We prefer surgical intervention when there is persistent air leak (>3 days), large air leak (>expiratory 46), failure of lung reexpansion, and in cases of recurrent spontaneous pneumothorax.7 Other indications for surgery include a space problem with air leak or occupations that predispose to pneumothorax, such as a pilot or scuba diver. Once the decision to proceed with surgery has been made, several different approaches can be taken, either by open, or by video-assisted thoracoscopic surgery (VATS) or robotic techniques. The latter is preferred by most surgeons because it affords the use of minimally invasive techniques, which can be particularly important when operating on patients with benign disease.8 However, newer techniques for thoracotomy have made this approach less painful with reduced morbidity. For example, open procedures can be performed using posterolateral muscle-sparing, rib-sparing, and nerve-sparing approaches.9,10 In addition, because this pathology requires access mainly to the upper hemithorax, axillary thoracotomy is also an option. Since VATS is by far the most common operation used for these patients, we will review the operative steps.
Minimally Invasive Techniques: Video-Assisted Thoracoscopy and Robotic Surgery
The goal of any operation in a patient with a recurrent pneumothorax is to prevent the patient from developing another symptomatic pneumothorax. Thus the conduct of the operation depends on the cause of the pneumothorax. If the patient has one large bleb, it should be resected and the staple line is buttressed with material and a sealant is also applied. Although one may not be able to prevent other parts of the lung from rupturing, the main goal is to prevent significant collapse and thus eliminate the risk of tension pneumothorax as well as shortness of breath. However, even when these goals are met, some patients still will have the sensation of an acute onset of chest pain postoperatively, and this probably signifies a small perforation in the lung. If the pleurodesis is successful, the lung will stay inflated, and the chest roentgenogram should be normal. To achieve these goals, some form of pleurodesis is usually needed. In this regard, we prefer to combine chemical with mechanical pleurodesis. In patients who have had more than one spontaneous pneumothorax every intraoperative technique should be applied to prevent further ones. This includes trying to identify the source of the air leak and removing or stapling it closed, maximizing this staple line from leaking by using buttressing material and a sealant and promoting apposition by performing a parietal pleurectomy and adding chemical pleurodesis in selected patients.
Patients should have a chest CT scan and pulmonary function testing performed before surgery. A CT scan is ordered to assess the number and severity of blebs, if any, and to ensure there are no indeterminate pulmonary nodules. In older patients with emphysema and hypercapnia, surgery would be ill-advised if numerous large blebs are found on CT scan. These patients should be managed with a chest tube and bedside sclerotherapy. This chapter, however, focuses on the more common phenomenon of a young patient with recurrent pneumothorax. We prefer to use an epidural, even when performing a VATS procedure because the need for pleurectomy as well as mechanical and chemical pleurodesis causes it to be more painful than a VATS wedge resection.
After the induction of general anesthesia, bronchoscopy is performed. A double-lumen endotracheal tube is placed as well as appropriate lines. The patient is positioned with operative side up, and all indwelling chest tubes are removed. Three standard VATS incisions are made. These incisions should be placed in a triangle to permit complete inspection and access to all areas of the chest. The apical segment of the upper lobe and the superior segment of the lower lobe are examined carefully. Even if a bleb cannot be located, we prefer to excise a wedge of the upper lobe and a small part of the lower lobe by using an endoscopic stapler that is buttressed with pericardial strips (Bovine Pericardial Strips, Synovis Surgical Innovations, St. Paul, MN) (Fig. 128-4). The recurrence rate after VATS by means of endoscopic stapler is less than 5%.9 These strips help to create adhesions. A complete pleurectomy from the mammary artery to the vertebral bodies is performed. It extends from the top of the chest to the diaphragm. The pleura is scraped by attaching a Bovie scratch pad to the end of a long, curved VATS ringed forceps (Fig. 128-5). This technique creates a pleural edge that can be grasped. A blunt instrument, such as a Kittner dissector, a finger to start, and then a sucker (Ethicon Endo-Surgery, Cincinnati, OH) are used to slowly remove the entire pleura. If the pleura is grasped with a long, curved VATS ringed forceps, it can be twisted and rotated, and this helps the operator to perform a complete pleurectomy quickly, usually in 15 to 25 minutes (Fig. 128-6). After the pleurectomy is completed, we prefer to add a chemical pleurodesis as well. We do not use talc in these young patients because of some of its potential side effects. The intrapleural injection of talc has resulted in acute respiratory distress syndrome in some patients treated for malignant pleural effusion. In addition, extensive pleural thickening with calcifications can develop many years after intrapleural talc,11 causing restriction of pulmonary function. Instead we use 500-mg doxycycline in 250-mL normal saline. The intrapleural injection of a tetracycline derivative decreases the recurrence rate for pneumothorax. In a prospective, randomized study of 229 patients with spontaneous pneumothorax, for example, the recurrence rate was 25% in the group treated with intrapleural tetracycline compared with 41% in the control group.12 Thus we add this to our intraoperative technique. This fluid is instilled in the chest for 10 minutes and then evacuated. Two chest tubes are placed through two more anterior incisions (the most inferior port used for the camera and the most anterior port). We prefer to place two soft 24 F drains. One tube is placed anteroapically, and the other is placed posteroapically.
A portion of the upper lobe is resected using an endoscopic stapler buttressed with pericardial strips, which help to create adhesions.
A Bovie scratch pad is used to create a pleural edge.
The pleural edge is grasped with a long, curved VATS ringed forceps, which is rotated and twisted as shown to facilitate the pleurectomy.
The chest tubes are placed on suction for a few days unless there is an air leak. Although we have written extensively about the benefits of the setting chest tubes to water seal, this applies to patients with an air leak. In patients, often with large and expansive chests, the lungs have difficulty filling this space, and thus we prefer suction. The epidural is removed on postoperative day 2 (or 3), and the patient can be discharged home on day 3 or 4. We usually send the patient home for a week or two with the anterior apical tube in place on a Heimlich valve or, more recently, connected to an Atrium Express (Atrium Medical Corporation, Hudson, NH) device. The patient returns to the outpatient clinic 1 to 2 weeks later. If the device shows no air leak and the radiograph shows no or only a minor pneumothorax, the chest tube is removed. If there is a large pneumothorax that is new, we prefer suction for another few days to help promote visceral–pleural to parietal–pleural apposition. Even if an air leak is present, the tubes can be removed safely if there is no new pneumothorax or subcutaneous emphysema.13
Chest tube insertion may result in empyema (1%–3%), lung parenchyma perforation (0.2%–0.6%), diaphragmatic perforation (0.4%), and subcutaneous placement (0.6%). In an analysis of 126 chest tube placements by pulmonologists at a teaching hospital, the complication rate was 11%; however, 10 of the 14 reported complications were related to clotting, kinking, or dislodgment of the chest tube.14
The most common short-term complication of VATS for a recurrent pneumothorax is an air leak. As described earlier, the initial treatment should be water seal, and if it persists, then outpatient management with an Atrium device is preferred. Persistent air leak commonly occurs in patients with secondary pneumothoraces. Pain is another common complaint after VATS, despite the fact that the ribs are not spread. The pain is usually secondary to impingement of the intercostal nerve. The best management is prevention. We do not use a trocar for the camera or for any of the ports. The trocar can be slipped over the camera once it is introduced into the chest. Pain can lead to inadequate ventilation of the lungs, thus promoting the incidence of atelectasis and pneumonia. Most patients have minimal postoperative discomfort; however, analgesics may be required to achieve adequate control of pain once the epidural is removed.
Recurrence of the pneumothorax is the most frequent and frustrating complication of primary spontaneous pneumothoraces; it occurs in up to 25% to 54% of untreated patients, and most recurrences occur within the first year of the first pneumothorax.15,16 After VATS, however, the incidence is much less. After a second pneumothorax, the risk of having a third increases by more than 50%.17 Hemorrhage related to VATS is uncommon. Arrhythmia, which is common after many thoracic procedures, should be managed as described in Chapter 8.