Chapter 11: Thoracic Surgery

Pneumothorax (PTX) (core)

SOB, chest pain

Traumatic—penetrating or blunt injury, often associated with rib fractures

Primary spontaneous pneumothorax (PSP)—tall, thin, young, males, smokers

Secondary spontaneous pneumothorax—COPD, interstitial lung disease, catamenial pneumothorax, lymphangioleiomyomatosis (LAM), cystic fibrosis, etc

CXR

CT chest—better anatomic definition, evaluate for blebs, occult pneumothorax (PTX seen on CT but no CXR)

Traumatic PTX—place chest tube

• - If it is a small/occult pneumothorax and patient is stable, can consider observation with repeat upright CXR in 6 h

PSP management:

• - Place chest tube

  • For small PTX (<3 cm to apex) can consider observing and getting repeat CXR in 6 h

• - Surgery can be performed to decrease risk of recurrence, discuss with patient

  • PSP recurrence rate without surgery:

    • First time → 20-30%

    • Second time → 60-75%

  • Surgery includes VATS blebectomy with pleurodesis and/or pleurectomy

    • 5-10% risk of recurrence after surgery

  • Indications for surgery after first episode:

    • Bilateral PTX

    • Complete PTX

    • High-risk occupation or hobbies (diver, pilot)

    • Live in remote area

Secondary spontaneous pneumothorax management:

• - Place chest tube for acute management

• - Surgical blebectomy and pleurodesis may be considered in appropriate candidates

  • Avoid large wedge resections because the residual space may lead to prolonged air leak

• - Consider chemical or talc pleurodesis for high risk surgical patients (ie, COPD with significant bleb disease)

Smoking cessation

Chest tube placement (core):

• - Select 16-24 Fr chest tube or 14 Fr pigtail

• - Position patient supine with arm raised above head, drape anatomic landmarks into the field, prep the field

• - Inject local anesthetic, make skin incision in fifth or sixth ICS between mid to anterior axillary line

• - Divide subcutaneous tissue and muscle down to the level of the rib

• - Enter the pleural space bluntly just above the rib and palpate lung/pleural space to confirm chest entry

• - Insert chest tube far enough that sentinel hole is several centimeters in the chest

• - Suture tube to the skin and place occlusive dressing

• - Connect tube to atrium, initially at -20 cm H2O, evaluate for tidaling and air leak

• - Obtain CXR to confirm tube position and assess lung expansion

VATS blebectomy and pleurodesis (core):

• - Double lumen ETT → single lung ventilation

• - Lateral decubitus, typically place 3 ports with the camera low in the chest ...