*Indications of Surgery in Pneumothorax DOI: http://dx.doi.org/10.5772/intechopen.88640*

*Pneumothorax*

**6**

**Ref.** Schramel

149 first episode

(Both first

(Both first and

Chest drain:

1 year: VATS

VATS < chest drain cost

of treating recurrence:

VATS similar to chest

drain

VATS: \$1925

Secondary pneumothorax

included chest drain

arm: 2

VATS arm: 4

Chest drain: \$2750

(cost of recurrence also

included)

—

(3%) < CD (19%)

2 years: VATS

(4%) < CD (22%)

VATS: 2.8%

Chest drain: 22.8%

96 ± 18 months

VATS: 29 ± 10

months

12 months

recurrent episode

included)

and recurrent

episode

included)

PSP VATS: 70

Chest drain: 79

et al., ERJ

[24]

Torresini

70 chest drain: 35

VATS: 3.9 days

VATS: 6 days

Chest drain: 12 days

Chest drain: 9

days

VATS: 35

et al., EJCTS

[25]

Chou et al.,

VATS: 51

2 days (54%)

3 days (54%)

38 months

0

ICTVS [26]

Margolis

VATS: 156

—

2.4 ± 0.5 days

2–96 months

0

—

Talc poudrage for all

patients intra-op

(median: 62

months)

13–163 months

Chest drain: 54.7%

—

Length of stay analysis

included both first and

recurrent episodes

Thoracotomy: 7.7%

VATS: 10.3%

(*P* < 0.001)

(thoracotomy vs. VATS:

*P* = 0.61)

VATS: 3.3%

Total cost of 1 hospital

All patients had failed

initial needle aspiration

stay VATS: \$1273 Chest

drain: \$865

Chest drain: 22.7%

(*P* = 0.038)

(mean: 78.3

months)

Not specified

for first episode

cases

3–38 months

(mean 16

months)

et al., ATS

[27]

Sawada

281 Chest drain:

—

Chest drain: 14.5

days

Thoracotomy: 22.2

days

VATS: 8.3 days

(*P* < 0.001)

VATS: 4.8

Chest drain: 6.1

(*P* = 0.034)

181

Thoracotomy: 13

VATS: 87

et al., Chest

[28]

Chen et al.,

52 chest drain: 22

—

VATS: 30

ATS [29]

**Table 2.**

*Studies using video-assisted thoracoscopy for management of first-attack spontaneous pneumothorax.*

**No. of patients**

**Chest drain** 

**Length of stay**

**Follow-up**

**Recurrence**

**Cost**

**Other**

**duration**

management of 'doing nothing' up to a VATS intervention on the next available list. Needle aspiration and chest tube drainage are commonly used modalities, but CTD will remain the most common and classic intervention for an attack of pneumothorax worldwide. It is the author's preference to send patients for a VATS intervention on the next available list without inserting a chest tube (provided there is no respiratory compromise) to allow a shorter hospital stay, allow patients to return to work or school as early as possible and most importantly avoid the high risk of recurrence. **Table 2** shows studies starting more than two decades ago considering VATS for first-attack pneumothorax.

A conservative approach with follow-up or needle aspiration seems as a reasonable first-line option in a first-attack small-sized pneumothorax. In patients with a large pneumothorax who are not keen for surgery or with hospital logistics that would hinder the availability of VATS intervention on the next morning list due to lack of facilities or personnel, a chest drain insertion is the most reasonable option. Further intervention will then be guided by the time of resolution of the pneumothorax, availability of a VATS intervention service and patient wishes after understanding the risks of recurrence after the first attack.
