**4. Management**

*Pneumothorax*

**Figure 1.**

most commonly associated with its development include necrotizing pneumonias, cystic fibrosis, chronic obstructive pulmonary disease, and malignancy. Chronic obstructive pulmonary disease is the cause of 50–70% of all secondary spontaneous pneumothoraces. Catamenial pneumothorax is a very interesting clinical entity that

It is important to note that despite the definition of primary spontaneous pneumothorax indicating that it occurs in the setting of patients with no known lung disease, this is not completely clinically accurate. The majority of these patients do in fact have underlying lung disease with subpleural blebs (**Figure 1**), and it is the spontaneous rupture of these blebs that leads to the development of their pneumothoraces [3]. Despite a wide array of potential clinical etiologies, the overall incidence of spontaneous pneumothorax has been estimated at 17–24/100,000 in males and 1–6/100,000 in the female population [1–3]. Smoking increases the risk of contracting a first pneumothorax approximately 9-fold among women and 22-fold among men [5]. Spontaneous pneumothorax recurrence rates were similar for both men and women, with approximately 26% of patients experiencing a recurrence

The management of pneumothorax has seen large advancements over the past few decades. Surgical management of the disease did not begin until the 1940s when it was first documented by Tyson and Crandall in 1941 [7]. Treatment at that time involved a traditional transaxillary thoracotomy with resection of blebs. Later addition of pleurectomy or pleurodesis became routine in these patients. In the early 1990s, with the introduction of video-assisted thoracoscopy and mechanical stapling, minimally invasive chest surgery began to become popular for a variety of indications [8]. As a matter of fact, video-assisted thoracoscopic surgery (VATS) was first documented for pneumothorax [9]. Subsequently, VATS blebectomy, with the addition of pleurodesis or pleurectomy, began to take on popularity and remains often the choice of many. It was also demonstrated that VATS is superior to conservative treatment soon after [10].

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

is another, although rare, type of secondary spontaneous pneumothorax.

within 5 years of initial pneumothorax diagnosis [6].

*Subpleural blebs of the apical lung with adhesion to the chest wall.*

**28**

**3. Indications**

**2. History**

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 pain and recovery time.

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.

**Figure 2.**

*Port placements for the classical three-port video-assisted thoracoscopic surgery. Different configurations, change according to the visual and staple requirements (a) camera through central port (b) Camera through posterior port.*

Once safely in the chest, the lungs are carefully inspected to identify any bullous changes and to detect the source of the air leak. Blebs will be air-filled areas of the lung less than 1 cm in size compared to bullae which are greater than 1 cm in size. Adhesions should be identified and lysed to allow for complete evaluation of the lung. Care should be taken to obtain hemostasis if any bleeding from the adhesions is encountered. Bullae that are identified can be stapled using an endo-stapler without crossing over any portion of the bullae in the staple line, as this may increase risk of recurrence. There should be good margin with the stapler traversing only "healthy" lung tissue in patients with spontaneous primary pneumothorax.

Mechanical pleurodesis involves creating abrasions to the pleural surface, or performing a limited pleurectomy, to initiate an inflammatory response which results in the formation of adhesions and prevents the lung from collapsing in situations of recurrence. The pleural abrasion is typically performed using an electrocautery scratch pad or gauze (**Figure 3**). Care should be taken when working at the apex, as a Horner's syndrome can occur if there is any injury to the stellate ganglion of the sympathetic chain. Additional operative complications include bleeding, particularly from intercostal or mammary vessels, and pain. One randomized prospective study comparing wedge resection to wedge resection, and adjunct mechanical pleurodesis, resulted in no difference in recurrence rates but did show an increase in complications for the pleurodesis group [20]. A meta-analysis comparing the different combinations of intraoperative treatment for primary spontaneous pneumothorax found that wedge resection combined with chemical pleurodesis, as well as wedge resection, combined with both mechanical pleural abrasion and chemical pleurodesis, had the lowest recurrence rates. Although

**31**

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

the complications of these procedures were not taken into account favoring chemical or mechanical pleurodesis, in addition to wedge resection to remove the source of the air leak [21, 22]. Mechanical pleurodesis should be considered on a case-by-case basis with good clinical judgment. This should be avoided in patient who may have a bleeding tendency either due to medications or underlying disease. A chemical pleurodesis would be appropriate using an agent that cause aseptic inflammation in the pleura and facilitate pleural adhesion. Debate continues over the most effective chemical pleurodesis agent to use which has led to the widest variation in overall technique among all of these strategies. Graduated talcum of particle size <10 mic m is the most popular currently and has a long-standing history as an effective and trusted agent for pleurodesis. In the past, tetracycline and doxycycline have been used; however, the success rate is lower than the graduated talcum powder [23–25]. Marcheix et al. published a large study of 603 consecutive patients who underwent VATS pleurodesis using silver nitrate for primary spontaneous pneumothorax. While only 39.6% of these cases involved wedge resection and pleurodesis, the recurrence rate at 1 month was 0.5% in this group. The last 250 patients were included in a longer-term follow-up (2.9 ± 2.3 years) in which the recurrence rate was approximately 1.1%; however, only 73% of patients were actually contacted and this represents 31% of the total study population [26]. While it is difficult to draw concrete conclusions from this study, it is clear that silver nitrate can be an effective pleurodesis agent. Similar studies exist showing minocycline to be an effective agent as well [27]. When comparing VATS to other treatment modalities, such as aspiration, chest

tube drainage, and pleurodesis, a recent meta-analysis of all available randomized control trials showed that VATS had the most favorable results with regard to recurrence and hospitalization days [21, 22]. The addition of pleurodesis to VATS bullectomy compared to VATS bullectomy alone further decreases recurrence rates, although this strategy comes with associated complications that include pain [21, 22]. Given the increased complications that arise from pleurodesis, some novel attempts at replacing the procedure, and at the same time achieving the same goal of promoting adhesions, have been developed. The use of an absorbable cellulose mesh and fibrin glue that are placed over blebectomy staple lines has been studied as an alternative to pleurodesis, with promising results [28]. This technique has been found to be noninferior in terms of recurrence rates when compared to pleurodesis and is without the complications of bleeding, pain, and Horner's syndrome that are associated with mechanical pleurodesis. The cost of these biological materials should be taken into consideration when the approach is sought. The use of autologous blood as a pleurodesis agent needs mention. Although various chemical agents all pose some risks, namely, significant pain or rarely development of acute respiratory distress syndrome, pleurectomy carries with it significant pain and bleeding. Autologous blood has been utilized in some instances with good success [29]. The majority of the literature on this topic involves using blood to treat persistent air leaks in the postoperative period. While this data cannot be directly utilized to construct guidelines for spontaneous pneumothorax, based on the body of evidence that exists, its reported efficacy is so compelling that one wonders if it could be similarly effective in this operative setting. Chang and colleagues compared pleurodesis combined with wedge resection utilizing "needlescopic" VATS technique with apical pleurectomy [30]. It is accurate to think of this technique as analogous to VATS, one 12 mm port for standard VATS instruments and the chest tube to that needlescopic technique which combines three 3 mm ports for "mini" endograspers and a "needlescope." In addition to demonstrating that pleurectomy was technically feasible, utilizing needlescopy with comparable pain indices, duration of chest tube drainage, and hospital stay, it also suggested a lower recurrence rate, 0%, when compared to the abrasion group, 8.6%. Studies comparing traditional VATS to needlescopic technique are lacking; however, in this author's experience, the former can be completed easily with only two 5 mm and

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

**Figure 3.** *Pleural abrasion using electrocautery scratch pad (a) before and (b) after.*
