Ann Thorac Surg 2008;85:1825-1827. doi:10.1016/j.athoracsur.2007.11.043
© 2008 The Society of Thoracic Surgeons
How To Do It
Thoracoscopic Total Parietal Pleurectomy for Primary Spontaneous Pneumothorax
Derek P. Nathan, MDa,
Nyali E. Taylor, MD, MPHa,
David W. Low, MDc,
Daniel Raymond, MDd,
Joseph B. Shrager, MDa,b,*
a Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
b Division of Thoracic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
c Division of Plastic Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
d Division of Thoracic and Foregut Surgery, University of Rochester School of Medicine, Rochester, New York
Accepted for publication November 14, 2007.
* Address correspondence to Dr Shrager, Stanford University School of Medicine, Department of Cardiothoracic Surgery, Falk Building, 2nd Floor, 300 Pasteur Drive, Stanford, CA 94305-5407 (Email: shrager{at}stanford.edu).
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Abstract
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Although the management of spontaneous pneumothorax through a thoracotomy traditionally included apical pleurectomy, thoracoscopic treatment of this problem does not generally include pleurectomy. Thoracoscopy in fact allows excellent exposure to perform total parietal pleurectomy, and we hypothesize that including total pleurectomy will reduce recurrences. We describe here the technique of thoracoscopic total parietal pleurectomy and the early outcomes afterward.
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Introduction
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Primary spontaneous pneumothorax (PSP) is a frequent cause of hospitalization in otherwise healthy young individuals. It is generally agreed that surgical therapy, when indicated, should include resection of identifiable blebs and some method of obliterating the pleural space.
Although thoracotomy with blebectomy and apical parietal pleurectomy perhaps remains the gold standard approach with recurrence rates generally below 2% (eg, see Ref [1]), most surgeons now use video-assisted thoracoscopy (VATS) in the management of PSP. The vast majority of publications describing VATS management of PSP, however, recommend blebectomy and pleurodesis rather than pleurectomy. It is possible that the failure to perform pleurectomy during VATS accounts for the four-fold greater risk of recurrence after VATS versus thoracotomy identified in a recent Cochrane systematic review and meta-analysis of comparative trials (relative risk for recurrence 4.73 after VATS vs thoracotomy; unweighted mean recurrence rate, 7.1% in VATS patients vs 1.0% in thoracotomy patients) [2]. A few investigators have published their experience with VATS techniques that include apical pleurectomy (eg, see Refs [3–5]), and at least one study reports tangentially on VATS complete pleurectomy [6], but we are unaware of publications describing the technical details of this operation. Therefore, this report describes the technique, pitfalls, and early outcomes of VATS total parietal pleurectomy.
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Technique
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General anesthesia with single-lung ventilation is induced. The patient is positioned in the lateral decubitus position, and the ipsilateral lung is collapsed. A three-incision approach is used. Any adhesions are taken down by cautery. Any intact or ruptured blebs are excised with a roticulating, endoscopic linear stapler. If no abnormalities are identified, sites of air leak are sought by submerging the partially inflated lung in saline, and any site of leak is resected. If no blebs or leak are identified, a wedge is taken from the apex for diagnostic purposes and to promote apical adhesions.
Total parietal pleurectomy is then undertaken. A ball-sponge protruding from the edges of a ring clamp is rubbed against the parietal pleura in the first interspace, away from the visible subclavian artery (Fig 1A) until the pleura begins to lift from the endothoracic fascia. A ring-type or Kelly-type clamp is then used to grasp the free edge of the parietal pleura (Fig 1B) and tear it down in large sheets. We usually begin by removing the pleura lining the anterior chest wall, grasping the pleura through the posterior working port while using the ball-sponge through the anterior port to exert additional traction. All of the pleura from the mid-lateral line to 2 cm posterior to the internal mammary vessels, and from the first rib to the anterior diaphragmatic insertion, is resected anteriorly (Fig 2). The posterior pleura is resected next, from the mid-lateral line to about 2 cm anterior to the sympathetic chain, and from the first rib to the posterior diaphragmatic insertion (Figs 3, 4).
At the highest apex, in the region of the subclavian artery above the first rib, and extending downward onto the mediastinum, the pleura is left intact to avoid injury to the underlying vessels and phrenic and vagus nerves. Mechanical pleurodesis with the ball-sponge is used in safe areas on this far-apical pleura.
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Fig 1. (A) Rubbing in the anterior first interspace causes the pleura to separate from the endothoracic fascia; the arrow indicates the subclavian artery. (B) The free edge of the pleura is grasped and placed under tension to progressively separate it from the chest wall.
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Fig 2. The pleurectomy from anterior chest wall has now progressed as far caudally as fifth interspace; the small arrow indicates the cut edge of the pleura and the large arrow indicates the mammary vessels. Note that mammaries are protected by taking pleurectomy only as far as shown.
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Fig 3. Initial stage of pleurectomy from posterior chest wall, showing leading edge of the pleura in this instance grasped through posterior incision while additional traction is exerted with ball-sponge through anterior incision; the small arrow indicates the line to which the pleurectomy will be taken and the large arrow indicates the sympathetic chain.
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Fig 4. The artist's depiction (right-sided operation) of technique and extent of dissection when one has completed posterior and is beginning anterior dissection. Note that pleura is maintained intact over sympathetic chain, mediastinum and far-medial apex adjacent to mediastinum.
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The pleura tends to remain intact as larger sheets, expediting the procedure, if traction is applied at nearly right angles to the chest wall. Rotating the grasping instrument to roll up the pleura as one would spaghetti is also a useful technique (Fig 5).
As the pleura is separated, punctuate oozing occurs from the intact endothoracic fascia (Fig 6). This blood may in fact be important in the creation of adhesions, so we do not irrigate the chest. By the time the pleurectomy has been completed, the oozing has generally stopped. A single 28-French drain is placed to suction for 48 hours to allow adhesion to develop.
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Fig 6. The completed pleurectomy; the small arrow indicates the cut edge of the pleura and the large arrow indicates the apex.
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Results
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Between December 2000 and February 2007, we performed a VATS wedge with total parietal pleurectomy for PSP (noncatamenial) 40 times in 39 patients. Follow-up was complete in 98% at a mean of 24.1 months (range, 1 to 72 months). Patients included 30 males and 9 females with a mean age of 30 years. Three patients underwent treatment after prior thoracoscopic talc pleurodesis. No patient required conversion from VATS to thoracotomy. Mean duration of postoperative thoracostomy tube drainage and mean postoperative stay were 3.6 and 3.4 days, respectively; two patients were discharged with Heimlich valves. The following complications occurred in 10% or 4 patients: bleeding requiring transfusion (1 cirrhotic patient), pneumonia (1 patient), prolonged air leak (2 patients), and inadvertent sympathectomy (1 patient). One patient (2.5%) recurred at 24 months but remains free of recurrence 12 months after the reoperation.
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Comment
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We hypothesize that the usual omission of pleurectomy during VATS management of PSP underlies the generally higher recurrence rate after VATS versus the traditional operation of thoracotomy with apical pleurectomy. Thoracoscopy actually provides ideal exposure for an expeditious complete parietal pleurectomy that would be difficult at limited thoracotomy. We have described a technique of VATS total parietal pleurectomy that has low morbidity and an early recurrence rate (2.5%) slightly lower than the great majority of reported VATS results (eg, see Refs [3–5]). We use this as our standard procedure for noncatemenial PSP.
Potential pitfalls of total parietal pleurectomy include several things. First, if one inadvertently enters a plane deep to the endothoracic fascia, troublesome capillary bleeding or even neurovascular injury may occur. Second, we have found that taking the pleurectomy only as far anteriorly as approximately 2 cm from the mammary vessels and only as far posteriorly as 2 cm from the sympathetic chain is advisable; we did incur one troublesome unilateral sympathectomy early in our experience. Third, care must be taken to keep the pleura intact over the critical structures at the junction of the mediastinum and the apex and the mediastinum proper. If these guidelines are followed, the procedure is fast, easy, and incurs little morbidity. In the long-term, there is no doubt that a total pleurectomy will render any future chest operation (eg, lung cancer resection) difficult in these patients. However, this issue would come into play in only very few individuals because the majority of PSP patients are healthy nonsmokers, and even heavy long-term smokers have a lung cancer risk of only approximately 15% to 20%.
It is interesting to note that our series includes 3 patients who underwent VATS total parietal pleurectomy after prior VATS talc pleurodesis had failed. This, along with the findings of Leo and colleagues [6] that pleurectomy far more effectively eliminates ultrasonographically identified "pleural sliding" than pleurodesis, suggests that total pleurectomy is the optimal adjunct to wedge resection during operation for PSP. Only with more cases and longer follow-up can we know if VATS wedge plus total parietal pleurectomy provides recurrence rates equivalent to thoracotomy with wedge plus apical pleurectomy.
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References
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- Deslauriers J, Beaulieu M, Despres JP, Lemieux M, Leblanc J, Desmeules M. Transaxillary pleurectomy for treatment of spontaneous pneumothorax Ann Thorac Surg 1980;30:569-574.[Abstract]
- Barker A, Maratos EC, Edmonds L, Lim E. Recurrence rates of video-assisted thoracoscopic versus open surgery in the prevention of recurrent pneumothoraces: a systematic review of randomized and non-randomised trials Lancet 2007;370:329-335.[Medline]
- Czerny M, Salat A, Fleck T, et al. Lung wedge resection improves outcome in stage I primary spontaneous pneumothorax Ann Thorac Surg 2004;77:1802-1805.[Abstract/Free Full Text]
- Cardillo G, Facciolo F, Giunti R, et al. Video-thoracoscopic treatment of primary spontaneous pneumothorax: a 6-year experience Ann Thorac Surg 2000;69:357-362.[Abstract/Free Full Text]
- Ayed AK, Al-Din HJ. The results of thoracoscopic surgery for primary spontaneous pneumothorax Chest 2000;118:235-238.[Medline]
- Leo F, Dellamonica J, Venissac N, Pop D, Mouroux J. Can chest ultrasonography assess pleurodesis after VATS for spontaneous pneumothorax Eur J Cardio-thoracic Surg 2005;28:47-49.[Abstract/Free Full Text]
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Abstract
Introduction
