Treatment of pneumothorax has not been standardised until 18- 19 years ago with the introduction of video assisted thoracoscopic surgery.
With simplicity of steps inovolved in bleb ligation and mechanical rub pleurodesis, the vision and access to majority of chest wall by videoscope allow easy performance of pleurodesis for patient.
Also the patient is usually is young and fit other than the pleural disease, the general anaesthesia procedure with double lumen endobronchial tube is well tolerated.
I remember the excitement when the laparoscopic instrument was put in the first few patient for VATS surgery back in 1992. We have looked at the bleb and feel extremely appealing and derive great satisfaction of putting the endo-loop on the apex. But not long after two or three such cases, dislodgement of the endo loop occur and we stick to using the endo stapler (the first generation of Autosuture endo GIA) for pneumothorax bleb resection.
For successful pleurodesis, certain amount of dense or extensive adhesion should be formed after the drain pulled and patient went home. Not infrequently, we do see patients with failed adhesion formation.
The means to prevent this include:
1. Keep the drain longer (but ususally drain has to pulled out after 6 or 7 days, usually the maximal duration that a young patient can tolerate without complaint.
2. Meticulous rubbing of pleural surface and chest wall is required.
3. Secure sealing of air leak point in lung
4. Modification of technique with addition of chemical sclerosant for every case.
There is discussion of the philosophy of first operation for VAT pleurodesis.
Some surgeon propose inclusion of small axillary or small maximally minithoracotomy in anteior port for better stapling of weak apex. The lung is mobilised down to the lung root near the SVC and hilar and lung apex delivered to outside through the throacotomy and single GIA application +/- oversewing is better than multiple fire.
Through the thoracotomy, the air leak can be tested and additional procedure of limited open pleurectomy can be added. Also the problem of intercostal neuralgia due to fulcrum pressure on the port site is avoided. The only small instrument port site will be the final drain site.
So there is revertion to minithoracotomy and Video assisted open thoracic surgery rather than keyhole VATS for pneumothorax.
The recurrence rate can be brought down from previously 10% to 4 or 5 %.
Recently I come across patients with immediate persistent air leak after first VAT surgery for pneumothorax and contralateral recurrence of pneumothorax.
I applied VAT endoscopic pleurectomy and ambulatory drainage method. The success is high and expected adhesion formation is secure.
I am practising specialist in pnemothorax and all kinds of thoracic surgery. I welcome question and queries for their problem with reasonable low consultation fee.
Clinic phone number: 3160 8865
