**5.5 Video-assisted thoracoscopic surgery (VATS)**

The thoracoscopic surgery for primary spontaneous pneumothorax has been proposed and studied by a lot of clinicians as the main treatment for recurrent or

**21**

*Primary Spontaneous Pneumothorax, a Clinical Challenge*

persistent spontaneous pneumothorax. Surgical treatment is more invasive and has a lower recurrence rate than the conservative treatment [49–51] but increases patient discomfort, which has restricted the application of open thoracotomy. Video-assisted thoracoscopic surgery (VATS) for primary spontaneous pneumothorax has been proposed as a new surgical technique and has taken over the role of open thoracotomy, due to its minimal invasiveness and low morbidity [52]. This technique has been used not only for prolonged air leak or recurrence but also in patients at the first episode of pneumothorax, when blebs or bullae are identified with CT scan. A study conducted at the Chest Diseases Hospital in Kuwait treated spontaneous pneumothorax in 72 patients using VATS technique. The study included 67 male and 5 female patients from 15 to 40 years with a recurrent episode of pneumothorax. Surgeons performed VATS unilateral technique in all cases, with gauze abrasion and apical pleurectomy to remove subpleural blebs or bullae and excision of the apex of the upper lobe in the absence of any identifiable lesion. They concluded that thoracoscopic surgery could be carried out safely and effectively in the treatment of recurrent or persistent spontaneous pneumothorax, allowing inspection of the entire lung, identification of bullae, and resection of the bullous disease [29]. Another study compared the results of conservative treatment, open thoracotomy, and VATS. The authors studied 281 patients who had primary spontaneous pneumothorax, finding recurrences in 56.4% of the patients with the conservative treatment, 3% for open thoracotomy and 11.7% for VATS with a hospital stay length of 14.5, 22.2, and 8.3 days, respectively. At the end, they concluded VATS was significantly superior to open thoracotomy measuring length of operation, bleeding volume, and length of hospital stay. In terms of morbidity, low invasive and cosmetic issue VATS is superior to open thoracotomy [52]. Conventional three-port VATS has advantage in hospital stay, postoperative pain, and chest drainage time. In 2005, Dr. Gaetano Rocco used simple-port VATS for the first time, a technique that requires a minimum incision of approximately 3 cm and facilitates the postopera-

tive recovery of the patient, compared with three-port VATS [53].

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

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

**5.6 Open thoracotomy**

the last years [56].

*DOI: http://dx.doi.org/10.5772/intechopen.83458*
