1� 2005 European Association for Cardio-thoracic Surgery

doi:10.1510/mmcts.2004.000349

Video-assisted thoracoscopic surgery (VATS)pleurodesis for pneumothorax

Calvin S.H. Nga, Gaetano Roccob, Anthony P.C. Yima,*

Division of Cardiothoracic Surgery, The Chinese University of Hong Kong, Prince of Walesa

Hospital, Shatin, NT, Hong Kong SAR, ChinaDepartment of Cardiothoracic Surgery, Northern General Hospital, Sheffield, United Kingdomb

Spontaneous pneumothorax is a common condition that impacts significantly on healthcareexpenditure. Its optimal management, however, remains a subject of considerable contro-versy. The proven safety and efficacy of minimal access video-assisted thoracic surgery(VATS) has changed the way we manage this condition. We present VATS pleurodesis util-izing the endoscopic stapling technique for the management of spontaneous pneumothorax.

Keywords: Spontaneous pneumothorax; Thoracoscopy; Video-assisted thoracic surgery(VATS)

Photo 1. Thoracoscopic image of apical blebs in patient with spon-taneous pneumothorax.

Introduction

Thoracoscopy, without video assistance and per-formed under local anesthesia has been practiced byEuropean pulmonologists for almost a century. Sattlerwas credited to be the first to identify bullae in apatient with spontaneous pneumothorax using thor-acoscopy and reported this in 1937 w1x. The devel-opment of solid state systems and microcameras inthe 1980s preceded the advent of video-assisted tho-racic surgery (VATS) in the 1990s. While thoracoscopyallows simple observation and talc poudrage, VATSpermits procedures like mechanical pleurodesis, pleu-rectomy and bullectomy. There is excellent consensusamong the surgeons that VATS (which commonlyinclude bullectomy and either mechanical pleurodesisor partial pleurectomy) is the approach of choice whenan interventional procedure is considered necessaryw2x. We routinely perform blebectomy or bullectomywhen it can be identified thoracoscopically (Photos 1and 2). Furthermore, patients who underwent isolatedVATS pleurodesis, without apical resection were asso-

* Corresponding author: Tel.: q852-26-322629; fax: q852-26-478273.E-mail: yimap@cuhk.edu.hk

ciated with a much higher rate of recurrence com-pared to when the resection was performed w2x. Wegenerally avoid pleurectomy and prefer pleurodesis,not only because bleeding is more common in theformer but also because there is a chance thatthese patients may need lung surgery, and prior pleu-

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Photo 2. Thoracoscopic image of multiple apical bulla in patientwith spontaneous pneumothorax.

Video 1. Adhesions are taken down and haemostasis secured withdiathermy. Extra care is required for apical adhesions to avoid injuryto the subclavian vessels.

Video 2. A small ruptured bleb may be difficult to identify.

rectomy would seriously complicate future surgicalmanagement.

With the lowered morbidity of VATS, the accepted sur-gical indications for pneumothorax include persistentair leak, recurrence, radiologically demonstrated hugebulla, spontaneous hemopneumothorax, incompleteexpansion of the lung, tension pneumothorax, bilat-eral involvement and SP in a high-risk occupation,

such as pilot or scuba diver w2x. Some authors haveeven recommended VATS for uncomplicated first timepneumothorax, which we currently do not advocate.However, there remain considerable controversies onissues such as the duration of persistent air leak andthe number of recurrences before surgery is deemedappropriate. A recent consensus from the AmericanCollege of Chest Physicians recommended the obser-vation of air leaks for 4 days prior to surgical inter-vention w3x. Our experience supports the use of VATSwhen persistent air leak is present for more than 3days, and on the second admission for SP w2x.

Surgical preparation and technique

The general strategies to VATS are similar to thosedescribed in our other contribution (see Ng CSH andYim APC. Video-assisted thoracoscopic surgery(VATS) bullectomy for emphysematous/bullous lungdisease – doi: 10.1510/mmcts.2004.000265).

Surgical procedure

1. Incision and port placement

The incision and port sites are similar to thosedescribed in our other contribution (see Ng CSH andYim APC. Video-assisted thoracoscopic surgery(VATS) bullectomy for emphysematous/bullous lungdisease – doi:10.1510/mmcts.2004.000265).

2. Exploration

The entire hemithorax should be inspected. Bluntatraumatic instruments (sponge-holding forceps)should be used for manipulation of the lung tissue.Adhesions should all be taken down to achieve agood operating field. Haemostasis is secured withdiathermy for any adhesion bands. Special attentionis needed for dividing apical adhesions because of theproximity of the subclavian vessels (Video 1). Thepresence of subpleural bullae has been reported tobe present in 76 to 100% of primary spontaneouspneumothorax patients during video-assisted thora-coscopic surgery w2x. The whole lung surface, partic-ularly at the apex and the lung edges, should becarefully searched for blebs and bullae. In a collapsedlung, a small bleb especially when ruptured (Video 2)can be difficult to identify. If left behind, these blebscould lead to recurrence.

3. Endoscopic stapled blebectomy/bullectomy

The endoscopic stapler resection line, which shouldbe across healthy lung tissue, is marked by sponge-

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Video 3. The target region with blebs or bullae is identified, andendoscopic stapled blebectomy/bullectomy is performed.

Video 4. During endoscopic stapled blebectomy/bullectomy, it isimportant to ensure the continuity of each staple line to prevent airleak. The resected abnormal wedge of lung is removed.

Video 5. Endoscopic Marlex mesh mechanical pleurodesis is per-formed to the whole pleural cavity including the diaphragmaticsurface.

Video 6. Endoscopic endo-loop bulla ligation performed using apre-tied commercial endo-loop or by a homemade polydioxanoneloop.

holding forceps. Endoscopic stapled blebectomy/bul-lectomy is performed, ensuring that there is continuityof each staple line to prevent air leak (Video 3).Crossing of staples is to be avoided, and only gentle

traction should be applied to prevent tearing of thelung. The resected lung wedge can best be retrievedthrough the anterior port with the wider intercostalsspace (Video 4). In our experience, the division of theinferior pulmonary ligament is generally not requiredunless a very large apical lung wedge is resected withthe bleb or bulla.

4. Mechanical pleurodesis

A piece of rolled up Marlex mesh is mounted at theend of the endoscopic grasper, and mechanical pleu-rodesis is performed to the whole pleural cavityincluding the diaphragmatic surface (Video 5). Partic-ular attention should be paid to ensure mechanicalpleurodesis is thoroughly performed at the apical andlateral regions of the pleural cavity. It is important tocheck that the piece of mesh covers the entire tip ofthe endoscopic grasper to prevent injury. Further-more, extra care is needed at the apex to avoid injuryto the subclavian vessels.

5. End of the procedure

The areas of adhesiolysis and port sites are inspectedfor bleeding and hemostasis secured with diathermy.Through the inferior port site, a 24Fr chest drain ispositioned under direct videoscopic vision to the apexand to lie antero-laterally in the pleural cavity. The lungis then reinflated under direct vision, and layered clo-sure of the stab wounds complete the operation. Wedo not routinely check for airleak from the staple line.

Other techniques for managing blebs/bullae

1. Endoloop ligation

Endoscopic endoloop bulla ligation can be suitable forbulla in primary and secondary SP w4x. It is performedusing a pre-tied commercial endo-loop or by a home-made polydioxanone loop (Video 6). Homemadedevices are, of course, more cost effective. However,a known complication of endoloop ligation is the acci-dental slipping off of the loop during lung expansionor after a forceful sneeze. The problem can be mini-mized by the placement of a double or triple looparound each bulla w5,6x. Furthermore, a small metalclip can be applied to prevent loosening of the endo-loop knot (Video 7).

2. Endoscopic suturing

Video-assisted thoracoscopic suturing of apical bullaewith mechanical pleurodesis has been shown to be a

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Video 7. Placement of a double loop around each bulla can preventaccidental falling off of the loop. A metal clip can be applied toprevent loosening of the endo-loop knot.

Photo 3. Endoscopic suturing of bleb is performed using conven-tional surgical instruments.

Photo 5. The ends of the sutures are tied and bleb has beenplicated.

Video 8. Argon beam coagulation of multiple blebs.

Photo 4. The long conventional needle holder and standardmonofilament polypropylene sutures used.

viable alternative to endoscopic stapled bullectomywith mechanical pleurodesis w7,8x. Parenteral narcoticrequirement, chest drainage duration, hospital stayand pneumothorax recurrence were similar for bothtechniques w7,8x. To minimize cost, the long conven-tional needle holder and standard monofilament poly-propylene sutures used were found to be as effectiveas the specialized endoscopic suturing equipment forthoracoscopic suturing of bullae (Photos 3, 4 and 5).Therefore, in view of the high cost of staple-cutters,endoscopic suturing of apical bullae should be con-sidered in selected cases of small localized bullae forPSP w7,8x. However, it must be emphasized thatendoscopic suturing should be performed by sur-geons adequately trained in the skill.

3. Argon beam coagulator

Argon beam coagulation (ABC) is less effective thanstapled, suturing or endo-loop ligation bullectomy inseveral patient series w7,8x. Patients treated with ABChad more post-operative prolonged air leaks (-10days), as well as pneumothorax recurrences w7,8x.Therefore, the consensus is that ABC should not

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Video 9. A roticulating endograsper is used to suspend the targetparenchymal area cranially. Subsequently, a roticulating endostapleris positioned just caudal to the lesion to be removed.

Video 10. Endoscopic bleb/bullectomy is performed and the endo-grasper repositioned more distally upon each firing. Roticulatingendoscissors are used to divide tissue not separated after stapling.Specimen is removed by endobag or directly by Roberts clamp.

Video 11. An electrocautery scratch-pad mounted on Robertsclamp is used for mechanical pleurodesis. This maneuver can cre-ate a tear in the parietal pleura where pleurectomy can be initiatedwith endo kittner.

be used as the primary treatment modality for SP(Video 8).

The uniportal VATS technique

Recently, Rocco et al. described the uniportal VATStechnique for the management of spontaneous pneu-mothorax. Usually, an incision of 2 to 2.5 cm is madefor uniportal VATS; if the chest cavity has beendrained before, the same incision where the chestdrain has been inserted can be used w9x. The port siteis created directly anterior to the scapular line (see

Rocco G. Endoscopic VATS sympathectomy: the uni-portal technique – doi: 10.1510/mmcts.2004.000323).

After thorough inspection of the lung for any emphy-sematous changes, the target area is usually identifiedat the upper lobe apex or at the apical segment of thelower lobe (Video 9). A roticulating endograsper (Roti-culator Endograsp, MMCTSLink 10) is introduced par-allel to the videothoracoscope in such way as tosuspend the target parenchymal area cranially. Sub-sequently, a roticulating endostapler (Endo GIA Roti-culator, MMCTSLink 15) is inserted on the oppositeside of the videothoracoscope through the same inci-sion. The jaws of the endostapler are opened insidethe chest and positioned just caudal to the lesion tobe removed. This maneuver is facilitated by having theendograsper ‘‘present’’ the parenchymal area to theendostapler which can then be gently pushed intoposition prior to firing.

The endostapler is fired and the endograsper reposi-tioned more distally onto the remaining lung to beresected (Video 10). Serial firings (up to three) are usu-ally needed to remove all diseased lung tissue. Shoulda bridge of parenchyma remain to hold the specimenin place, a roticulating endoscissors can also be intro-duced. At this point the specimen can be removedeither through an endobag (EndoCatch, MMCTSLink16) or directly by using a long Roberts clamp.

A simple electrocautery scratch-pad, secured with along stitch to facilitate its retrieval and mounted onthe same Roberts clamp, is used to start the parietalpleural abrasion (Video 11). This maneuver is meantto create a tear in the parietal pleura from where aformal pleurectomy can be initiated with the aid of anendo kittner. Alternatively, a pleural abrasion can beperformed throughout the chest cavity.

Technical considerations

Complication associated with the technique includeair leak from the staple line, particularly when there iscrossing of staple lines w5x. Furthermore, we have pre-viously reported endoscopic staple cutter malfunc-tioning as a potential hazard w6x. We normally keepthe chest drain on continuous 15 cmH2O suction forat least 24 h before considering removal to allow pleu-rodesis. Any pleural airspace in the early post-oper-ative period should be dealt with aggressively, forexample by increasing suction pressure or reposition-ing the drain to allow full lung expansion, becausepleural apposition is the key to effective pleurodesis.Similarly, avoiding air leak into the pleural space dur-ing chest drain removal is also important. wNg CSH,Yim APC. Insertion of Chest Drain Guidelines: Other

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Tab

le1.

VATS

for

spon

tane

ous

pne

umot

hora

x

Aut

hors

Cas

eP

atie

ntB

leb

s/b

ulla

eS

tap

led

End

oloo

p/

Ab

rasi

onP

rolo

nged

Mea

nM

ean

orS

Pd

escr

iptio

nN

o.se

enat

VATS

bul

lect

omy

end

o-p

leur

odes

isp

ost-

hosp

itals

tay

med

ian

follo

w-

recu

rren

ce(%

)su

turin

g/(%

)op

erat

ive

air

ind

ays

upin

mon

ths

(%)

AB

Cle

ak(%

)(r

ange

)(r

ange

)

Yim

w7x

PS

P48

387

196

261/

35/6

100

33

(1–3

0)20

(1–3

6)1.

7(1

997)

(alo

nein

20ca

ses)

Liu

w8x

PS

P&

757

8931

235

2/52

/6(a

lone

in4

4.5

30(1

–60)

2.1

(199

9)S

SP

49ca

ses)

()10

day

s)(0

–27)

Hat

zw1

3xP

SP

&P

SP

:95

NA

109

034

2.8

PS

P:

4(2

–14)

53(2

–86)

4.6

(200

0)S

SP

SS

P:

14(a

lone

in72

)()

2d

ays)

SS

P:

8(1

–18)

Aye

dw1

1xP

SP

7278

560

546.

94

42(3

6–5

4)5.

5(2

000)

()5

day

s)(fr

omga

uze

abra

sion

)Lo

uban

iw12

xP

SP

49N

A52

00

NA

6.8/

4.8

38(3

6–4

0)20

/4(2

000)

("ac

rom

ycin

)C

ard

illo

w10x

PS

P43

278

235

104/

0/0

01.

46

38(2

–72)

4.4

(200

0)()

5d

ays)

Cha

nw1

4xP

SP

82N

AN

AN

A/0

/010

0N

AN

A44

(8–8

5)5.

7(2

001)

AB

C,

argo

nb

eam

coag

ulat

ion;

NA

,d

ata

not

avai

lab

le;

PS

P,p

rimar

ysp

onta

neou

sp

neum

otho

rax;

SS

P,se

cond

ary

spon

tane

ous.

Experiences. Thorax 8th Aug 2003. http://tho-rax.bmjjournals.com/cgi/eletters/58/suppl–2/ii53x

Results

At experienced centres the recurrence rate after VATShas consistently been reported to be as low as treat-ment via thoracotomy w5–8,10x (Table 1). Missed bul-lae and more conservative surgical procedures maylead to more frequent recurrences. Some evidencesuggests that apical lung excision, even in theabsence of visible lesion, may reduce spontaneouspneumothorax recurrence w11x.

Stapled bullectomy is a safe and reliable method,which is unlikely to be complicated by prolonged airleak and pneumothorax recurrence, particularly whenused with a form of pleurodesis w7,8,12,13x. Abrasionpleurodesis is preferred by ourselves, which is oftenperformed with Marlex� mesh w7,8,13x. Abrasion pleu-rodesis with dry gauze is less effective and has higherrecurrence in the treatment of spontaneous pneumo-thorax w11x. Thorough pleural abrasion remains thekey for reducing pneumothorax recurrence w5,6x.Some reports have suggested apical pleurectomymay be marginally better at preventing recurrencesthan abrasion pleurodesis w11,14x although the risk ofbleeding and post-operative neuralgia is higher w14x,and it is likely to make future thoracic surgery difficult.The results from endo-loop bullous ligation in termsof post-operative prolonged air leak, hospital stay andpneumothorax recurrence has been generally com-parable with other bullectomy procedures, particularlywhen applied to small bullae, w7,8x although Cardilloet al. reported higher recurrence with endo-loop liga-tion compared to stapled bullectomy w10x. On thewhole, endo-loop bullous ligation is viable, safe andcost effective in selected cases.

In secondary pneumothorax, treatment by VATSresulted in similar post-operative prolonged air leakand recurrence when compared with thoracotomy orprimary spontaneous pneumothorax treated by VATS(Table 1) w8,13x. However, the length of hospital staywas longer (mean 8 days) for secondary spontaneouspneumothorax patients treated by VATS when com-pared with primary spontaneous pneumothorax (mean4 days) w13x.

References

w1x Sattler A. Zur Behandlung der Spontan-pneumothorax mit besonnnberer Beruck-

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C.S.H. Ng et al. / Multimedia Manual of Cardiothoracic Surgery / doi:10.1510/mmcts.2004.000349

sichtigung der Thorakoskopie. Beitr Klin TuberkSpezif Tuberkuloseforsch 1937;89:394–408.

w2x Yim APC, Ng CSH. Thoracoscopic managementof spontaneous pneumothorax. Curr Opin PulmMed 2001;7:210–214.

w3x Baumann MH, Strange C, Heffner JE, Light R,Kirby TJ, Klein J, Luketich JD, Panacek EA, SahnSA, AACP Pneumothorax Consensus Group.Management of spontaneous pneumothorax. AnAmerican College of Chest Physicians DelphiConsensus Statement. Chest 2001;119:590–602.

w4x Liu HP, Chang CH, Lin PJ, Chu JJ, Hsieh MJ. Analternative technique in the management ofbullous emphysema thoracoscopic endo-loopligation of bulla. Chest 1997;111:489.

w5x Yim APC. Negative outcomes following video-assisted thoracic surgery. Asian CardiovascThorac Ann 1996;4:133–138.

w6x Yim APC, Liu HP. Complications and failures ofvideo-assisted thoracic surgery: experience fromtwo centres in Asia. Ann Thorac Surg1996;61:538–541.

w7x Yim APC, Liu HP. Video-assisted thoracoscopicmanagement of primary spontaneous pneumo-thorax. Surg Laparosc Endosc 1997;7:236–240.

w8x Liu HP, Yim APC, Izzat BM, Lin PJ, Chang CH.

Thoracoscopic surgery for spontaneouspneumothorax. World J Surg 1999;23:1133–1136.

w9x Rocco G, Martin-Ucar A, Passera E. Uniportalwedge pulmonary resections. Annals of ThoracicSurgery 2004;77:726–728.

w10x Cardillo G, Facciolo F, Giunti R, Gasparri R,Lopergolo M, Orsetti R, Martelli M. Video-thoracoscopic treatment of primary spontaneouspneumothorax: a 6-year experience. Ann ThoracSurg 2000;69:357–361.

w11x Ayed AK, Al-Din HJ. The results of thoracoscopicsurgery for primary spontaneous pneumothorax.Chest 2000;118:235–238.

w12x Loubani M, Lynch V. Video assisted thoraco-scopic bullectomy and acromycin pleurodesis: aneffective treatment for spontaneous pneumo-thorax. Respir Med 2000;94:888–890.

w13x Hatz RA, Kaps MF, Meimarakis G, Loehe F, MullerC, Furst H. Long-term results after video-assistedthoracoscopic surgery for first-time and recurrentspontaneous pneumothorax. Ann Thorac Surg2000;70:253–257.

w14x Chan P, Clarke P, Daniel FJ, Knight SR,Seevanayagam S. Efficacy study of video-assisted thoracoscopic surgery pleurodesis forspontaneous pneumothorax. Ann Thorac Surg2001;71:452–454.