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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
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
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: firstname.lastname@example.org.
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.
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
The first incision (Minithoracotomy)
Video-assisted Thoracic Surgery for Spontaneous Pneumothorax
The lung was explored via three incisions
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.
Demographic characteristics in spontaneous pneumothorax (SP) (Chi-square and fisher’s exact test)
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
pneumothorax. Nevertheless, future clinical trials are
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
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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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