Thoracoscopy for Spontaneous Pneumothorax
There are two broad categories describing collapsed lungs. Patients with primary pneumothorax tend to be tall, young, and thin. Patients with secondary pneumothorax tend to be older, with moderate to severe emphysema, and large bullae. Primary spontaneous pneumothorax or secondary pneumothorax which does not resolve with a chest tube, or which recurs, should be treated surgically. Patients who have primary spontaneous pneumothorax often can tolerate a pneumothorax with few symptoms. The source of the pneumothorax is usually a ruptured bleb from the top of either the upper or lower lobes. Approximately 20% to 40% will experience recurrence after a first episode. If that second event is similarly treated without surgery, the probability of a third occurrence is greater than 60%. Surgery will be necessary in about 20% of patients, usually because of recurrent pneumothoraces. Less common indications for surgery are: prolonged air leaks from the chest tube, and associated hemothorax, or patients at high risk because of their occupations or lifestyles. Our preferred surgical approach in patients requiring surgery for spontaneous pneumothorax is thoracoscopy, with resection of the apical blebs or bullae, and abrasion of the pleura producing firm adhesions between the lung and chest wall. Thoracoscopy affords better visualization of the entire lung surface, especially the lower lobe which cannot be seen when the traditional axillary approach is used. We tend to identify more blebs with the thoracoscopic approach. In our experience, patients treated for pneumothorax this way seem to experience less postoperative pain, both immediately after surgery, and when seen several months afterwards. There has been no difference in our experience with recurrent pneumothorax provided blebs are identified and removed. Despite advocating this less invasive procedure, the indications have not been changed. We reserve surgery for patients who either have recurrence or a persistent pneumothorax for five to seven days.