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Ann Thorac Surg 2003;76:1665-1667
© 2003 The Society of Thoracic Surgeons

Original article: general thoracic

Thoracoscopic ipsilateral approach to contralateral bullous lesion in patients with bilateral spontaneous pneumothorax

Yi-Cheng Wu, MDa, Yen Chu, MmedSca, Yun-Hen Liu, MDa, Chi-Hsiao Yeh, MDa, Tzu-Ping Chen, MDa, Hui-Ping Liu, MDa*

a Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan

Accepted for publication May 29, 2003.

* Address reprint requests to Dr Hui-Ping Liu, Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, 199 Tun-Hwa N Rd, Taipei, 105 Taiwan.
e-mail: hpliu125{at}ms21.hinet.net


   Abstract
Top
 Abstract
Introduction
 Material and methods
 Results
 Comment
 References
 
BACKGROUND: Video-assisted thoracic surgery (VATS) has gained a prominent role in routine thoracic surgical practice. This study describes a novel ipsilateral approach to a contralateral bullous lesion using VATS to achieve simultaneous bilateral bleb excision and pleurodesis.

METHODS: From 2001 to 2003, 6 patients underwent our ipsilateral approach with VATS for bilateral pneumothorax. The clinical features, surgical indications, and patient outcomes were reviewed.

RESULTS: All the patients were men between 18 and 35 years old (mean age, 25.8 years). The ipsilateral-approach VATS procedure for bilateral pneumothorax was performed successfully in 4 patients. Two patients were switched to a one-stage sequential bilateral VATS procedure. The bullous lesions were at the apex or confined to the upper lobe in 5 patients; multiple lobes were involved in 1 patient. The bullae were resected with an Endo-GIA stapler or ligated with a homemade endoloop. The mean duration of operation was 54.8 minutes. The mean time of chest tube removal was 4.7 days after insertion, and the mean postoperative stay was 5.7 days. There was no recurrence of pneumothorax during the follow-up period.

CONCLUSIONS: The thoracoscopic ipsilateral approach is technically feasible for treating patients with bilateral pneumothorax.


   Introduction
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 Abstract
 Introduction
Material and methods
 Results
 Comment
 References
 
Pneumothorax therapy aims to eliminate the intrapleural air collection and prevent its recurrence. The treatment policy depends on the size of the pneumothorax, the severity of the symptoms, the presence of a persistent air leak, and the primary or secondary nature of the pneumothorax. Thoracotomy with various intraoperative interventions has been a mainstay of definitive therapy to prevent recurrence in patients with a spontaneous pneumothorax [1]. Baronovsky and associates [2] first introduced the concept of simultaneous bilateral treatment for spontaneous pneumothorax, and since then, several approaches have been advocated for treating bilateral bullous lesions simultaneously [3, 4]. Bilateral one-stage video-assisted thoracic surgery (VATS) to bilateral pneumothorax was reported in 2000 [3]. This study presents a novel ipsilateral approach to the contralateral bullous lesion using VATS to perform simultaneous bilateral bleb excision and pleurodesis.


   Material and methods
Top
 Abstract
 Introduction
 Material and methods
Results
 Comment
 References
 
Patient population
From January 2001 to January 2003, 6 patients underwent an ipsilateral-approach VATS procedure for bilateral pneumothorax in Chang Gung Memorial Hospital, Linkou Medical Center. All the patients were men be-tween 18 and 35 years old (mean age, 25.8 years). Inclusion criteria were as follows: an otherwise healthy patient without any medical history or any underlying disease; chest roentgenogram showing bilateral pneumothorax; and no previous sternotomy. The surgical indications were bilateral pneumothorax and persistent air leakage for more than 7 days or failure of the lung to reexpand despite proper functioning of a chest tube with suction drainage. All patients were referred to our medical center because of bilateral pneumothorax, and chest computed tomography revealed bilateral apical bullae (Fig 1A). After the patients were informed about the surgical benefits of our method, they chose to undergo a single-sided VATS approach for bilateral bullectomy.



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  		Fig 1. (A) High-resolution chest computed tomography shows bilateral apical bullae. (B) Chest incisions for operation. (C) The contralateral mediastinal pleura is opened, and the bullous lesion is resected with an endostaple. (D) Drainage of pleural cavity with one chest tube.

 
Surgical technique
All the patients were anesthetized using single-lung ventilation with a double-lumen endotracheal tube. The patient was placed in the supine position with a rolled blanket behind his back. The initial trocar (10 mm in diameter) was introduced into the right thoracic cavity through the previously created chest tube hole (sixth intercostal space in the midaxillary line). A thoracoscope was inserted into the thoracic cavity through the trocar, and the entire thoracic cavity was carefully examined, with meticulous attention paid to the apex of the upper lobe of the lung. Two more chest stab wounds (1.5 cm) were made in the midline between the nipple and sternum (third intercostal and fifth intercostal spaces) (Fig 1B). The operative procedure began with the introduction of grasping forceps through one of these incisions to help in the manipulation and exploration of the thoracic cavity. After its identification, the ipsilateral apical bulla was excised with an endoscopic stapling device (Endo-GIA stapler; AutoSuture Company, United States Surgical Corporation, Norwalk, CT) or ligated at its base with a homemade endoloop. The mediastinal pleura between the substernal and pericardial spaces was then incised using electrocautery. Blunt dissection was performed behind the sternum over the endothoracic fascia toward the contralateral side.

After the left mediastinal pleura was widely opened, selective deflation of the left lung and inflation of the right lung was smoothly carried out. Two long conventional grasping forceps were inserted into the left pleural cavity, and the left lung was carefully examined with the aid of a thoracoscope. The endoscopic stapler or homemade endoloop was inserted, and an apical bullectomy was carried out (Fig 1C). Bilateral pleural abrasion with sterilized mesh was performed over the entire apical surface of the parietal pleura, and the lung was then manually inflated and tested under water to ensure that no air leaks remained. At the end of the procedure, a 32F chest tube was inserted into the right-sided incision to drain the pleural cavity (Fig 1D).


   Results
Top
 Abstract
 Introduction
 Material and methods
 Results
Comment
 References
 
The ipsilateral-approach VATS procedure for bilateral pneumothorax was performed successfully in 4 patients. Two patients were switched to a one-stage sequential bilateral VATS procedure because of severe pleural adhesions or difficulty with the bullectomy on the contralateral side. Blebs or bullae were positively identified in all patients. The bullae were resected with an Endo-GIA stapler or were ligated with a homemade endoloop. The bullous lesions were at the apex or confined to the upper lobe in 5 patients; multiple lobes were involved in 1 patient. The mean duration of operation was 54.8 minutes (range, 43 to 80 minutes). The postoperative course for these patients was uneventful. The chest tube was removed after a mean time of 4.7 days (range, 4 to 5 days), and the mean postoperative stay was 5.7 days (range, 5 to 6 days). No patient had recurrence of spontaneous pneumothorax during follow-up.


   Comment
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 Abstract
 Introduction
 Material and methods
 Results
 Comment
References
 
Spontaneous pneumothorax in apparently healthy individuals is relatively common, particularly in those in the second or third decade of life. Treatment aims to fully expand the affected lung, control the complications, and prevent recurrence. However, closed tube thoracostomy and other nonoperative therapies such as chemical pleurodesis with sclerosing agents have frequently been associated with undesirable side effects and low success rates [5], and the only treatment that effectively prevents recurrence is surgical resection of the lung lesions.

A long and painful axillary or lateral thoracotomy is the standard approach for bulla ablation or pleurodesis. However, incisional pain, poor cosmetic outcome, and possible respiratory impairment occasionally cause trouble. With the rapid expansion of and improvements in thoracoscopy, VATS has been used not only to diagnose chest lesions but also to treat various thoracic diseases [3, 6]. We began performing VATS bleb excision and pleural abrasion for primary spontaneous pneumothorax in 1991. On the basis of our experience [6], we believe that the single-sided approach to bilateral bullous lesions is a good alternative to the traditional operative procedure. The benefits offered by VATS have encouraged us to use it to treat bilateral pneumothorax.

The sporadic literature on this topic has demonstrated that bilateral subpleural apical blebs have an occurrence of nearly 100% in patients with spontaneous pneumothorax and has suggested simultaneous bilateral treatment through bilateral thoracotomy [2]. However, the scale of surgical intervention that was appropriate for what appeared to be prophylaxis remained controversial [4]. The solutions advocated include median sternotomy, single-stage bilateral transaxillary thoracotomy, and recently, one-stage treatment by bilateral videothoracoscopy [3, 4]. The ideal approach to treat both lungs simultaneously must be one that leads to less incisional trauma, better bleb exposure, and better pulmonary function recovery. We suggest that the one-sided VATS approach is appropriate for bilateral pleural lesions, even though it is technically demanding. We developed this procedure while doing VATS thymectomy and considered it feasible for bilateral bullectomy.

On the basis of our experience with VATS thymectomy, we suggest using the right-sided approach with blunt dissection of the endothoracic fascia behind the sternum toward the contralateral side. This approach is better because it involves less cardiac compression by instruments than does the left-sided approach. Once the left mediastinal pleura is widely opened, selective deflation of the left lung can ensure good visualization of the pleural cavity. A 30-degree thoracoscope may be better than a 0-degree thoracoscope for exploring the contralateral pleural cavity.

In our opinion, there are some relative contraindications for this surgical procedure. These include previous sternotomy, right heart enlargement, bulla with multiple lobar involvement, bilateral emphysematous lung with air leakage, and severe pleural adhesions in the contralateral pleural cavity. Nevertheless, the conventional instruments and the thoracoscope can overlook the posterior aspects of the chest on the contralateral side. Hence, we suggest that preoperative high-resolution computed tomography be performed to rule out patients who are not candidates for the ipsilateral approach. For patients with bilateral pneumothorax who qualify, the thoracoscopic ipsilateral approach may be a good option. Patients for whom this approach is not applicable can undergo a one-stage sequential VATS operation.

After reviewing the results of this preliminary study, we think the single-sided VATS approach is technically feasible for treating bilateral pneumothorax and deserves further investigation. At present, this operative procedure should be performed only by VATS-experienced surgeons under a strict protocol. Further studies with long-term follow-up will clarify the role of ipsilateral VATS for bilateral bullous lesions.


   References
Top
 Abstract
 Introduction
 Material and methods
 Results
 Comment
 References
 

  1. Berger R. Pleurodesis for spontaneous pneumothorax: will the procedure of choice please stand up?. Chest 1994;106:992-994.[Free Full Text]
  2. Baronofsky I.D., Warden H.G., Kaufman J., Whatley J., Hanner J.M. Bilateral therapy for unilateral spontaneous pneumothorax. J Thorac Surg 1957;34:310-322.
  3. Lang-Lazdunski L., de Kerangal X., Pons F., Jancovici R. Primary spontaneous pneumothorax: one-stage treatment by bilateral videothoracoscopy. Ann Thorac Surg 2000;70:412-417.[Abstract/Free Full Text]
  4. Neal J.F., Vargas G., Smith D.E., Aki B.F., Edwards W.S. Bilateral bleb excision through median sternotomy. Am J Surg 1979;138:794-797.[Medline]
  5. Atassi K., Pilorget A., Lemaire F., Menu P., Bignon J. Thoracostomy tube pleurodysis by collagen instillation. Intensive Care Med 1986;12:335-336.
  6. Liu H.P., Chang C.H., Lin P.J., Chu J.J., Hsieh M.J. An alternative technique in the management of bullous emphysema. Thoracoscopic endoloop ligation of bullae. Chest 1997;111:489-493.[Abstract/Free Full Text]



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