The adequacy of single-incisional thoracoscopic surgery as a first-line endoscopic approach for the management of recurrent primary spontaneous pneumothorax: a retrospective study

Abstract

Background: Thoracoscopic surgery is a commonly used endoscopic surgical treatment approach in patients with primary spontaneous pneumothorax. The conventional thoracoscopic approach utilizes three or more small wounds for surgery. Currently, a single port approach is a potential alternative procedure in general thoracoscopic surgery. We investigated whether a single-port approach is suitable as a first-line endoscopic approach for all patients with primary spontaneous pneumothorax requiring surgery.

Methods: From July 1st, 2008 to Dec 31, 2009, a total of 62 patients was included in this study. All the patients were admitted to our ward because they had surgical indications for surgery. Twenty-six patients underwent conventional three-port thoracoscopic surgery and thirty-six underwent single-port thoracoscopic surgery. All of the clinical data were analyzed retrospectively. Variables were compared and analyzed to determine the outcomes of the different surgical approaches.

Results: The mean age of the 62 patients was 27.2 years. Forty-nine patients were men and thirteen patients were women. The mean time required for the operation was 61.6 minutes. There was one patient who had a recurrence in single-port group and 2 patients had a recurrence in three-port group during the period of follow-up. The average pain scores at 24 and 48 hrs after the operation were similar, but the pain scores at 72 hrs in the single-port group were better than the three-port group. There was no case that required conversion from a single-port to multiple wound approach in this study. There was no immediate postoperative recurrence. The follow-up duration was greater than 12 months.

Conclusion: This study showed that single-port thoracoscopic surgery is a feasible and reasonable first-line endoscopic approach in the surgical treatment of primary spontaneous pneumothorax.

Figure 1

The single wound approach in the patient with primary spontaneous pneumothorax. The wound is usually 15 mm in length (1A). All of the working tools, including the grasp, stapler and endoscope, were placed through the wound (1B). This is the smallest wound achieved with the currently popular endoscopic instruments.

Figure 2

A case of conventional multi-portal thoracoscopic surgery for pneumothorax. The lesion site can be approached from different angles (2A), which made surgery easier and helped create a three-dimensional working environment. After localization of the abnormal lung, a stapler can be used for resection (2B).

Figure 3

The setting for single-port thoracoscopic surgery. We initially confirmed the site of the abnormal lung (the green arrow in 3A). Then a grasp was used to assist in resection with a linear stapler (3B). At times, the instruments may become crossed in the course of completing the procedure, because of the restriction by the tiny wound (3C). Scissors may be required to cut the specimen from the remaining lung (3D).

Figure 4

Pleurodesis with abrasion using a cleansing pad can be performed with instruments positioned at different angles, such as a linear endoscopic grasp to approach the apex (4A), and a long, curved clamp to approach other regions (4B). In all of the cases, we performed abrasion pleurodesis along with administering minocycline, but we did not perform pleurectomy. The specimen was removed through the small wound (4C). Resection with a stapler was shown to be as feasible as in conventional multi-portal thoracoscopic surgery (4D).

Figure 5

In some cases recurrent pneumothorax, there may be one or multiple neovascularizations in the apex (5A) that cause excessive bleeding. With a single-port thoracoscopic surgery, clipping was slightly difficult because the vessel was usually in the most apical region of the pleural space. However, it is still feasible(the green arrow in 5B).

Figure 6

Wedge resection of the apical lung with hyperemic changes (6A) and neovascularization(6B).

Figure 7

Although the mean operative time required for single-port surgery did not differ from that for conventional multi-port thoracoscopic surgery, it seems obvious that the time required for single-port thoracoscopic surgery decreased substantially along with increasing skill in the procedure.