorax Consensus
Group. Management of spontaneous pneumothorax: an American
College of Chest Physicians Delfi consensus statement. Chest 2001;
119: 590–602.
Boutin C, Viallat JR, Aelony Y. Practical Thoracoscopy. Springer-Verlag,
Berlin, 1991.
Deslauriers J, Beaulieu M, Després JP, Lemieux M, Leblanc J, Desmeules
M. Transaxillary Pleurectomy for Treatment of Spontaneous
Pneumothorax.
Henry M, Arnold T, Harvey J. Pleural Diseases Group, Standards of Care
Committee, British Thoracic Society. BTS guidelines for the
management of spontaneous pneumothorax. Thorax 2003; 58 Suppl
2: 39–52.
Killen DA, Gobbel WG. Spontaneous Pneumothorax. Little Brown,
Boston, 1968.
Light RW. Pleural Diseases. 2nd Ed. Lea & Febiger. Philadelphia, 1990.
Annals of Thoracic Surgery 1980; 30: 569–74.
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