Thoracoscopy for Treatment of Spontaneous Pneumothorax

Indications for Workup and Operation

Thoracoscopy is now the preferred approach for the operative treatment of primary spontaneous pneumothorax (PSP) due to ease of operation and patient tolerance, with minimization of postoperative pain and good results.

PSP is a pneumothorax that develops outside of an underlying preexisting pulmonary disease, such as malignancy or trauma, which is termed secondary spontaneous pneumothorax. The pathophysiology and treatment of secondary pneumothorax are complex and outside the scope of this chapter. PSPs usually present in teenagers with chest pain and shortness of breath. Chest auscultation may reveal decreased breath sounds on the affected side. When a significant pneumothorax is present, with or without tension physiology, there may be an associated tracheal deviation away from the affected side.

The vast majority of patients with a PSP are teenagers who present with stable vital signs and without signs and symptoms of tension pneumothorax. Although rare with PSP, if tension pneumothorax is present, immediate decompression with a chest tube or angiocatheter is necessary. In the majority of patients, the first step in PSP management is radiographic imaging including a posteroanterior and lateral chest radiograph ( Fig. 35-1 ). On occasion, a bleb is seen on the chest radiograph ( Fig. 35-2 ).

The next steps in management consist of obtaining intravenous access, and if the pneumothorax is sizable and/or the patient is symptomatic, then tube/catheter drainage is indicated. A recent prospective pilot study demonstrated that a trial of simple aspiration using a small-bore catheter predicts the need for further intervention. The drainage tube acts in three ways: (1) drains the extrapleural air, (2) achieves symptom resolution, and (3) acts as a test for tolerance of aspiration. If the pneumothorax resolves on radiograph after initial aspiration, the tube is clamped. If the pneumothorax returns, then the tube is unclamped, and the patient is scheduled for an operation during the hospitalization, preferably that day or the next day.

The indications for operative intervention of PSPs are in continued evolution. Periods of prolonged chest tube management are shifting toward a trend of more prompt operative intervention. Therefore, the most common indications for operation for PSP at this time are recurrence, persistent air leak, and inadequate immediate access to quality medical care. The use of chest computed tomography (CT) has not been consistently demonstrated to be of significant value in the initial operative decision making and is therefore not routinely used in our institution.

Operative Technique