**3. Indications**

Failure of conservative management and recurrence of pneumothorax are the most frequent indications for surgical intervention. In spontaneous pneumothorax,

**29**

pain and recovery time.

*Video-Assisted Thoracoscopy in the Management of Primary and Secondary Pneumothorax*

a large number of first episodes will be treated conservatively with non-operative intervention. Asymptomatic, small pneumothorax (less than 2 cm) can typically be observed with serial imaging. Larger symptomatic episodes need to be treated by drainage with needle decompression or with a chest tube. However, when the first episode is complicated and the pneumothoraces are unlikely to resolve using conservative management, surgical intervention may be necessary. These pneumothoraces include those complicated by hemothorax, bilaterality, persistent air leaks, or the inability of the lung to re-expand with conservative treatment [11–13].

Recurrence rates for primary and secondary pneumothorax, when the initial episode was treated with chest tube drainage, have been reported as high as 18% in primary and 40% in secondary pneumothoraces [13]. Review of inpatient-treated pneumothorax demonstrated approximately 75% of recurrent pneumothoraces, which occurred in the first year following the initial pneumothorax. The probability of recurrence varied, depending on age group and the presence of underlying lung disease. For example, male patients aged 15–34 years, with underlying chronic lung disorders, had the highest probability of recurrent pneumothorax within 5 years of initial pneumothorax (39.2% recurrence rate) [6]. Some centers have reported being aggressive with first episode pneumothorax by treating these first episodes with VATS, significantly decreasing the recurrence rate in these patients [13]. In the past, open thoracotomy was the mainstay of surgical treatment for spontaneous pneumothorax, but with the institution of video-assisted thoracoscopic treatments, the number of surgeons performing open cases has decreased significantly. The objective of each operation is to prevent recurrence by resecting apical bullae or other causative blebs and perform a pleurodesis so future pneumothoraxes are unlikely [14]. With the heavy adoption of VATS, studies have attempted to identify differences in results and morbidity between the VATS and open thoracotomy techniques. VATS intervention was found to have recurrences in 3.8% compared to 1.8% in thoracotomy patients [15]. One meta-analysis, analyzing 4 randomized and 25 nonrandomized trials, assessed the recurrence rates of minimally invasive approach versus open [16]. It was stated that despite a fourfold increase recurrence rate for minimally invasive approach, this method was used three times more commonly than open in the United Kingdom [16]. Importantly however, the complication rates and pain can be significantly higher with thoracotomy than VATS, advocating a minimally invasive approach [15–17]. Some attribute the increased recurrence rate associated with VATS to the decreased amount of adhesions created with the smaller incisions than thoracotomy [17]. The decision as to the appropriate approach for these operations should involve a discussion with the patient for an informed decision, taking into consideration the balance between recurrence against decreased

The technical approach to VATS treatment of spontaneous pneumothorax involves patients undergoing general anesthesia with one-lung ventilation. The first incision is typically placed in the fifth or sixth interspace in the midaxillary line. Two additional incisions can typically be made in the fourth interspace in the anterior axillary line, as well as the fifth interspace in the auscultatory triangle [18]. There have been modifications to this strategy over the years, with variations in the number of incisions ranging to as low as one incision(**Figure 2**). Novel new methods are also being discussed such as a subxiphoid uniport incision [19]. This type of incision is currently being studied to assess for a decrease in the amount of intercostal nerve injury that is typically observed with intercostal incisions.

*DOI: http://dx.doi.org/10.5772/intechopen.83669*

**4. Management**

*Video-Assisted Thoracoscopy in the Management of Primary and Secondary Pneumothorax DOI: http://dx.doi.org/10.5772/intechopen.83669*

a large number of first episodes will be treated conservatively with non-operative intervention. Asymptomatic, small pneumothorax (less than 2 cm) can typically be observed with serial imaging. Larger symptomatic episodes need to be treated by drainage with needle decompression or with a chest tube. However, when the first episode is complicated and the pneumothoraces are unlikely to resolve using conservative management, surgical intervention may be necessary. These pneumothoraces include those complicated by hemothorax, bilaterality, persistent air leaks, or the inability of the lung to re-expand with conservative treatment [11–13].
