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Eur J Cardiothorac Surg 2000;18:608-610
© 2000 Elsevier Science NL

How to do it

Bilateral open treatment of spontaneous pneumothorax: a new access

^a Department of Surgery, IRCCS San Matteo, University of Pavia, Pavia, Italy
^b Foundation A. Carrel, Pavia, Italy

Received 16 September 1999; received in revised form 24 July 2000; accepted 22 August 2000.

Corresponding author. Residenza Parco 152, 20080 Basiglio, Milano 3, Italy. Tel.: +39-0382-529118; fax: +39-0382-525853
e-mail: nazaris{at}tin.it

	Abstract

Top Abstract 1. Introduction 2. Surgical technique 3. Comment References

 
A new technique for bilateral apical bullectomy and pleurectomy via axillary minithoracotomy and transmediastinal access to the contralateral side, was used in 13 patients with bilateral apical blebs and/or pneumothorax. The contralateral space is reached at the posterior superior mediastinum, passing between the first thoracic vertebral bodies (T1–T4) and the oesophagus. The contralateral lung apex is then pulled into the thoracotomy side and apical bullectomy carried out by linear stapler. The obvious advantages of avoiding a second thoracotomy while providing complete solution to the clinical problem are particularly important in young patients with spontaneous pneumothorax caused by bilateral apical blebs.

Key Words: Pneumothorax • Pleurectomy • Blebs • Bullae

	1. Introduction

Top Abstract 1. Introduction 2. Surgical technique 3. Comment References

 
A technique for bilateral apical bullectomy and pleurectomy via axillary minithoracotomy and transmediastinal access to the contralateral side was utilized in a series of 13 patients with spontaneous pneumothorax and bilateral apical blebs.

	2. Surgical technique

Top Abstract 1. Introduction 2. Surgical technique 3. Comment References

 
Parietal pleurectomy of the upper half of the hemithorax and apical bullectomy were carried out via standard [1] third space axillary minithoracotomy (7–10 cm) on the side of the more recent pneumothorax. Brushing of the residual parietal pleura was also carried out.

At the anterior margin of the first thoracic vertebral bodies (Fig. 1) , the mediastinal pleura is sectioned and the oesophagus displaced anteriorly by blunt dissection. The contralateral lung parenchyma then becomes clearly visible underneath the contralateral mediastinal pleura. Taking care to avoid, in this phase, the opening of the contralateral pleural space, the apical parietal pleura is mobilized as much as possible by blunt dissection. The pleura is then opened widely and the apex of the left lung is drawn into the right space (Fig. 2) . The blebs of the apex can then be easily resected by stapling (roticulator@) or base ligature.

View larger version (126K): [in this window] [in a new window]   Fig. 1. Schematic representation of the upper mediastinum viewed from the right. The access to the right hemithorax is achieved through a standard third space axillary minithoracotomy. The left pleural space is reached passing between the oesophagus and the vertebral bodies from T1 to T4. At this level the lungs are separated only by the mediastinal pleurae, often in contact with each other, which can be identified on the CT scan as the posterior junction line [2] (inset).

View larger version (109K): [in this window] [in a new window]   Fig. 2. The right mediastinal pleura is sectioned along the anterior margin of the vertebral bodies and the oesophagus is displaced anteriorly by blunt dissection. The contralateral pleura is mobilised as far as possible by blunt dissection and then opened widely. The contralateral lung apex is grasped with an appropriate clamp and pulled into the right side where the bullectomy can be carried out with the linear stapler (inset) or with base ligature. The technical steps are identical from the left to the right. Pleural adhesions may occasionally prevent mobility of the contralateral lung apex; their individual exposure by means of long and narrow flat spatulas and division by electrocautery allows to the apex to be mobilised and drawn into the thoracotomy side.

	3. Comment

Top Abstract 1. Introduction 2. Surgical technique 3. Comment References

 
With this technique, contralateral transmediastinal bullectomy can be carried out through the standard axillary minithoracotomy commonly used when a single lung is treated [1]. From a technical point of view contralateral bullectomy is obviously more demanding, but achievable in full safety and good exposure. Moreover, in case of previous pneumothorax episodes, the contralateral apical parietal pleura can also be removed to an extent sufficient to achieve firm apical pleurodhesis. Care should be taken to reserve this therapeutic strategy exclusively to patients with spontaneous pneumothorax (pnx) caused by apical dystrophic blebs, excluding in particular those cases in which apical bullae are part of the picture of diffuse enphysema.

Contralateral surgical manoeuvres require very long instruments. Long spatulas may be useful for individual exposure and electrocoagulation of occasional pleural adhesions that prevent contralateral apex full mobilization. Contralateral bullectomy requires stapler with rotating head (roticulator@) or can be carried out by means of absorbable running suture.

In this patient series, reported in detail elsewhere [3], there were no complications that can be referred to the transmediastinal access to the contralateral lung; in particular no lesions occurred to the thoracic duct which lies at this level to the left side of the oesophagus.

Although videothoracoscopy approach is now the choice treatment of spontaneous pneumothorax [4] its recurrence rate was never reported to equal that of open standard surgical approach, being in the range 5–10% [5]; moreover reports on simultaneous bilateral videothoracoscopic treatment are still anecdotal [6] and the corresponding recurrence rate is lacking.

This approach may be reasonably expected to offer the virtual zero recurrence rate of standard open treatment on one side and at least that of videothoracoscopic bullectomy on the transmediastinally treated side; all this with a surgical trauma substantially similar to that of open, one side treatment.

Obviously the described technique is not intended to be a substitute for the videothoracoscopy bullectomy with parietal pleurectomy or other appropriate pleurodhesis manoeuvres [7] but rather an option to be adopted in appropriate cases. These may include cases in which recurrence after videthoracoscopic treatment would indicate an open access, as well as those cases seeking zero recurrence treatment after many pneumothorax at one side only, in which the preoperative CT scan shows clinically still silent apical blebs also at the other side.

The philosophy at the basis of this approach is the feeling that this particular patients population looks for surgery not for the pneumothorax itself, which is usually already fixed when they are referred for surgery, but for the prevention of possible (probable) future recurrences, the fear of which may condition their life style [8]; in these patients then the presence of contralateral apical blebs, documented by CT scan, of course cannot rule out the chance of future pneumothorax also on the contralateral side, even though this has not yet occurred. Thus the possibility of removing, through the same surgical wound used for one side treatment, also the contralateral blebs may be particularly appreciated by this particular patient subsetting.

In practical terms our policy has been to reserve this operation to all patients in which radical open treatment of one side was independently decided for any reasons and apical blebs (and/or previous pneumothorax) where documented also at the other side.

Whether the subaxillary surgical cicatrix plus the three drain holes is less cosmetic and/or traumatic than the three+three holes on both sides of the bilateral videothoracoscopy may be debatable; of course videothoracoscopy accomplishment also of this transmediastinal approach, theoretically hypothesizable, in combination with standard videothoracoscopy homolateral bullectomy and pleurectomy would annul this debate.

	Footnotes

 
Presented at the 13th Annual Meeting of the European Association for Cardio-thoracic Surgery, Glasgow, Scotland, UK, September 5–8, 1999 and at the 36th Annual Meeting the Society of Thoracic Surgeons, Fort Lauderdale, FL, USA, January 31, 2000.

	References

Top Abstract 1. Introduction 2. Surgical technique 3. Comment References

 

1. Deslauriers J.P., Beaulieu M., Despres J.P., Lemieux M., Leblanc J., Desmeules M. Transaxillary pleurectomy for treatment of spontaneous pneumothorax. Ann Thorac Surg 1980;30:569-574.[Abstract]
2. Heitzman E.R. The supra-azygos recess. In: Heitzman E.R., ed. The mediastinum. Berlin: Springer-Verlag, 1988:245-308.
3. Buniva P., Aluffi A., Salvi S., Mourad Z., Tommaselli S., Nazari S. Trattamento chirurgico simultaneo bilaterale del pneumotorace spontaneo giovanile. Un nuovo accesso. Bollettino Della Società Medico Chirurgica Di Pavia 1994;108:91-110.
4. Mouroux J., Elkaim D., Padovani B., Myx A., Perrin C., Rotomondo C., Chavaillon J., Blaive B., Richelme H. Video-assisted thoracoscopic treatment of spontaneous pneumothorax: technique and results of one hundred cases. J Thorac Cardiovasc Surg 1996;112:385-391.[Abstract/Free Full Text]
5. Massard G., Thomas P., Wihlm J. Minimally invasive management for first and recurrent pneumothorax. Ann Thorac Surg 1998;66:592-599.[Abstract/Free Full Text]
6. Yim A. Simultaneous vs staged bilateral video-assisted thoracoscopic surgery. Surg Endosc 1996;10:1029-1030.[Medline]
7. Maggi G., Ardissone F., Oliaro A., Ruffini E., Cianci R. Pleural abrasion in the treatment of recurrent or persistent spontaneous pneumothorax. Results of 94 consecutive cases. Int Surg 1992;77:99-101.[Medline]
8. Nazari S. Psychological implications in surgery for the pneumothorax. Ann Thorac Surg 1997;63:1830-1831.[Free Full Text]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Stefano Nazari Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Nazari, S. Articles by Salvi, S. Search for Related Content PubMed PubMed Citation Articles by Nazari, S. Articles by Salvi, S.