MULTIMEDIA MANUAL OF
doi:10.1093/mmcts/mmu012 published online 25 June 2014.
MMCTS
CARDIO-THORACIC SURGERY
Needlescopic video-assisted thoracic surgery pleurodesis for primary pneumothorax Alan D.L. Sihoe*, Michael K.Y. Hsin and Peter S.Y. Yu Division of Cardiothoracic Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China *Corresponding author. Tel: +852-2255-3571; fax: +852-2553-3436; e-mail: [email protected] (A.D.L. Sihoe). Received 19 March 2014; revised 4 May 2014; accepted 20 May 2014
Summary Conventional video-assisted thoracic surgery (VATS) is already well established as the approach of choice for definitive surgical management for primary pneumothorax. However, VATS itself is a constantly evolving technique. The needlescopic VATS (nVATS) approach uses the existing chest drain wound as a working port and adds only two 3-mm ports to provide equally effective pleurodesis as conventional VATS. Staple resection of bullae or blebs plus complete mechanical parietal pleural abrasion is achievable using nVATS. By potentially reducing morbidity for the individual patient, the nVATS approach may lower thresholds for surgical candidacy—even for first episodes of primary pneumothorax. Keywords: Video-assisted thoracic surgery • Thoracoscopic surgery • Primary pneumothorax
INTRODUCTION
SURGICAL TECHNIQUE
Primary spontaneous pneumothorax (PSP) is one of the commonest chest conditions managed by the thoracic surgeon, with a reported incidence of 18–28/100 000 cases per annum for men and 1.2–6/100 000 for women [1]. Its management is very well defined [2]. The acute management may involve conser vative measures, needle aspiration or chest tube insertion. Definitive management is required in specific situations— including second ipsilateral PSP, first contralateral PSP, synchronous bilateral PSP and persistent air leak (despite 5–7 days of chest tube drainage). Such definitive management usually means pleurodesis—for which surgery is preferred over chemical pleurodesis where possible because of lower recurrence rates after the former [3–5]. Video-assisted thoracic surgery (VATS) has been well established as the approach of choice for surgical pleurodesis for PSP. The conventional VATS approach involves the use of three ports of 8–15 mm size, a 10-mm diameter 0° or 30° video- thoracoscope and conventional open thoracic surgical instruments [6, 7]. Reported benefits include reduced pain, faster recovery and better cosmesis [8, 9]. Nonetheless, a proportion of patients still experience significant pain or paraesthesia following conventional VATS [6, 10]. There is obviously room for improvement. Using 2–3 mm diameter video-thoracoscopes and instruments, the needlescopic VATS (nVATS) approach promises even less morbidity than conventional VATS for procedures such as sympathectomy for palmar hyperhidrosis and simple lung wedge resections [11, 12]. Here, we report our nVATS technique for pleurodesis in patients with PSP.
Patient selection and preparation The indications for surgery for spontaneous pneumothorax are well recognized [2]. We now routinely use the nVATS approach in all patients with PSP and most patients with secondary pneumothorax. We would use conventional VATS for patients with previous ipsilateral pleurodesis or thoracic surgery, and with complex secondary pneumothorax (e.g. giant bullae and anticipated dense adhesions). Preoperative investigations and preparations are identical to those for conventional VATS [6, 7]. All patients receive one-lung ventilation and are positioned in the full lateral decubitus position with flexion of the operating table to 30° just inferior to the level of the nipples, to open up the upper intercostal spaces for video-thoracoscope insertion and instrumentation [6–9].
Placement of ports Most of the patients with PSP receive surgery during their acute admission, and hence arrive in the operating room with a chest tube in situ. The tube is removed after patient positioning. If the chest tube thoracostomy wound is not grossly infected or inflamed, it can be used as one of the nVATS ports. In most patients nowadays, the chest tube thoracostomy wound has typically been placed in the ‘safety triangle’ [13], and that relatively anterior and low location makes it suitable for the anterior stapler port. During skin preparation, that thoracostomy wound should be thoroughly scrubbed (including along its tract into the pleural
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
A.D.L. Sihoe et al. / Multimedia Manual of Cardio-Thoracic Surgery
space) using an antiseptic solution such as povidone-iodine or chlorhexidine. The wound typically does not need to be widened or extended: a thoracostomy wound that can admit a 28-F chest tube can accommodate a standard endoscopic stapler. If the thoracostomy wound is grossly infected, another 10- to 11-mm stapler port should be created. We routinely use a 3-mm 30° video-thoracoscope. With modern high-definition video cameras, such needlescopes offer adequate illumination inside the thorax and good quality images, allowing even intricate procedures to be done. This scope is placed via the chest tube thoracostomy wound for an initial inspection of the chest and confirmation that there are no adhesions at the sites for the other two nVATS ports. Any adhesions can be cleared from under the port sites using a Uniportal technique [14]. Our port strategy is illustrated in Figure 1. The camera port is made in the posterior axillary line around the seventh or eighth intercostal space. The wound is made by using a No. 11 scalpel blade to create a 3mm stab incision through the skin. A 3-mm trocar is pushed through and the 3-mm 30° video-thoracoscope placed through it. Alternatively, a tract is created into the pleural space by pushing a small mosquito forceps through the skin-stab incision, and a 5-mm 30° video-thoracoscope is placed directly through this tract without a trocar. The lens tip can be wiped within the chest using a pledget held on a Roberts forceps, lightly soaked with anti-fogging solution and inserted via the chest tube thoracostomy wound. We place an apical nVATS instrument port for lung retraction at a slightly higher level than the chest tube thoracostomy wound (e.g. fourth intercostal space) and in the posterior or mid axillary line. Again, this is created using a No. 11 scalpel blade to stab and a 3-mm trocar is pushed through (Video 1). Through this trocar, we use a 3-mm endoscopic forceps with as blunt a tip and as wide a grasping surface as possible to retract the lung. Although smaller 2-mm instruments can be used, in our experience we have found these to be too flexible to allow precise surgery to be performed within the chest. When creating each of the above ports, we apply pre-emptive local anaesthetic infiltration of the port sites [15]. Typically, we use
2
a total of 5–10 ml of 0.5% bupivacaine (adjusted according to body weight) and distributed among the three ports.
Bleb resection Using a 3-mm endoscopic forceps via the apical nVATS port and a sponge-holding ring forceps via the chest tube thoracostomy wound, the entire lung is manipulated gently and explored to detect any blebs or bullae (Video 2). Any such bleb found is grasped with the apical 3-mm endoscopic forceps and an endoscopic stapler is introduced via the chest tube thoracostomy
Video 1: Introduction of 3-mm apical port trocar as viewed from inside the chest. The lung is then gently manipulated to locate blebs using a 3-mm endoscopic forceps inserted through this trocar, and an open sponge-holding ring forceps inserted through the existing chest drain wound.
Figure 1: Port strategy for left needlescopic video-assisted thoracic surgery pleurodesis. The existing chest tube thoracostomy wound is used as the anterior port for the endoscopic stapler and pleural abrasion. An apico-posterior 3-mm port is used for retraction. A lower 3-mm camera port is used for the video-thoracoscope.
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A.D.L. Sihoe et al. / Multimedia Manual of Cardio-Thoracic Surgery
Video 2: The lung bleb is identified, grasped with the 3-mm endoscopic forceps and then staple-resected using a stapler introduced via the chest tube thoracostomy wound. Roticulation of the stapler allows precise placement of the staple line.
wound to staple-resect the bleb. Roticulating staplers are especially useful to allow accurate placement of the staple line through healthy lung tissue across the base of the bleb. Every effort must be made to carefully explore the entire lung surface for blebs as missed blebs are among the commonest causes of recurrence. When doing so, care must be taken not to retract too forcefully using the 3-mm endoscopic forceps as this may cause puncture or tearing of the lung surface by the narrow tip of the forceps.
Mechanical pleurodesis Mechanical abrasion pleurodesis to all the parietal pleural surfaces is performed using a Prolene mesh wrapped over a Roberts forceps tip and inserted via the chest tube thoracostomy wound (Video 3). In taller patients, the mesh may need to be mounted on a long endoscopic grasper to allow the superior sulcus to be reached for abrasion. For the lateral chest wall and areas closer to the chest tube wound, the mesh can be mounted on the tip of a right-angled Rumel forceps. Apical pleurectomy is possible using the nVATS approach, and we have performed this in selected patients. However, it is not usually done as mechanical pleurodesis offers a better compromise between effective pleurodesis and limiting postoperative pain and bleeding. In patients where the diaphragm surface cannot be reached by any instrument via the chest tube wound, we sometimes instil an antibiotic (such as minocycline or oxytetracycline) to provide additional chemical pleurodesis there [16].
End of the procedure One 20- or 24-F chest tube is placed after surgery via the chest tube thoracostomy wound [6]. At this port, there is chest tube placement before and after surgery and instrumentation during
Video 3: Mechanical abrasion pleurodesis is performed over the entire apical and posterior chest wall parietal pleura using a Prolene mesh mounted on the tip of an endoscopic grasper introduced via the chest tube thoracostomy wound. For abrasion to the lateral and anterior chest wall closer to the chest drain wound, the mesh is mounted on a right-angled Rumel forceps. At the end of the procedure, a chest tube is placed via the pre-existing chest drain wound to the apex.
surgery, and so a wound closure suture across this incision must be placed to assist wound apposition at the time of drain removal [13]. The lung is re-inflated under vision by the video-thoracoscope. The other two 3-mm nVATS ports can be closed with skin adhesive tape, but we prefer placing a simple 5/0 nylon stitch to achieve a better cosmetic result. We do recognize that different opinions exist as to the role of suction and chest drain durations following pneumothorax surgery. Our own practice is to connect the chest drain to 15 cm H2O of suction and to remove it on the second postoperative day if there is no air leak. We previously removed the chest drain on the morning after surgery, but have since delayed this by 1 day to allow suction to effect greater and longer contact between the pleural layers after surgery. To this end, we keep the suction on the chest drain until the moment of tube removal. We find that the use of modern digital chest drain systems with in-built suction systems is particularly useful in allowing patients’ complete mobility during this time before removal while maintaining continuous regulated suction (Figure 2). Adequate analgesia is also important to allow deep breathing exercises and vigorous use of the incentive spirometer that may further enhance interpleural apposition postoperatively. However, when prescribing analgesics, it should be noted that a handful of animal studies have suggested that non-steroidal anti-inflammatory drugs (NSAIDs) may adversely affect the quality of pleural adhesions following a pleurodesis procedure, and hence there have been calls from some to avoid the routine use of NSAIDs following pleurodesis in humans [17].
RESULTS Although we have since used the nVATS approach for many more patients with PSP, our initial experience with the first 67
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Table 1: Outcomes for the first 67 consecutive patients receiving nVATS pleurodesis for PSP Male Mean age (years) Mean operation duration (min) Mean blood loss (ml) Conversion to conventional VATS or thoracotomy (%) Mortality (%) Procedure-related complications (%) Mean chest drain duration (days) Mean postoperative length of stay (days)
82% 22.7 ± 6.2 45 ± 19 3 ± 25 0 0 0 2.4 ± 0.8 3.8 ± 2.2
nVATS: needlescopic video-assisted thoracic surgery; PSP: primary spontaneous pneumothorax.
Figure 2: A modern portable digital chest drain system complements needlescopic video-assisted thoracic surgery pleurodesis. Even with continuous suction applied, the patient can be fully mobile because the system has in-built regulated suction generation.
c onsecutive patients is summarized in Table 1. The safety of the approach is demonstrated. Chest drain durations were arbitrarily set to no less than 2 days as explained above. On average, the last tablet of oral analgesics taken by patients was at 7 days after surgery. After a median follow-up of 14 months (range 1–45 months), the recurrence rate was 3%.
DISCUSSION Conventional VATS is well established as the preferred approach for PSP surgery. Although the rate of recurrence has been suggested to be higher with VATS than with open thoracotomy [2], many would accept that the trade-off is very reasonable given the reduced morbidity associated with VATS, and few surgeons would contemplate thoracotomy for PSP nowadays. With advances in video and surgical instrument technology today, nVATS can be considered the next step of evolution in the direction towards even less invasiveness. The concept of nVATS actually emerged over a decade ago, and variations in terms of number, sizes and instrumentation of the ports have been described [18–20]. We believe that the nVATS technique described above may be the simplest to master and requires the least switching around of instruments between the ports. We acknowledge that the nVATS technique is essentially an evolution of the conventional VATS approach rather than a complete revolution: a similar basic three-port strategy is maintained, but the smaller wounds call for modification of details of the technique.
Figure 3: Photos of the same patient in the operating room immediately before and immediately after needlescopic video-assisted thoracic surgery pleurodesis. Patients typically arrived in the operating room with a chest tube in situ. That chest tube thoracostomy wound is used as the anterior port without any enlargement, and only two 3-mm stab incisions are added to give complete bleb resection and mechanical pleurodesis.
However, we feel that this gentle evolution is an advantage in that it should be consequently easier for the average VATS surgeon to learn. Data to date have shown that at least nVATS can be performed as safely as conventional VATS. However, it is still too early to say whether the nVATS approach has any significant advantage over conventional VATS. Indeed, it should always be borne in mind that, in addition to surgical access trauma, the pain following any surgery for pneumothorax may be a product of the mechanical abrasion or pleurectomy, torquing of the instruments in the intercostal spaces during surgery and the presence of the chest tube before and after surgery [6, 10]. One small study has so far shown encouraging outcomes for nVATS compared with conventional VATS [20], but it is clear that considerable experience from future studies will be necessary to clarify the issue. An alternative approach to reducing the surgical footprint compared with conventional three-port VATS is the use of Uniportal VATS [7, 14]. For PSP surgery, Uniportal VATS is certainly feasible. However, the wound created is 2–2.5 cm long, and hence greater than the sum of wound lengths when using nVATS. Again, further studies will be required to determine which offers the bigger advantage over conventional VATS.
A.D.L. Sihoe et al. / Multimedia Manual of Cardio-Thoracic Surgery
Regardless of hard clinical data of superiority, Figure 3 demonstrates the clear cosmetic appeal of nVATS. For a patient with PSP who already has a chest drain wound, nVATS allows safe, effective pleurodesis at the ‘cost’ of only two extra tiny 3-mm stab incisions. These needlescopic wounds are virtually invisible within a few weeks after surgery. In this context, it is reasonable for the patient to think ‘why not accept surgery since the largest wound (for the chest drain) has been made already’? The impact of thereby reducing the ‘intimidation’ factor of surgery for patients is hard to quantify but should not be underestimated. In the past, surgery was not recommended for first episodes of ipsilateral PSP largely because of: (i) a belief that ipsilateral recurrence rates after a first episode of PSP were low and (ii) the cost of surgery in terms of pain and morbidity was too high. However, the latest guidelines show that the ‘risk of recurrence of PSP is as high as 54% within the first 4 years’ [2, 21]. It can no longer be dismissed as low: a 20-year-old patient with PSP will have a greater than 50% chance of suffering another episode before his/her 24th birthday, and the accumulated risk can only get higher throughout the many years of his/her adult life. In this context, a very minimally invasive approach such as nVATS may represent a palatable choice for patients even on their first episode of PSP. Extrapolating this further, it has been demonstrated that future occurrences of PSP may be predicted by detection of lung blebs on imaging [22]. Although controversial today, might it be possible in future to offer very minimally invasive surgery pre-emptively to persons incidentally found to have such blebs? Conflict of interest: none declared.
REFERENCES [1] Melton LJ, Hepper NCG, Offord KP. Incidence of spontaneous pneumothorax in Olmsted County, Minnesota: 1950–1974. Am Rev Respir Dis 1987;29:1379–82. [2] MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65:ii18–31. [3] Almind M, Lange P, Viskum K. Spontaneous pneumothorax: comparison of simple drainage, talc pleurodesis and tetracycline pleurodesis. Thorax 1989;44:627–30. [4] Olsen PS, Anderson HO. Long term results after tetracycline pleurodesis in spontaneous pneumothorax. Ann Thorac Surg 1992;53:1015–17. [5] Massard G, Thomas P, Wihlm J-M. Minimally invasive management for first and recurrent pneumothorax. Ann Thorac Surg 1998;66:592–9.
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[6] Sihoe ADL, Au SS, Cheung ML, Chow IK, Chu KM, Law CY et al. Incidence of chest wall paresthesia after video-assisted thoracic surgery for primary spontaneous pneumothorax. Eur J Cardiothorac Surg 2004; 25:1054–8. [7] Ng CSH, Rocco G, Yim APC. Video-assisted thoracoscopic surgery (VATS) pleurodesis for pneumothorax. Multimed Man Cardiothorac Surg 2005; doi:10.1510/mmcts.2004.000349. [8] Sihoe ADL. The evolution of VATS lobectomy. In: Cardoso P (ed). Topics in Thoracic Surgery. Rijeka, Croatia: Intech, 2011, 181–210. [9] Sihoe ADL, Yim APC. Video-assisted pulmonary resections. In: Patterson GA, Cooper JD, Deslauriers J, Lerut AEMR, Luketich JD, Rice TW et al. (eds). Thoracic Surgery. 3rd edn. Philadelphia, USA: Elsevier, 2008, 970–88. [10] Passlick B, Born CH, Sienel W, Thetter O. Incidence of chronic pain after minimal-invasive surgery for spontaneous pneumothorax. Eur J Cardiothorac Surg 2001;19:355–9. [11] Sihoe ADL, Cheung CS, Lai HK, Lee TW, Thung KH, Yim APC. Incidence of chest wall paresthesia after needlescopic video-assisted thoracic surgery for palmar hyperhidrosis. Eur J Cardiothorac Surg 2005;27:313–9. [12] Yim APC, Sihoe ADL, Lee TW, Arifi AA. A simple maneuver to detect airleak on-table following ‘needlescopic’ VATS. J Thorac Cardiovasc Surg 2002;124:1029–30. [13] Laws D, Neville E, Duffy J. British Thoracic Society guidelines for the insertion of a chest drain. Thorax 2003;58:ii53–9. [14] Rocco G, Martin-Ucar A, Passera E. Uniportal wedge pulmonary resections. Ann Thorac Surg 2004;77:726–8. [15] Sihoe ADL, Manlulu AV, Lee TW, Thung KH, Yim APC. Pre-emptive local anesthesia for needlescopic video-assisted thoracic surgery: a randomized controlled trial. Eur J Cardiothorac Surg 2007;31:103–8. [16] Chen JS, Hsu HH, Kuo SW, Tsai PR, Chen RJ, Lee JM et al. Effects of additional minocycline pleurodesis after thoracoscopic procedures for primary spontaneous pneumothorax. Chest 2004;125:50–5. [17] Hunt I, The E, Southon R, Treasure T. Using non-steroidal anti- inflammatory drugs (NSAIDs) following pleurodesis. Interact CardioVasc Thorac Surg 2007;6:102–4. [18] Yoon YH, Kim KH, Han JY, Beak WK, Lee CS, Kim JT. Management of persistent or recurrent pneumothorax with a two-millimeter mini-videothoracoscope. J Korean Med Sci 2000;15:507–9. [19] Tagaya N, Kasama K, Suzuki N, Taketsuka S, Horie K, Kubota K. Videoassisted bullectomy using needlescopic instruments for spontaneous pneumothorax. Surg Endosc 2003;17:1486–7. [20] Chen JS, Hsu HH, Kuo SW, Tsai PR, Chen RJ, Lee JM et al. Needlescopic versus conventional video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: a comparative study. Ann Thorac Surg 2003;75:1080–5. [21] Smit HJM, Chatrou M, Postmus PE. The impact of spontaneous pneumothorax, and its treatment, on the smoking behaviour of young adult smokers. Respir Med 1998;92:1132–6. [22] Sihoe ADL, Yim APC, Lee TW, Wan S, Yuen EHY, Wan IYP et al. Can CT be used to select patients with unilateral primary spontaneous pneumothorax for bilateral surgery? Chest 2000;118:380–3.
doi:10.1093/mmcts/mmu012 published online 25 June 2014.
MMCTS
CARDIO-THORACIC SURGERY
Needlescopic video-assisted thoracic surgery pleurodesis for primary pneumothorax Alan D.L. Sihoe*, Michael K.Y. Hsin and Peter S.Y. Yu Division of Cardiothoracic Surgery, Department of Surgery, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong SAR, China *Corresponding author. Tel: +852-2255-3571; fax: +852-2553-3436; e-mail: [email protected] (A.D.L. Sihoe). Received 19 March 2014; revised 4 May 2014; accepted 20 May 2014
Summary Conventional video-assisted thoracic surgery (VATS) is already well established as the approach of choice for definitive surgical management for primary pneumothorax. However, VATS itself is a constantly evolving technique. The needlescopic VATS (nVATS) approach uses the existing chest drain wound as a working port and adds only two 3-mm ports to provide equally effective pleurodesis as conventional VATS. Staple resection of bullae or blebs plus complete mechanical parietal pleural abrasion is achievable using nVATS. By potentially reducing morbidity for the individual patient, the nVATS approach may lower thresholds for surgical candidacy—even for first episodes of primary pneumothorax. Keywords: Video-assisted thoracic surgery • Thoracoscopic surgery • Primary pneumothorax
INTRODUCTION
SURGICAL TECHNIQUE
Primary spontaneous pneumothorax (PSP) is one of the commonest chest conditions managed by the thoracic surgeon, with a reported incidence of 18–28/100 000 cases per annum for men and 1.2–6/100 000 for women [1]. Its management is very well defined [2]. The acute management may involve conser vative measures, needle aspiration or chest tube insertion. Definitive management is required in specific situations— including second ipsilateral PSP, first contralateral PSP, synchronous bilateral PSP and persistent air leak (despite 5–7 days of chest tube drainage). Such definitive management usually means pleurodesis—for which surgery is preferred over chemical pleurodesis where possible because of lower recurrence rates after the former [3–5]. Video-assisted thoracic surgery (VATS) has been well established as the approach of choice for surgical pleurodesis for PSP. The conventional VATS approach involves the use of three ports of 8–15 mm size, a 10-mm diameter 0° or 30° video- thoracoscope and conventional open thoracic surgical instruments [6, 7]. Reported benefits include reduced pain, faster recovery and better cosmesis [8, 9]. Nonetheless, a proportion of patients still experience significant pain or paraesthesia following conventional VATS [6, 10]. There is obviously room for improvement. Using 2–3 mm diameter video-thoracoscopes and instruments, the needlescopic VATS (nVATS) approach promises even less morbidity than conventional VATS for procedures such as sympathectomy for palmar hyperhidrosis and simple lung wedge resections [11, 12]. Here, we report our nVATS technique for pleurodesis in patients with PSP.
Patient selection and preparation The indications for surgery for spontaneous pneumothorax are well recognized [2]. We now routinely use the nVATS approach in all patients with PSP and most patients with secondary pneumothorax. We would use conventional VATS for patients with previous ipsilateral pleurodesis or thoracic surgery, and with complex secondary pneumothorax (e.g. giant bullae and anticipated dense adhesions). Preoperative investigations and preparations are identical to those for conventional VATS [6, 7]. All patients receive one-lung ventilation and are positioned in the full lateral decubitus position with flexion of the operating table to 30° just inferior to the level of the nipples, to open up the upper intercostal spaces for video-thoracoscope insertion and instrumentation [6–9].
Placement of ports Most of the patients with PSP receive surgery during their acute admission, and hence arrive in the operating room with a chest tube in situ. The tube is removed after patient positioning. If the chest tube thoracostomy wound is not grossly infected or inflamed, it can be used as one of the nVATS ports. In most patients nowadays, the chest tube thoracostomy wound has typically been placed in the ‘safety triangle’ [13], and that relatively anterior and low location makes it suitable for the anterior stapler port. During skin preparation, that thoracostomy wound should be thoroughly scrubbed (including along its tract into the pleural
© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
A.D.L. Sihoe et al. / Multimedia Manual of Cardio-Thoracic Surgery
space) using an antiseptic solution such as povidone-iodine or chlorhexidine. The wound typically does not need to be widened or extended: a thoracostomy wound that can admit a 28-F chest tube can accommodate a standard endoscopic stapler. If the thoracostomy wound is grossly infected, another 10- to 11-mm stapler port should be created. We routinely use a 3-mm 30° video-thoracoscope. With modern high-definition video cameras, such needlescopes offer adequate illumination inside the thorax and good quality images, allowing even intricate procedures to be done. This scope is placed via the chest tube thoracostomy wound for an initial inspection of the chest and confirmation that there are no adhesions at the sites for the other two nVATS ports. Any adhesions can be cleared from under the port sites using a Uniportal technique [14]. Our port strategy is illustrated in Figure 1. The camera port is made in the posterior axillary line around the seventh or eighth intercostal space. The wound is made by using a No. 11 scalpel blade to create a 3mm stab incision through the skin. A 3-mm trocar is pushed through and the 3-mm 30° video-thoracoscope placed through it. Alternatively, a tract is created into the pleural space by pushing a small mosquito forceps through the skin-stab incision, and a 5-mm 30° video-thoracoscope is placed directly through this tract without a trocar. The lens tip can be wiped within the chest using a pledget held on a Roberts forceps, lightly soaked with anti-fogging solution and inserted via the chest tube thoracostomy wound. We place an apical nVATS instrument port for lung retraction at a slightly higher level than the chest tube thoracostomy wound (e.g. fourth intercostal space) and in the posterior or mid axillary line. Again, this is created using a No. 11 scalpel blade to stab and a 3-mm trocar is pushed through (Video 1). Through this trocar, we use a 3-mm endoscopic forceps with as blunt a tip and as wide a grasping surface as possible to retract the lung. Although smaller 2-mm instruments can be used, in our experience we have found these to be too flexible to allow precise surgery to be performed within the chest. When creating each of the above ports, we apply pre-emptive local anaesthetic infiltration of the port sites [15]. Typically, we use
2
a total of 5–10 ml of 0.5% bupivacaine (adjusted according to body weight) and distributed among the three ports.
Bleb resection Using a 3-mm endoscopic forceps via the apical nVATS port and a sponge-holding ring forceps via the chest tube thoracostomy wound, the entire lung is manipulated gently and explored to detect any blebs or bullae (Video 2). Any such bleb found is grasped with the apical 3-mm endoscopic forceps and an endoscopic stapler is introduced via the chest tube thoracostomy
Video 1: Introduction of 3-mm apical port trocar as viewed from inside the chest. The lung is then gently manipulated to locate blebs using a 3-mm endoscopic forceps inserted through this trocar, and an open sponge-holding ring forceps inserted through the existing chest drain wound.
Figure 1: Port strategy for left needlescopic video-assisted thoracic surgery pleurodesis. The existing chest tube thoracostomy wound is used as the anterior port for the endoscopic stapler and pleural abrasion. An apico-posterior 3-mm port is used for retraction. A lower 3-mm camera port is used for the video-thoracoscope.
3
A.D.L. Sihoe et al. / Multimedia Manual of Cardio-Thoracic Surgery
Video 2: The lung bleb is identified, grasped with the 3-mm endoscopic forceps and then staple-resected using a stapler introduced via the chest tube thoracostomy wound. Roticulation of the stapler allows precise placement of the staple line.
wound to staple-resect the bleb. Roticulating staplers are especially useful to allow accurate placement of the staple line through healthy lung tissue across the base of the bleb. Every effort must be made to carefully explore the entire lung surface for blebs as missed blebs are among the commonest causes of recurrence. When doing so, care must be taken not to retract too forcefully using the 3-mm endoscopic forceps as this may cause puncture or tearing of the lung surface by the narrow tip of the forceps.
Mechanical pleurodesis Mechanical abrasion pleurodesis to all the parietal pleural surfaces is performed using a Prolene mesh wrapped over a Roberts forceps tip and inserted via the chest tube thoracostomy wound (Video 3). In taller patients, the mesh may need to be mounted on a long endoscopic grasper to allow the superior sulcus to be reached for abrasion. For the lateral chest wall and areas closer to the chest tube wound, the mesh can be mounted on the tip of a right-angled Rumel forceps. Apical pleurectomy is possible using the nVATS approach, and we have performed this in selected patients. However, it is not usually done as mechanical pleurodesis offers a better compromise between effective pleurodesis and limiting postoperative pain and bleeding. In patients where the diaphragm surface cannot be reached by any instrument via the chest tube wound, we sometimes instil an antibiotic (such as minocycline or oxytetracycline) to provide additional chemical pleurodesis there [16].
End of the procedure One 20- or 24-F chest tube is placed after surgery via the chest tube thoracostomy wound [6]. At this port, there is chest tube placement before and after surgery and instrumentation during
Video 3: Mechanical abrasion pleurodesis is performed over the entire apical and posterior chest wall parietal pleura using a Prolene mesh mounted on the tip of an endoscopic grasper introduced via the chest tube thoracostomy wound. For abrasion to the lateral and anterior chest wall closer to the chest drain wound, the mesh is mounted on a right-angled Rumel forceps. At the end of the procedure, a chest tube is placed via the pre-existing chest drain wound to the apex.
surgery, and so a wound closure suture across this incision must be placed to assist wound apposition at the time of drain removal [13]. The lung is re-inflated under vision by the video-thoracoscope. The other two 3-mm nVATS ports can be closed with skin adhesive tape, but we prefer placing a simple 5/0 nylon stitch to achieve a better cosmetic result. We do recognize that different opinions exist as to the role of suction and chest drain durations following pneumothorax surgery. Our own practice is to connect the chest drain to 15 cm H2O of suction and to remove it on the second postoperative day if there is no air leak. We previously removed the chest drain on the morning after surgery, but have since delayed this by 1 day to allow suction to effect greater and longer contact between the pleural layers after surgery. To this end, we keep the suction on the chest drain until the moment of tube removal. We find that the use of modern digital chest drain systems with in-built suction systems is particularly useful in allowing patients’ complete mobility during this time before removal while maintaining continuous regulated suction (Figure 2). Adequate analgesia is also important to allow deep breathing exercises and vigorous use of the incentive spirometer that may further enhance interpleural apposition postoperatively. However, when prescribing analgesics, it should be noted that a handful of animal studies have suggested that non-steroidal anti-inflammatory drugs (NSAIDs) may adversely affect the quality of pleural adhesions following a pleurodesis procedure, and hence there have been calls from some to avoid the routine use of NSAIDs following pleurodesis in humans [17].
RESULTS Although we have since used the nVATS approach for many more patients with PSP, our initial experience with the first 67
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A.D.L. Sihoe et al. / Multimedia Manual of Cardio-Thoracic Surgery
Table 1: Outcomes for the first 67 consecutive patients receiving nVATS pleurodesis for PSP Male Mean age (years) Mean operation duration (min) Mean blood loss (ml) Conversion to conventional VATS or thoracotomy (%) Mortality (%) Procedure-related complications (%) Mean chest drain duration (days) Mean postoperative length of stay (days)
82% 22.7 ± 6.2 45 ± 19 3 ± 25 0 0 0 2.4 ± 0.8 3.8 ± 2.2
nVATS: needlescopic video-assisted thoracic surgery; PSP: primary spontaneous pneumothorax.
Figure 2: A modern portable digital chest drain system complements needlescopic video-assisted thoracic surgery pleurodesis. Even with continuous suction applied, the patient can be fully mobile because the system has in-built regulated suction generation.
c onsecutive patients is summarized in Table 1. The safety of the approach is demonstrated. Chest drain durations were arbitrarily set to no less than 2 days as explained above. On average, the last tablet of oral analgesics taken by patients was at 7 days after surgery. After a median follow-up of 14 months (range 1–45 months), the recurrence rate was 3%.
DISCUSSION Conventional VATS is well established as the preferred approach for PSP surgery. Although the rate of recurrence has been suggested to be higher with VATS than with open thoracotomy [2], many would accept that the trade-off is very reasonable given the reduced morbidity associated with VATS, and few surgeons would contemplate thoracotomy for PSP nowadays. With advances in video and surgical instrument technology today, nVATS can be considered the next step of evolution in the direction towards even less invasiveness. The concept of nVATS actually emerged over a decade ago, and variations in terms of number, sizes and instrumentation of the ports have been described [18–20]. We believe that the nVATS technique described above may be the simplest to master and requires the least switching around of instruments between the ports. We acknowledge that the nVATS technique is essentially an evolution of the conventional VATS approach rather than a complete revolution: a similar basic three-port strategy is maintained, but the smaller wounds call for modification of details of the technique.
Figure 3: Photos of the same patient in the operating room immediately before and immediately after needlescopic video-assisted thoracic surgery pleurodesis. Patients typically arrived in the operating room with a chest tube in situ. That chest tube thoracostomy wound is used as the anterior port without any enlargement, and only two 3-mm stab incisions are added to give complete bleb resection and mechanical pleurodesis.
However, we feel that this gentle evolution is an advantage in that it should be consequently easier for the average VATS surgeon to learn. Data to date have shown that at least nVATS can be performed as safely as conventional VATS. However, it is still too early to say whether the nVATS approach has any significant advantage over conventional VATS. Indeed, it should always be borne in mind that, in addition to surgical access trauma, the pain following any surgery for pneumothorax may be a product of the mechanical abrasion or pleurectomy, torquing of the instruments in the intercostal spaces during surgery and the presence of the chest tube before and after surgery [6, 10]. One small study has so far shown encouraging outcomes for nVATS compared with conventional VATS [20], but it is clear that considerable experience from future studies will be necessary to clarify the issue. An alternative approach to reducing the surgical footprint compared with conventional three-port VATS is the use of Uniportal VATS [7, 14]. For PSP surgery, Uniportal VATS is certainly feasible. However, the wound created is 2–2.5 cm long, and hence greater than the sum of wound lengths when using nVATS. Again, further studies will be required to determine which offers the bigger advantage over conventional VATS.
A.D.L. Sihoe et al. / Multimedia Manual of Cardio-Thoracic Surgery
Regardless of hard clinical data of superiority, Figure 3 demonstrates the clear cosmetic appeal of nVATS. For a patient with PSP who already has a chest drain wound, nVATS allows safe, effective pleurodesis at the ‘cost’ of only two extra tiny 3-mm stab incisions. These needlescopic wounds are virtually invisible within a few weeks after surgery. In this context, it is reasonable for the patient to think ‘why not accept surgery since the largest wound (for the chest drain) has been made already’? The impact of thereby reducing the ‘intimidation’ factor of surgery for patients is hard to quantify but should not be underestimated. In the past, surgery was not recommended for first episodes of ipsilateral PSP largely because of: (i) a belief that ipsilateral recurrence rates after a first episode of PSP were low and (ii) the cost of surgery in terms of pain and morbidity was too high. However, the latest guidelines show that the ‘risk of recurrence of PSP is as high as 54% within the first 4 years’ [2, 21]. It can no longer be dismissed as low: a 20-year-old patient with PSP will have a greater than 50% chance of suffering another episode before his/her 24th birthday, and the accumulated risk can only get higher throughout the many years of his/her adult life. In this context, a very minimally invasive approach such as nVATS may represent a palatable choice for patients even on their first episode of PSP. Extrapolating this further, it has been demonstrated that future occurrences of PSP may be predicted by detection of lung blebs on imaging [22]. Although controversial today, might it be possible in future to offer very minimally invasive surgery pre-emptively to persons incidentally found to have such blebs? Conflict of interest: none declared.
REFERENCES [1] Melton LJ, Hepper NCG, Offord KP. Incidence of spontaneous pneumothorax in Olmsted County, Minnesota: 1950–1974. Am Rev Respir Dis 1987;29:1379–82. [2] MacDuff A, Arnold A, Harvey J. Management of spontaneous pneumothorax: British Thoracic Society pleural disease guideline 2010. Thorax 2010;65:ii18–31. [3] Almind M, Lange P, Viskum K. Spontaneous pneumothorax: comparison of simple drainage, talc pleurodesis and tetracycline pleurodesis. Thorax 1989;44:627–30. [4] Olsen PS, Anderson HO. Long term results after tetracycline pleurodesis in spontaneous pneumothorax. Ann Thorac Surg 1992;53:1015–17. [5] Massard G, Thomas P, Wihlm J-M. Minimally invasive management for first and recurrent pneumothorax. Ann Thorac Surg 1998;66:592–9.
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[6] Sihoe ADL, Au SS, Cheung ML, Chow IK, Chu KM, Law CY et al. Incidence of chest wall paresthesia after video-assisted thoracic surgery for primary spontaneous pneumothorax. Eur J Cardiothorac Surg 2004; 25:1054–8. [7] Ng CSH, Rocco G, Yim APC. Video-assisted thoracoscopic surgery (VATS) pleurodesis for pneumothorax. Multimed Man Cardiothorac Surg 2005; doi:10.1510/mmcts.2004.000349. [8] Sihoe ADL. The evolution of VATS lobectomy. In: Cardoso P (ed). Topics in Thoracic Surgery. Rijeka, Croatia: Intech, 2011, 181–210. [9] Sihoe ADL, Yim APC. Video-assisted pulmonary resections. In: Patterson GA, Cooper JD, Deslauriers J, Lerut AEMR, Luketich JD, Rice TW et al. (eds). Thoracic Surgery. 3rd edn. Philadelphia, USA: Elsevier, 2008, 970–88. [10] Passlick B, Born CH, Sienel W, Thetter O. Incidence of chronic pain after minimal-invasive surgery for spontaneous pneumothorax. Eur J Cardiothorac Surg 2001;19:355–9. [11] Sihoe ADL, Cheung CS, Lai HK, Lee TW, Thung KH, Yim APC. Incidence of chest wall paresthesia after needlescopic video-assisted thoracic surgery for palmar hyperhidrosis. Eur J Cardiothorac Surg 2005;27:313–9. [12] Yim APC, Sihoe ADL, Lee TW, Arifi AA. A simple maneuver to detect airleak on-table following ‘needlescopic’ VATS. J Thorac Cardiovasc Surg 2002;124:1029–30. [13] Laws D, Neville E, Duffy J. British Thoracic Society guidelines for the insertion of a chest drain. Thorax 2003;58:ii53–9. [14] Rocco G, Martin-Ucar A, Passera E. Uniportal wedge pulmonary resections. Ann Thorac Surg 2004;77:726–8. [15] Sihoe ADL, Manlulu AV, Lee TW, Thung KH, Yim APC. Pre-emptive local anesthesia for needlescopic video-assisted thoracic surgery: a randomized controlled trial. Eur J Cardiothorac Surg 2007;31:103–8. [16] Chen JS, Hsu HH, Kuo SW, Tsai PR, Chen RJ, Lee JM et al. Effects of additional minocycline pleurodesis after thoracoscopic procedures for primary spontaneous pneumothorax. Chest 2004;125:50–5. [17] Hunt I, The E, Southon R, Treasure T. Using non-steroidal anti- inflammatory drugs (NSAIDs) following pleurodesis. Interact CardioVasc Thorac Surg 2007;6:102–4. [18] Yoon YH, Kim KH, Han JY, Beak WK, Lee CS, Kim JT. Management of persistent or recurrent pneumothorax with a two-millimeter mini-videothoracoscope. J Korean Med Sci 2000;15:507–9. [19] Tagaya N, Kasama K, Suzuki N, Taketsuka S, Horie K, Kubota K. Videoassisted bullectomy using needlescopic instruments for spontaneous pneumothorax. Surg Endosc 2003;17:1486–7. [20] Chen JS, Hsu HH, Kuo SW, Tsai PR, Chen RJ, Lee JM et al. Needlescopic versus conventional video-assisted thoracoscopic surgery for primary spontaneous pneumothorax: a comparative study. Ann Thorac Surg 2003;75:1080–5. [21] Smit HJM, Chatrou M, Postmus PE. The impact of spontaneous pneumothorax, and its treatment, on the smoking behaviour of young adult smokers. Respir Med 1998;92:1132–6. [22] Sihoe ADL, Yim APC, Lee TW, Wan S, Yuen EHY, Wan IYP et al. Can CT be used to select patients with unilateral primary spontaneous pneumothorax for bilateral surgery? Chest 2000;118:380–3.
