Blebectomy and pleurectomy is recommended for the second episode of ipsilateral spontaneous pneumothorax, or the first episode of spontaneous pneumothorax with an apical bleb on CT scan. Patients who are severely symptomatic during the first spontaneous pneumothorax, or who may not be able to obtain rapid treatment for a second spontaneous pneumothorax by virtue of poor access to specialized care, may benefit from pleurectomy after a single spontaneous pneumothorax.
A CT scan of the chest identifies the target areas, usually in the apices of the lung (Figure 1). A bleb may also be seen in the superior segment of the lower lobe. Women should be questioned about their menstrual history to rule in (or out) catamenial pneumothorax. Underlying emphysema is not a contraindication to surgery but substantially increases its complexity and postoperative morbidity. With underlying emphysema, the area of potential air leak is less predictable, occurring anywhere along the surface of the lung, and is therefore more difficult to localize. The delicate nature of emphysematous lung and the often-associated pleural adhesions require expertise in lung handling. Routine use of gentle lung handling, buttressed staple lines, and mechanical pleurodesis or pleurectomy are required.
General anesthesia is performed with single-lung ventilation. A double-lumen tube allows the anesthesiologist to assist in localizing blebs with gentle hand ventilations on the ipsilateral side, while still fully ventilating the contralateral side.
The patient is placed in the appropriate lateral decubitus position, slightly rolled forward in case of the need for posterolateral thoracotomy. The surgeon stands in front of the patient with the assistant standing to the surgeon’s left or behind the patient. The anesthesiologist stands at the head of the patient. The surgical nurse stands on the same side as the surgical assistant. Monitors are positioned at the head of the bed and on either side of the patient (Figure 2).
The skin may be prepared using any suitable prep, but the prep should anticipate the possibility of a thoracotomy. The skin prep should be from the nipples medially, to the spine laterally; and from above the shoulder superiorly, to below the level of the costal margin inferiorly.
The incision for the thoracoscope is placed in the 7th intercostal space (ICS) in the midaxillary line. A 5-mm port in the 5th ICS posteriorly can be used for retraction and may provide the best angle for stapling of the bleb. A second 2- to 3-cm incision is made in the 4th intercostal space between the midaxillary line ...