The THAI Journal of SURGERY 2010;31:43-47.
Official Publication of the Royal College of Surgeons of Thailand Minithoracotomy with Video-assisted ThoracicSurgery for Spontaneous Pneumothorax:Results of Subtotal Parietal Pleurectomy VersusPleural Abrasion Montien Ngodngamthaweesuk, MD*
Narumol Kijjanon, RN**
Pornpimol Masnaragorn, RN**

*Division of Cardiothoracic Surgery, Department of Surgery, **Department of Nursing, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand Abstract
This study aimed to compare two pleurodesis strategies: subtotal parietal pleurectomy and
pleural abrasion by using minithoracotomy with video-assisted thoracic surgery, and to assess which one should
be used for the treatment of spontaneous pneumothorax.
Materials and Methods:
A retrospective study was carried out to include 18 cases of spontaneous
pneumothorax treated by minithoracotomy with video-assisted thoracic surgery at our institution between July
2004 to May 2007. Eight cases (Group A) had eight operations for pleural abrasion. Ten cases (Group B) had
eleven operations for subtotal parietal pleurectomy. All patents (Groups A and B) had pleurodesis after
resection of lung blebs or blind apical resection. Clinical features of these patients were analyzed.
In both groups, there were no significant differences in term of preoperative factors (age and
sex, underlying diseases, site of spontaneous pneumothorax, indication for operation, and onset and symptoms),
intra-operative factors (duration of operation, blood loss), postoperative factors (chest tube removal),
pathological reports and complication (reoperation). However, exposure attributable risk (EAR) for reoperation
of Group A (pleural abrasion) was 0.125. None in both groups were dead and required blood transfusion. Two
patients with COPD in Group A needed mechanical ventilation after operation. A patient with COPD in Group
A needed reoperation due to prolonged air leakage from a new small ruptured lung bleb at right middle lobe.
Minithoracotomy with video-assisted thoracic surgery is a reliable and safe method to treat
spontaneous pneumothorax. In surgical pleurodesis, subtotal parietal pleurectomy may be better than pleural
abrasion because it can reduce recurrent spontaneous pneumothorax.
Keywords: Minithoracotomy, pleurectomy, pleurodesis, spontaneous pneumothorax. video-assisted thoracic
surgery (VATS)
Correspondence address : Montien Ngodngamthaweesuk, MD, Division of Cardiothoracic Surgery, Department of Surgery,
Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok 10400, Thailand; Telephone: +66 2201 1315; Fax: +66 2201 1316; E-mail: ramnn@mahidol.ac.th.
Ngodngamthaweesuk M, et al.
the lateral decubitus position. The chest and trunk Gaensler and colleagues1 reported the first series were bent. If a chest tube was in place before operation of patients with recurrent spontaneous pneumothorax it was removed before preparation. There were three in whom parietal pleurectomy was done. Deslauriers and colleagues2 reported a modified form of a trans¢ The first incision started on the anterior border axillary approach for reducing postoperative morbidity of the latissimus dorsi muscle and extended anteriorly and achieving prompt restoration of working capacity.
for 5 to 7 cm in length (Figure 2). A small thoracic In the past years, many thoracoscopic procedures such retracter was used to access the pleural space and lung.
as ablating blebs or emphysematous bullae by stapling, The second incision was done at the eighth intercostal suture ligation, electrocautery and pleurodesis by space in the midaxillary line followed by the pleural abrasion3, instillation of talc4 were done.
introduction of a 10-mm rigid thoracoscope with a 30 This report described lung blebs or bullae degree lens. The third incision (1.5-2.0 cm. in length) resection and sutures and subsequently pleurodesis was done at the fourth intercostal space in the anterior (subtotal parietal pleurectomy or pleural abrasion) by axillary line under direct thoracoscopic visualization.
using minithoracotomy with video-assisted thoracic The lung was explored via the first incision surgery. The aim of this study was to compare two (minithoracotomy) while it was grasped with sponge- possible pleurodesis strategies: subtotal pleurectomy holding forceps through the third incision (Figure 3).
and pleural abrasion using minithoracotomy with video- If there was lung adhesion, it would be lysed by an assisted thoracic surgery, in order to assess which one electrocautery under direct thoracoscopic visualization.
was better adapted for the treatment of spontaneous All lung bullae or blebs (Figure 4) were resected by Kelly clamps and Metzenbaum scissors and repairedwith continuous and interrupted 2-0 dexon without endostaplers. If there was no lung bulla (e), the apical ATIENTS AND METHODS
lung would be resected. At the end of the procedure, This retrospective study was performed by reviewing medical records between July 2004 and May 2007 at Ramathibodi Hospital, Mahidol University, Bangkok. Patients diagnosed with spontaneous pneumothorax who received surgical treatment(minithoracotomy and video-assisted thoracic surgery)were divided into 2 groups. The first group (group A)had 8 cases with eight operations of pleural abrasionand another group (group B) had 10 cases with elevenoperations of subtotal parietal pleurectomy afterresection of lung blebs or blind apical resection whenno obvious lesions had been identified.
Figure 1 Three mini incision sites
Pre-operative and intra-operative factors, pathological reports and post-operative complicationswere analyzed with chi-square and fisher’s exact test(when count was less than 5) and Mann-Whitney testwith statistical significance when P <0.05.
All procedures were performed in the operating room by a thoracic surgeon during general anesthesiausing a double-lumen endotracheal tube that allowedventilation of the contralateral lung while the ipsilaterallung remained in atelectasis. The patient was placed in Figure 2 The first incision (Minithoracotomy)
Video-assisted Thoracic Surgery for Spontaneous Pneumothorax
Figure 3 The lung was explored via three incisions
Figure 4 Lung bleb
we divided all patients into two groups. The first group apical perforations or even blind apical stapling when (Group A) was pleural abrasion which was done by dry no obvious lesion has been identified; 2) to create gauzes or electrocautery cleaners. The second group diffuse lung adhesions to prevent further recurrence.
(Group B) was subtotal parietal pleurectomy which Recurrent rate of pneumothorax after simple chest was done by sponge-holding forceps and dissector. If tube drainage of a first episode range from 10% to there was another air leakage or bronchopleural fistula 20%; recurrence after a second episode is about 50% during underwater test, it would be repaired with and close to 80% after a third episode5,6. According to interrupted 2-0 dexon. Then a 28-French silicone the risk of recurrence, indications for operative chest tube was placed through the second incision (the intervention have been recognized to follows: 1) second thoracoscopic site) toward the apex of the pleural ipsilateral recurrence, 2) first contralateral recurrence, cavity and connected to an underwater seal suction 3) bilateral simultaneous pneumothorax, 4) persisting with a negative pressure of 10 cm water. Expansion of pneumothorax (air leaks > 7 days), 5) spontaneous the lung was reconfirmed by chest x-ray. The chest hemopneumothorax, and 6) professions at risk (eg.
tube was removed when air leakage had ceased and pleural fluid was less than 100 mL per day.
Minimal invasive techniques can shorten hospital stay, reduce physical disability and lower the cost oftreatment, while yielding at least comparable long- term results in comparison with standard open Details of patients’ characteristics in Group A (8 procedures. Weeden D et al (1983) demonstrated a cases) and Group B (11 cases) were shown in Table 1.
slight advantage of pleurectomy over abrasion: the None of the patients in both groups were dead or recurrent rate was 0.4% after pleurectomy and 2.3% required blood transfusion. Two patients with chronic after abrasion7. In chemical pleurodesis; the recurrent obstructive pulmonary disease (COPD) in Group A rate was 36% after simple drainage, 13% after needed mechanical ventilation after operation. One tetracycline pleurodesis, and 8% after talc poudrage8.
patient with COPD in Group A needed reoperation However, most surgeons prefer pleural abrasion or due to prolonged air leakage. His pathological report pleurectomy because granuloma formation from showed focal interstitial fibrosis with emphysematous chemical pleurodesis is considered excessive. In change at apical segment of right upper lobe after contrast, patchy distribution of talc may fail to prevent blind apical resection. Reoperative finding showed a recurrences and require a subsequent thoracotomy in new small ruptured lung bleb at right middle lobe.
technically critical conditions. Fibrin glue also hadunacceptably high recurrent rate of 25% with highcost and biologic risks of this material9.
The most complications are related to the patient’s Surgical management of spontaneous pneumo- status rather than the thoracotomy itself. Postoperative thorax has two objectives: 1) the underlying cause hemothorax occurred more after pleurectomy (0% to should be treated either by resection of blebs, suture of 4% of cases)7. Recurrent rate of pneumothorax after Ngodngamthaweesuk M, et al.
Table 1 Demographic characteristics in spontaneous pneumothorax (SP) (Chi-square and fisher’s exact test)
(Pleural abrasion)
Chronic obstructive pulmonary disease (COPD) Subpleural blebs with emphysematous change Focal interstitial fibrosis with emphysematous change *When pleural fluid <100mL/days and no air leak**EAR (Exposure attributable risk) Video-assisted Thoracic Surgery for Spontaneous Pneumothorax
Comparative duration of postoperative chest tube recommend minithoracotomy with subtotal parietal pleurectomy in all patients of spontaneous Drainage
pneumothorax. Nevertheless, future clinical trials are Thoracotomy
1. Gaensler EA. Parietal pleurectomy for recurrent spontaneous pneumothorax. Surg Gynecol Obstet 1956;102:293-308.
2. Deslauriers J, Beaulieu M, et al. Transaxillary pleurectomy for treatment of spontaneous pneumothorax. Ann Thorac Surg 3. Clark TA, Hutchinsion DE, Deaner RM, Fitchett VH.
VATS procedure was higher than thoracotomy (6% vs Spontaneous pneumothorax. Am J Surg 1972;124:728-31.
0.4%)10. The lower success rate of VATS may be 4. Guérin JC, Champel F, Biron E, Kalb JC. Talcage pleural par thoracoscopie dans le traitement du pneumothorax. Etude explained by 1) fewer blebs are recognized and treated d’une s’erie de 109 cas trait’es en 3 ans. Rev Mal Respir during VATS11, 2) some blebs are deflated together with the lung and therefore missed, and 3) lower 5. Inderbitzi RGC, Leiser A, Furrer M, Althaus U. Three years degree of tissue trauma and less intense biological experience in video-assisted thoracic surgery (VATS) for spontaneous pneumothorax. J Thorac Cardiovasc Surg Duration of drainage is one of the main deter- 6. Cran IR, Rumball CA. Survey of spontaneous pneumothorax minants of hospital stay after thoracic surgery (Table in Royal Air Force. Thorax 1967;22:462-5.
2). In this studies showed 90 ± 40.06 hours in pleural 7. Weeden D, Smith GH. Surgical experience in the abrasion group and 111.27 ± 43.30 hours in pleurectomy management of spontaneous pneumothorax, 1972-82.
8. Almind M, Lange P, Viskum K. Spontaneous pneumothorax: In this study, there were no difference between comparison of simple drainage, talc pleurodesis, and two groups in term of age, sex, underlying diseases, site tetracycline pleurodesis. Thorax 1989;44:627-30.
of SP, onset and symptoms of SP, indications for 9. Gúerin JC, Van Der Schueren RG. Traitement des operation, duration of operation and chest tube pneumothorax recidivants par application de colle de fibrine sous endoscopie. Rev Mal Respir 1989;6:443-5.
placement, amount of blood loss, underlying pathology 10. Naunheim KS, Mack MJ, Hazelrigg SR, et al. Safety and and complications (re-operation). However, exposure efficacy of video-assisted thoracic surgical techniques for attributable risk (EAR) of reoperation for pleural the treatment of spontaneous pneumothorax. J Thorac abrasion group was 0.125. One patient with COPD in 11. Bertrand PC, Regnard JF, Spaggiari L, et al. Immediate and Group A needed reoperation due to prolonged air long-term results after surgical treatment of primary leakage and pathological report showed focal interstitial spontaneous pneumothorax by VATS. Ann Thorac Surg fibrosis with emphysematous change. Operative finding showed a new ruptured lung bleb at right middle lobe.
12. Gebhard FT, Becher HP, Gerngross H, Bruckner UB. Reduced No patient in both groups was dead and required inflammatory response in minimal invasive surgery of pneumothorax. Arch Surg 1996;131:1079-82.
blood transfusion. Two patients with COPD in Group 13. Dumont P, Diemont F, Massard G, Toumieux B, Wihlm JM, A (abrasion) needed mechanical ventilator after Morand G. Does a thoracoscopic approach for surgical treatment of spontaneous pneumothorax represent In conclusion, the present study revealed that progress? Eur J Cardiothorac Surg 1997;11:27-31.
14. Mouroux J, Elkaim D, et al. Video-assisted thoracoscopic minithoracotomy and pleurodesis (subtotal parietal treatment of spontaneous pneumothorax: technique and pleurectomy or pleural abrasion) for the management results of one hundred cases. J Thorac Cardiovasc Surg of spontaneous pneumothorax offered substantial saving in cost. While subtotal parietal pleurectomy 15. Bernard A, Bélichard C, Goudet P, Lombard JN, Viard H.
may be better than pleural abrasion because it can Pneumothorax spontane’. Comparaison de la thoraco- scopic et de la thoracotomie. Rev Mal Respir 1993;10:433-6.
reduce recurrent spontaneous pneumothorax, blood 16. Yim AP, Ho JK. One hundred consecutive cases of video- loss and recovery duration of subtotal parietal assisted thoracoscopic surgery for primary spontaneous pleurectomy are higher than pleural abrasion. We pneumothorax. Surg Endosc 1995;9:322-6.

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