**10. The future**

There is a trend for single-port VATS procedures under sedation/epidural anaesthesia [88]. The so-called tubeless surgery has a lot to commend, avoiding the risk of general anaesthesia, early recovery and discharge from hospital. However, they have the inherent caveat of suitability for selected patients. Understanding of the technique and cooperation in case of conversion to general anaesthesia is mandatory.

Advances in diagnostic techniques have increasingly allowed the identification of lung abnormalities in patients previously labelled as having a primary spontaneous pneumothorax. This allowed different managements from that of simple pneumothorax. A good example of this is demonstrated in secondary SP. The choices for lung reduction surgery and the advent of valves have revolutionised the options for this category of severe COPD [89]. Bronchial valves have been used to treat prolonged air leak, especially in ventilated patients in the intensive care, with

large air leaks and inflated lungs [90, 91]. In future we might see expansion of the use of "easily removable" and temporary bronchial valves especially in the subgroup of patients who are high risk for surgical intervention.

As the cost of VATS surgery comes down, as well as capacity increases in tertiary referral hospitals, we will see more of the operative treatment for first episode of spontaneous pneumothorax, on a semi-urgent basis (1–2 days from start of episode). Better risk stratification will identify those at high risk of recurrence and put them forward for early operation.

The economic reality of reducing cost and the technological advances might team up to drive change. It is possible to see scenarios whereby pneumothorax is treated as a day case. Patients are discharged home on the same operative day, with a chest drain in situ. They would be asked to enter the reading of air flow from the digital device daily. The information is transmitted by a social media application such as WhatsApp to the hospital which instructs the patient to call in for removal of the drain. Better still, the visiting district nurse could pay the patient a visit at home to remove the drain without the need for readmission. Fiction? Perhaps not!

Currently robotic surgery is too expensive for this type of surgery, and we have not come across any meaningful publications in this regard. However, when robotic expenses come down in due course, we might see a surge in the use of the robot.
