Technical note

Technical note Acta chir belg, 2005, 105, 397-399

Video-Assisted Thoracic Surgery (VATS) For Primary Spontaneous Pneumothorax : How I Do It ? P. Van Schil, L. Bellens, M. De Maeseneer, J. Hendriks, P. Lauwers Department of Thoracic and Vascular Surgery, University Hospital of Antwerp, Edegem (Antwerp), Belgium.

Key words. Primary spontaneous pneumothorax ; VATS ; pleurectomy ; pleurodesis. Abstract. The precise management of primary spontaneous pneumothorax remains controversial due to the lack of large prospective randomized trials. This not only regards the indications for conservative or invasive treatment but also the precise technique for air evacuation and recurrence prevention. The technique of video-assisted thoracic surgery is described as it is performed in our centre for the treatment of primary spontaneous pneumothorax.

Introduction Pneumothorax is defined as air entering the pleural space resulting in loss of the negative pleural pressure and a variable degree of lung collapse. Spontaneous pneumothorax is divided into secondary when there is an underlying lung disorder such as chronic obstructive pulmonary disease, and primary when there is no clinically apparent lung disease. The latter is a misnomer however, as in most patients apical blebs or emphysemalike changes are found on chest computed tomography or during the intervention (Fig. 1). Within the Belgian Society of Pneumology a task force recently established guidelines for the management of pneumothorax (1). A first episode of primary spontaneous pneumothorax (PSP) is usually treated conservatively by simple aspiration or intercostal tube drainage. In this report we will focus on the technique of video-assisted thoracic surgery (VATS) for the treatment of PSP which is part of the invasive surgical procedures. Generally accepted indications for invasive treatment are listed in table I and the different thoracic surgical approaches are given in table II. In contrast to medical pleuroscopy, VATS offers the possibility to treat the lung and pleura at the same time to prevent recurrences. However, as there are no prospective randomized trials comparing different VATS techniques or comparing VATS to medical pleuroscopy, the procedure remains controversial regarding its precise indications, the resection of blebs and bullae, and the extent of pleurectomy, abrasion or other methods to obtain pleurodesis. In this regard only grade C recommendations can be given and management may vary considerably from one centre to another. The subsequently described tech-

nique reflects the VATS procedure for pneumothorax as it is performed in our own department. VATS technique for primary spontaneous pneumothorax (PSP) The procedure is performed under general anaesthesia with double lumen intubation and single lung ventilation. As a pleurectomy is a rather painful procedure, a thoracic epidural catheter is inserted at the beginning of the intervention. The patient is placed in a full lateral position ; the operating table is angulated or an inflatable pillow is placed underneath the chest to open up the intercostal spaces. Usually 3 ports are used : the camera is inserted at the midaxillary line in the 5th intercostal space and 2 additional ports are placed in the 4th or 5th intercostal space on the anterior axillary line and subscapularly to introduce instruments and endostaplers (Fig. 2 and 3). In this way, the ports lie on the line of a thoracotomy incision in the event conversion to an open procedure might be necessary. A triangular configuration of instruments is aimed at to facilitate intra-operative procedures. The optimal angle between the optic and instruments varies between 30° and 60° but should remain below 90°. Do not work towards yourself as this is difficult to follow on the monitor. Equally, crossing of instruments themselves or with the camera should be avoided. To obtain a general overview of the hemithorax the thoracoscope is usually

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Presented at the 6th Belgian Surgical Week, How I do it session, Ostend, April 28, 2005.

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Fig. 1 Bleb removed during VATS procedure for primary spontaneous pneumothorax.

Fig. 3 View from the dorsal side showing the edge of scapula (sc) and posterior port for the introduction of instruments or camera.

Fig. 2 View from the ventral side showing the camera in the midaxillary line and a ventral port made under direct vision.

Fig. 4 Articulating endostaplers specifically designed for VATS procedures.

Table I

Table II

Accepted indications for invasive treatment of primary spontaneous pneumothorax

Thoracic surgical approaches for primary spontaneous pneumothorax

recurrent or persisting pneumothorax haemopneumothorax bilateral, first contralateral pneumothorax professions at risk (aircraft personnel, divers)

inserted in the central port, although the posterior one provides an alternative location. It should also be noted that on the ventral side of the chest the interspaces are wider ; so, larger instruments as endostaplers can be introduced at this side and manipulated without causing too much soft tissue damage. A higher anterior port

open lateral thoracotomy + total pleurectomy limited axillary thoracotomy VATS single lung ventilation treatment of lung (blebs, bullae) treatment of pleura (pleurectomy, abrasion)

insertion is avoided for cosmetic reasons as well as a previous drain site, especially when the latter is infected. By way of the anterior and central port the thoracic drains will be inserted at the end of the procedure. Following precise localization of the port sites, 2 to 2.5 cm incisions are made after injection of a local

VATS for Pneumothorax anaesthetic with adrenalin to reduce troublesome bleeding. The subcutaneous fatty tissue is cauterized and the underlying muscle fibres are divided or split with blunt dissection. Cautery is applied over the top border of the caudal rib, the edge of which is precisely identified and the parietal pleura is cut or perforated. With careful finger palpation, adhesions between visceral and parietal pleura are localized and bluntly divided, not to damage the underlying lung when the thoracoport is inserted. The other ports are created under direct vision. The thoracoscope is always introduced through a thoracoport not to obscure vision on the camera, but for the working channels thoracoports are not necessarily utilized. The incisions should not been made too small to allow smooth manipulation of instruments inside the chest. However, excessive leverage or angulation should be avoided not to damage the intercostal nerve which can give rise to diffuse and invalidating chronic pain complaints. Inside the chest a careful exploration is performed. If present, adhesions between visceral and parietal pleura are coagulated and cut. Visible blebs, bullae or a fibrotic zone are usually found in the apex of the upper lobe and resected by endostaplers, preferentially in an inverted U shape. The use of articulating endostaplers facilitates the procedure (Fig. 4). Warm saline solution is subsequently poured into the thoracic cavity, the lung is gently inflated and checked for air leaks or remaining blebs, especially at the apex of the lower lobe. This is followed by an apical pleurectomy from the top of the thoracic cavity to the 3rd or 4th intercostal space, and a pleural abrasion of the parietal pleura down to the diaphragm. In this way, an adequate obliteration of the pleural space is obtained and the chest cavity remains accessible in case a thoracotomy would become necessary in the future. As mentioned previously, two thoracic drains are inserted : one apical for the evacuation of air and one basal drain for drainage of blood and serous fluid. The patient is extubated at the end of the procedure.

399 Most common operative morbidity is a prolonged air leak. Although a minimally invasive procedure is used, chronic thoracic pain may occur in up to 30% of patients. In a combined series from 2 thoracic surgical departments of the University of Antwerp 74 patients undergoing 76 VATS procedures for pneumothorax were retrospectively reviewed (2). There were 63 procedures for PSP. Treatment of the lung consisted mostly of an apical resection (81.6 %), and treatment of the pleura mainly of a subtotal (71.1 %) or total (21.1 %) pleurectomy. After a mean follow-up time of 36 months recurrence rate for PSP was 4.8 % (3 patients). One of these had to be treated by a re-VATS procedure, the other two were managed conservatively. Postoperative neuralgia occurred in 13 patients (17.1 %) but only one required chronic pain medication. These results are consistent with recent literature (3). In conclusion, VATS is an effective therapy for recurrent or persisting PSP. However, there is no consensus yet on the optimal VATS technique regarding the resection of blebs or bullae or the precise technique to obliterate the pleural space. References 1. P. DE LEYN, M. LISMONDE, V. NINANE, M. NOPPEN, H. SLABBYNCK, A. VAN MEERHAEGHE, P. VAN SCHIL, F. VERMASSEN. Belgian Society of Pneumology. Guidelines on the management of spontaneous pneumothorax. Acta Chir Belg, 2005 ; 105 :265-267. 2. DE VOS B., HENDRIKS J., VAN SCHIL P., VAN HEE R., HENDRICKX L. Long-term results after video-assisted thoracic surgery for spontaneous pneumothorax. Acta Chir Belg, 2002 ; 102 :439-434. 3. VAN SCHIL P., DE VOS B. Traitement actuel du pneumothorax primaire et secondaire. Rev Mal Resp, 2004 ; 21 :372-380 P. Van Schil, M.D., Ph.D. Department of Thoracic and Vascular Surgery University Hospital of Antwerp Wilrijkstraat 10 B-2650 Edegem (Antwerp), Belgium Tel. : +32-3-8214360 Fax : +32-3-8214396 E-mail : [email protected]