**5.6 Open thoracotomy**

Thoracotomy is an incision into the pleural space of the chest, and it has been the classic surgical treatment of PSP. Surgery is indicated when there is a recurrence of an initial episode of PSP, which produces persistent air leaks, or collapsed lung after placement of pleural drainage [54]. The advantages of this procedure over thoracoscopic techniques are the ability to perform extensive mechanical pleurodesis and the resection of blebs [55]. In order to prevent recurrence of pneumothorax, segments of the lung with bullae or blebs need to be resected. In 1941, Tyson and Grandall described open thoracotomy with pleural abrasion for the treatment of pneumothorax, and then Gaensler introduced parietal pleurectomy and less invasive procedures (like axillary thoracotomy); this became more common during the last years [56].

After the surgical treatment, the next step is to prevent the recurrence of spontaneous pneumothorax, which is estimated from 23 to 50% of all the patients. The highest risk occurs in the first 30 days, and, during this time, patients must avoid activities which involve acute variation of the pressure in the lungs, like flying or diving; these activities increase the risk of recurrent spontaneous pneumothorax. The recommendation for patients with the first episode of spontaneous pneumothorax is to avoid flying or diving. Patients may be able to fly 6 weeks after a definitive surgical intervention and resolution of the pneumothorax and after treatment; patients must perform a control X-ray to confirm the resolution and wait at least 6 weeks before flying. Recurrence of spontaneous pneumothorax is not common
