Thoracoscopic pleurectomy for treatment of complicated spontaneous pneumothorax

General Thoracic Surgery

Thoracoscopic pleurectomy for treatment of complicated spontaneous pneumothorax This report describes a thoracoscopic approach for performing parietal pleurectomy. We have developed and used this technique successfully in 12 patients for treatment of recurrent spontaneous pneumothorax with extended bullous lung alterations (stage 4 according to the classification of Vanderschueren). For this purpose we need videoendoscopy and specially designed equipment, including pliable silicone trocars and angled instruments. The mean age of the patients was 38 years; no deaths and no complications occurred. The average period of postoperative hospitalization was 3.3 days. During the follow-up period ranging between 5 and 10 months (mean 7.5), no relapsing pneumothorax was observed. (J 'fHORAC CARDIOVASC SURG 1993;105:84-8)

R. G. C. Inderbitzi, MD, M. Furrer, MD, H. Striffeler, MD, and U. Althaus, MD, Berne, Switzerland

In 1956 Gaensler and colleagues 1 reported the first series of patients with recurrent spontaneous pneumothorax in whom parietal pleurectomy was performed as a major therapeutic measure. Since then numerous other studies have shown that parietal pleurectomy affords the best long-term results in the treatment of complicated spontaneous pneumothorax.c" In 1980 Deslauriers and colleagues" described a modified form of open pleurectomy with use of a transaxillary approach, with the aim to reduce postoperative morbidity significantly and to achieve prompt restoration of working capacity. In the past years several thoracoscopic procedures (such as sealing of leaks either by coagulation' or by Nd:YAG laser" and a pleurodesis by instillation of talc? or adhesive fibrin)" have been recommended. The present report describes a recently developed From the Department of Thoracic and Cardiovascular Surgery, University of Berne, Berne, Switzerland. Received for publication Dec. 4, 1991. Accepted for publication May I, 1992. Address for reprints: R. Inderbitzi, MD,Department of Thoracic and Cardiovascular Surgery, University of Berne, Inselspital, 3010 Berne Switzerland. 12/1/39847

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method, the thoracoscopic parietal pleurectomy. Using the videoendoscopy technique, any blebs or bullae are ligated by chromic catgut loops (ROder sling), and, subsequently, parietal pleurectomy is performed. The serial steps of the operative approach are outlined and illustrated by documentation of our initial clinical experience with 12 patients.

Patients and methods Patients. From January 1990 to August 1991, videothoracoscopy was performed in more than 170 patients in the Department of Thoracic and Cardiovascular Surgery in Berne. The group includes 32 patients who had spontaneous pneumothorax. After introductory endoscopic assessment, 20 patients weresubmitted to isolatedleak closurewith application of a ligature. In 12 more patients, additional endoscopic parietal pleurectomy was performed. In Table I age and sex of the patients undergoing pleurectomy, as well as operative indications and gross surgical pathology, are listed. The ages ranged between 23 and 64 years, with an average of 38 years. On II occasions the indication for endoscopic pleurectomywas based on pathologic findings verifiedas stage 4 according to the classification of Vanderschueren (Table II); one patient showed a pneumothorax due to cystic fibrosis. Pneumothorax on all previous occasions was treated by drainage. This was combined three times with additional pleurodesis(patients 2, 7, and 12). Operative technique. With the patient in a lateral position the operation is performed under general anesthesia with useof 0022-5223/93/$1.00/+ 0.10

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Table I. Clinical data of 12 patients treated by thoracoscopic pleurectomy Age (yr)

Sex

Pneumothorax events (n)

2

34 36

M M

3 3

3 4

23 51

M F

I I

5

26

M

6

27

M

3

7

30

M

5

8

64

M

Patient

I

9

37

M

10

52

M

II

53

F

12

24

F

Persistent Actually on the left; 2 events on the right

I

Persistent Actually on the left; 3 events on the right I

4

Gross lung pathology

Multiple blebs Multiple blebs and bullae Cystic fibrosis Bulla, 4 em, COPD

Duration of pleurectomy (min)

Hospitalization period (days) Postoperative

Follow-up (mo)

3 2

10 9

I

2

2

3

9 8

Preoperative

45 55 40 50

Air leak with fibrinous exudate

50

4

8

Multiple blebs and bullae Multiple blebs and bullae Multiple blebs and bullae, COPD Multiple blebs and bullae

55

3

8

55

2

7

7

7

60

2

7

65

4

6

4

6

3

5

Multiple blebs, I large bulla, COPD, small cell cancer Bullae (5 em, 3 em), multipleblebs Bullae (3 em, 4 em), multipleblebs

60

75 45

10

2

COPD, Chronic obstructive pulmonary disease.

double-lumen endobronchial intubation. Percutaneous oxygen saturation and end-tidal carbon dioxide were routinely measured. Approximately every 20 minutes bilateral pulmonary ventilation is carried out for about 2 minutes to prevent atelectasis, pulmonary vasoconstriction, and the adverse effects of arteriovenous shunting. Three miniincision sites are marked in the axillary triangle formed by the axilla, the lower border of the pectoralis major muscle, and the anterior border of the latissimus dorsi muscle (Fig. I). The incisions are made triangularly in the third, fourth, and fifth intercostal spaces, with a distance of at least 6 em between each entry. The first skin incision is performed in the fourth intercostal space anteriorly to the edge of the latissimus dorsi muscle. A straight telescope connected to the video camera is inserted via the trocar. The endoscopic procedure is transmitted to a TV monitor. The picture produced by the endoscope then facilitates the insertion of the other two trocars. Usually only the skin is incised, while the intercostal muscles are bluntly separated by the inserted trocars. All trocars have a 7 mm diameter, allowing for flexibility in changing and positioning of the instruments. Once the equipment has been installed, a standard exploration of the thoracic cavity and its anatomic structures is undertaken, moving in a clockwise direction. To facilitate thoracoscopic interventions, we developed our own equipment with pliable silicone tubes and angled (25 degree) instruments (Fig. 2). Leaks were captured in a Roeder loop (chromic catgut) and ligated. When widespread bullous changes are present, this can be done by serial ligatures. Care must be taken to ensure that the ligature is placed in the parenchyma, by defining the area

Table II. Classification ofpneumothorax based on pathologic findings (according to Vanderschueren'- 10; modified by Boutin' J • Stage

Description

Stage I

Idiopathicpneumothorax, no endoscopic abnormalities Pneumothoraxwith pleuropulmonary adhesions Patients with blebs and small bullae lessthan 2 em in diameter Patients with numerouslarge bullae more than 2 em in diameter

Stage 2 Stage 3 Stage 4

of pathologic change. If pleurectomy is to be performed, the limits of the resection should now be defined. Their position depends on the site and extent of the pathologic lung areas (see Table I, gross lung pathology). This usually affects the apical zone of the upper lobe (more rarely the lower lobe) so that the line of the fifth rib is adequate as caudal limit for an adequate pleurectomy. The basal lung section, which is most important in terms of ventilation, is thus not restricted. The longitudinal paravertebral limit provides the anatomic guideline for the sympathic nerve. The pleural incision is made 1 em to the side of the latter and runs apically to the level of the left subclavian artery, or, on the right side, the truncus brachiocephalicus. Fig. 3 reflects the course of the resection line in relation to the

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8 6 Inderbitzi et al.

mixedwith fibrinstriations. Antibioticdrugs wereadministered during the operation and continued for 5 additional days. The operative procedure lasted from 45 to 75 minutes (mean 55 minutes). Radiologic evaluation on the first postoperativeday revealed an open, infiltration-freelung without effusion or residual pneumothorax in all patients; thus the drains could be removedwithin the first 24 hours. The postoperativehospitalizationperiod ranged between 2 and 6 days (mean 3.33 days). The follow-up periodwas between 5 and 10months, with an average of 7.5 months. During this interval no relapse of pneumothorax was observed, and all patients had resumed their normal activity within 3 weeks. Discussion

Fig. 1. Portalplacements.

endoscopic anatomy. The pleura is grasped at the inferior borderwith a forceps andlifted within theavascular layer ina cranial/ventral direction from the base (Fig. 4). A T-shaped incision of the lifted pleura is made apically at the level of the left subclavian arteryorthetruncus brachiocephalicus (Fig. 5).The pleural flap thusfreed isextended toward theventral/parasternal limit and to the apical/mediastinal limit. The pleurectomized areaat theendofthe procedure isshown inFig. 3.At this stage a precise hemostasis mustbe ensured and a search made for anyinadvertently inflicted leak of theparenchyma. Thelatter can best be achieved by pushing portions of the carefully ventilated lung intothesaline solution with a probe. Two drains (24 and 28 gauge Charriere) are inserted through the existing miniincisions with useofa bluntguide andendoscopic viewing. Their tipsshould be placed toward the apex and intothe sinus phrenicocostalis, respectively. Finally, the pneumothorax is carefully evacuated under endoscopic visualization, so as to avoid creating an interstitial lung edema. In thisway the position of the pathologic lung areas in relation to the pleurectomized surface can be examined. Allabnormal pulmonary surface should correspond to the pleurectomized area. Results

There was no surgical morbidity nor untoward incident related to anesthesia. No patient required bloodproducts. All patients were extubated immediately after the operation, intensivecare monitoring being unnecessary in all instances. In 10patients noantibioticswereadministered. One patient (patient 5) had a leaking bulla (more than 10 em in diameter) with bronchopulmonaryfistula,resulting in pneumonia before thoracoscopy. Antibiotic therapy was therefore started before the operation. The bulla could be restricted by sectional reduction of the wall through four ligatures. Another patient (patient II) was referred to our unit after 10 days of unsuccessful chest tube drainage. The drained fluid was cloudy and inter-

Before planning treatment of a patient with pneumothorax, several questions should be answered. Some of them are related to pathology and pathogenesis: Is there an underlying chronic lung disease or other pulmonary disorder, or can no cause be found? How extensive is the lung alteration? Is it a recurrent pneumothorax? The last question is of vital importance, when we take the analysis conducted by BoutinII into consideration: Among 4982 cases extracted from 75 published articles, the risk of relapsing pneumothorax amounted to 21% if the initial episode was treated by simple drainage only, and the menace of recurrence further increased with the number of incidents. Successful pneumothorax management should regard cause and extent of the air leak and must be directed toward elimination of the causative lesion, rapid and full expansionof the lung, minimal risk of recurrence, lowor no morbidity and mortality, low cost, and short hospital stay. The application of the thoracoscopic technique meets these requirements. Particularly, in the majority of patients, endoscopypermits the safe distinction between primary and secondary pneumothorax. In the presenceof a circumscribedleak, weconfined the procedure to local ligature of the lesion. For extended bullae or multiple blebs, corresponding to stage 4 of the Vanderschuerenclassification (see Table II) and without well-defined borders to the surrounding healthy lung tissue, as well as for recurrent pneumothorax without detectable leak, additional endoscopic pleurectomy was performed. With open pleurectomy, relapse is anticipated in less than 5% of the patients.v" In the treatment of recurrent pneumothorax, thoracoscopic pleurectomy combines the effectiveness of open pleurectomy with the advantages of thoracoscopy. The endoscope affords a precise surgical approach with all anatomic structures in view, as wellas an efficient hemostasis. The miniincisions

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Fig. 2. Equipment with pliablesilicone tubes and angled (25 degrees) instruments.

Fig. 3. Courseof the resection borderlinein relationto endoscopic anatomy. do not damage any respiratory muscles; this feature is reflected by the short hospital stay (average 3.3 days) and by the fact that no patients required intensive care (including the four patients with severe chronic obstructive lung disease). The unrestricted visualization of the pleural cavity by videoendoscopy allows the accurate

Fig. 4. The pleura is grasped at its inferior limit and lifted withinthe avascularlayer with use of a dissector from the base in a cranial/ventral direction.

assessment of the lung, comprising extent of air leak and staging of lung pathology. The extension of pleural resection can be clearly delineated by determining the anatomic juxtaposition of the abnormal lung surface. In con-

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8 8 Inderbitzi et at.

is confirmed by the radiologic findings showing neither atelectasis nor pleural effusion 24 hours after the operation. Last, short hospitalization and early return to work demonstrate the cost effectiveness of the procedure.

I.

2. 3. 4. Fig. 5. A T-shaped incision is performed in the pleura at the levelof the subclavian artery or the truncus brachiocephalicus. The dissection of the pleural flap thus created is extended in a ventral/parasternal and apical/mediastinal direction. trast to chemical pleurodesis, this procedure permits a circumscribed pleurectomy while protecting the basal lung segments important for ventilation. Obviously, thoracoscopic pleurectomy makes any subsequent lung operations more difficult than after chemical pleurodesis in which the anatomic extraparietallayer remains intact. However, this drawback is compensated by the limited extent of pleural resection. Full expansion of the lung carried out under endoscopic visualization at the end of the operation and careful control of hemostasis, as well as the precise positioning of apicoventral and dorsobasal chest tubes into the sinus phrenicocostalis, are regarded as essential prerequisites for uneventful postoperative recovery and for a short hospital stay. The suitability of the thoracoscopic approach

5. 6. 7.

8. 9. 10.

II.

REFERENCES Gaensler EA. Parietal pleurectomyfor recurrent spontaneous pneumothorax. Surg Gynecol Obstet 1956;102:293308. Gobbel VG, Rhea WG, Nelson lA, et al. Spontaneous pneumothorax. J THoRAc CARDIOVASC SURG 1963; 46:331-45. Getz SB, BeasleyWE. Spontaneous pneumothorax. Am J Surg 1983;145:823-8. Deslauriers J, Beaulieu M, Despres JP, et al. Transaxillary pleurectomy for treatment of spontaneous pneumothorax. Ann Thorac Surg 1980;30:569-74. Wakabayashi A. Thoracoscopic ablation of blebs in the treatment of recurrent or persistent spontaneous pneumothorax. Ann Thorac Surg 1989;48:651-3. Torre M, Belloni P. Nd:YAG laser pleurodesis through thoracoscopy: new curative therapy in spontaneous pneumothorax. Ann Thorac Surg 1989;47:887-9. Guerin JC, Champel F, Birou E, et al. Talcage pleural par thoracoscopiedans Ie traitement du pneumothorax. Etude d'une serie de 109 cas traites en 3 ans. Rev Mal Respir 1985;2:25-9. Hansen MK, Kruse-Anderson S, Watt-Boolsen S, et al. Spontaneous pneumothorax and fibrin glue sealant during thoracoscopy. Eur J Cardiothorac Surg 1989;3:512-4. Vanderschueren RG. Le talcage pleural dans Ie pneumothorax spontane, Poumon Coeur 1981;37:273-6. Vanderschueren RGJRA. The role of thoracoscopy in the evaluation and management of pneumothorax. Lung 1990;168(suppl):1122-5. Boutin C. Thoracoscopy in the diagnosis and treatment of spontaneous pneumothorax. In: Boutin C, Viallat JR, Aelony Y. Practical thoracoscopy. 1st ed. Berlin: Springer, 1990:73-81.