Access the accompanying videos for this chapter online. Available on ExpertConsult.com .
Indications for Workup and Operation
Thoracoscopy is now the preferred approach for the operative treatment of primary spontaneous pneumothorax (PSP) due to ease of operation and patient tolerance, with minimization of postoperative pain and good results.
PSP is a pneumothorax that develops outside of an underlying preexisting pulmonary disease, such as malignancy or trauma, which is termed secondary spontaneous pneumothorax. The pathophysiology and treatment of secondary pneumothorax are complex and outside the scope of this chapter. PSPs usually present in teenagers with chest pain and shortness of breath. Chest auscultation may reveal decreased breath sounds on the affected side. When a significant pneumothorax is present, with or without tension physiology, there may be an associated tracheal deviation away from the affected side.
The vast majority of patients with a PSP are teenagers who present with stable vital signs and without signs and symptoms of tension pneumothorax. Although rare with PSP, if tension pneumothorax is present, immediate decompression with a chest tube or angiocatheter is necessary. In the majority of patients, the first step in PSP management is radiographic imaging including a posteroanterior and lateral chest radiograph ( Fig. 35-1 ). On occasion, a bleb is seen on the chest radiograph ( Fig. 35-2 ).
The next steps in management consist of obtaining intravenous access, and if the pneumothorax is sizable and/or the patient is symptomatic, then tube/catheter drainage is indicated. A recent prospective pilot study demonstrated that a trial of simple aspiration using a small-bore catheter predicts the need for further intervention. The drainage tube acts in three ways: (1) drains the extrapleural air, (2) achieves symptom resolution, and (3) acts as a test for tolerance of aspiration. If the pneumothorax resolves on radiograph after initial aspiration, the tube is clamped. If the pneumothorax returns, then the tube is unclamped, and the patient is scheduled for an operation during the hospitalization, preferably that day or the next day.
The indications for operative intervention of PSPs are in continued evolution. Periods of prolonged chest tube management are shifting toward a trend of more prompt operative intervention. Therefore, the most common indications for operation for PSP at this time are recurrence, persistent air leak, and inadequate immediate access to quality medical care. The use of chest computed tomography (CT) has not been consistently demonstrated to be of significant value in the initial operative decision making and is therefore not routinely used in our institution.
The thoracoscopic treatment of PSPs requires general anesthesia. Single-lung ventilation is usually employed either with contralateral mainstem intubation, a double-lumen endotracheal tube, or bronchial blockers. Recently, we have begun to employ tracheal intubation without lung isolation and simply let the gentle pneumothorax (from the insufflation) provide adequate ipsilateral lung collapse. This works well as only the lung parenchyma and the chest wall need complete visualization and total lung collapse is not a necessity. Adequate visualization can usually be obtained without physiologic consequence to the patient if the insufflating pressure is kept low.
The patient is usually positioned in the lateral decubitus position with the affected side up. This can also be accomplished with just a bump under the affected side. If full decubitus is used, special attention must be paid to placement of a shoulder roll and to ensure the patient is well padded and secured to the bed. This can be done using large gel rolls or a bean bag. If the procedure is expected to take longer than 1 hour, sequential compression devices on the legs should be considered based on local policies and practices. As these operations are not typically lengthy, a bladder catheter is not routinely necessary.
Port Selection and Placement
The surgeon and assistant stand on opposite sides of the patient ( Fig. 35-3 ). The chest is usually accessed just below the tip of the scapula by introducing a 5-mm port. This site works well for the camera position as it gives a central and cranial directed view of the chest cavity. Once intrathoracic placement of the port is confirmed, a gentle pneumothorax is created. When adequate visualization and working space have been achieved, two additional ports are then inserted: one 12-mm port for the stapling device and an additional 5-mm working port. One port can be inserted through the chest tube site, depending on its location ( Fig. 35-4 ). A 3-mm port or stab incision can also be used depending on patient size or surgeon preference. While triangulation of the instruments is important, it is less so in this operation as the chest is large in the typical teenage patient. Therefore, the ports can be placed in locations that are both operatively and cosmetically advantageous. The 12-mm port for the stapler is often placed more posteriorly and inferiorly at about the posterior axillary line. The 5-mm port is consequently placed at the other apex of the triangle, more anteriorly and inferiorly in the anterior axillary line.