Interact CardioVasc Thorac Surg 2008;7:352-354. doi:10.1510/icvts.2007.165217
© 2008 European Association of Cardio-Thoracic Surgery
Case report - Thoracic general |
Thoracoscopic apico-posterior transmediastinal approach for bilateral spontaneous pneumothorax
Deog Gon Cho*,
Kyu Do Cho,
Chul Ung Kang and
Min Seop Jo
Department of Thoracic and Cardiovascular Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea 93-6, Ji-dong Paldal-gu, Suwon, Gyeonggi-do, 442-723, South Korea
Received 17 August 2007;
received in revised form 30 October 2007;
accepted 6 December 2007
*Corresponding author. Tel.: +82-31-249-7200; fax: +82-31-251-1755.
E-mail address: cscho{at}catholic.ac.kr; ebstein8{at}hitel.net (D.G. Cho).
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Abstract
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Thoracotomic, trans-sternal or thoracoscopic approaches through transmediastinal access for contralateral lung are operative alternatives for bilateral pulmonary lesions. Video-assisted thoracoscopic surgery (VATS) for spontaneous pneumothorax (PTX) is now considered as a standard approach. Herein, we report a novel method of apico-posterior transmediastinal ipsilateral approach using VATS to perform simultaneous bilateral bullectomy in two young men with simultaneous bilateral spontaneous PTX. This new VATS access is technically feasible and may mitigate postoperative pain and avoid a secondary thoracic incision.
Key Words: Mediastinum; Pneumothorax; Thoracoscopy/VATS
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1. Introduction
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Bilateral bullectomy (BB) through thoracotomy or video-assisted thoracoscopic surgery (VATS) has been a mainstay of definitive treatment to prevent recurrence in patients with bilateral spontaneous pneumothorax (BPTX). Recently, transmediastinal approaches for BB have been performed by a posterolateral or axillary thoracotomy either anteriorly or posteriorly [1–3]. Also, an ipsilateral approach through anterior transmediastinal access to the contralateral lung using VATS was introduced to perform BB and pleurodesis [4]. We report a newly modified technique for BB via VATS and apico-posterior transmediastinal access to the contralateral thoracic cavity in two patients with simultaneous BPTX.
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2. Case report
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Two male patients of 16- and 18-year-old were admitted with simultaneously developed BPTX on 1st attack (case 1), and the first episode of right PTX with a previous history of left PTX four months ago (case 2). In case 1, the chest X-ray showed partial lung collapse developed in both lungs (Fig. 1a). First of all, a chest tube was inserted in the right pleural cavity and then a subclavian venous catheter (7 Fr) was inserted into the left thorax. Thin sectioned high resonance computed tomography (HRCT) scan demonstrated several blebs located at the apex of both upper lobes (Fig. 1b). In case 2, the patient did not undergo closed tube drainage (CTD) because of minimal collapse of the lung (Fig. 1c), and HRCT scan showed large blebs at the apex of both lungs (Fig. 1d). The patients were informed about our surgical method and its benefits or risks. The right thoracoscopic approach was used during one-lung ventilation with double-lumen endotracheal tube (Mallinckrodt Medical, Athlone, Ireland). The first thoracoport for the 5 mm, 0-degree thoracoscope was placed at the 6th intercostal space (IC) on the middle axillary line. Two other thoracoports (5 mm, 12 mm sized) were inserted at the 3rd and 4th IC on the posterior and anterior axillary line for other instruments. In case 2, a 2 mm thoracoport for a grasper was additionally needed. Right bullectomy was easily performed and then the left pleural cavity was reached passing the apico-posterior mediastinal region between the esophagus and the vertebral bodies (T1–T4). We modified the open technique that was described in detail by Nazari et al. [1]. At first, the right sided mediastinal pleura and surrounding tissue was carefully dissected by endo-dissector or Harmonic curved shear (Ethicon Endo-Surgery, Cincinnati, OH) and the esophagus displaced anteriorly. The contralateral pleura was widely opened on the level from the apex of the thoracic cavity to the bifurcation of highest intercostal and azygos vein avoiding injury to the thoracic duct (Fig. 2a). The apical bleb of the left lung was carefully identified and excised by two 35 mm flexible endo-staplers (ETS-Flex 35, Ethicon Endo-Surgery, Cincinnati, OH) controlling one-lung ventilation (Fig. 2b,c). The right CTD and left silastic tube drain (Evacuator Barovac®, Sewoon Medical, Seoul, Korea) were placed (Fig. 2d). We did not perform any type of pleurodesis due to meticulous resection of blebs which were precisely confirmed by thin sectioned HRCT. There were no postoperative complications. Operation time was 120 and 65 min, respectively. Both drains were removed at postoperative day (POD) 1 and 2 in case 1, and at POD 2 and 3 in case 2, respectively. There was no recurrence during the follow up period in each case (12 and 4 months).
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Fig. 1. (a) Chest X-ray shows simultaneously developed partial lung collapse in both lungs of case 1. (b) Coronal view of high resonance computed tomography (HRCT) demonstrates single large bleb at the apex of left lung. (c) Bilateral minimal lung collapse in case 2. (d) HRCT reveals large blebs at the apex of both lungs.
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Fig. 2. (a) Opened contralateral mediastinal pleura between vertebrae (v) and esophagus (e) including thoracic duct (arrow). (b) Apical bleb of the left lung through transmediastinal access. (c) Excision of the bleb using flexible endo-stapler. (d) Placement of drainage catheters.
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3. Discussion
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The appropriate surgical approach for bilateral lung lesions is clinically important and still challenging. Several data reported that single-stage bilateral VATS for BB were safe and reliable for selected patients with BPTX [5, 6]. Also, transmediastinal contralateral approach may be a good therapeutic option in selected cases of BPTX [1, 4]. Theoretically, this transmediastinal approach may decrease operation time and operative morbidity, have a cosmetic advantage, and be reasonably expected to prevent possible future recurrence [1, 3]. Nazari et al. reported a new technique for BB and pleurectomy via axillary minithoracotomy and apico-posterior transmediastinal access to the contralateral side in selected 13 BPTX patients [1]. They advocated that this approach might be offered the virtual zero recurrence rates compared with bilateral VATS, but that the thoracotomic wound with the drain holes is less traumatic than the bilateral VATS wound may be debatable. Therefore, our new modified technique using the one-sided VATS may provide the solution of this debate in selected patients of BPTX. Namely, this access may mitigate postoperative morbidity (e.g. pain) and avoid a secondary thoracic incision. Based on reported literatures, we tried to perform this approach with the one-sided VATS, even though it is technically more demanding than with minithoracotomy. Although the approach is easily accessible by a well-trained thoracoscopic surgeon, several controversies remain: limited exposure of contralateral thoracic cavity through narrow access space; potential injury of surrounding mediastinal structures; anesthetic difficulties; and need for development of newly designed thoracoscopic instruments. In fact, right now we cannot exactly verify whether this procedure is hazardous or not because of our few experiences. However this new technique is challenging, and may be carefully performed once an experienced surgeon is sufficiently aware of exact surgical anatomy and potential complications. Also, this procedure is expected to be one of the reliable methods for bilateral thoracic procedures in highly selected cases. This procedure absolutely needs the adequate examination of the bleb using thin sectioned (<2 mm thickness) and multi-directional (axial, coronal and sagittal section) HRCT in the whole lung. According to the advancement of spiral CT scan (over 64 channels), we can precisely evaluate the characteristics of bleb or bulla (location, size, number etc.) in the apex of the lung or even in posterior or basal regions that we could not reach through the new access. We advocate that highly selective patients of BPTX may be indicated, who have fully examined localized left apical blebs by HRCT, without pleural adhesion or previous thoracotomy. However, long-term follow-up, corrective or comparative studies are needed to clarify the role of this new procedure. In conclusion, although this new VATS access for BPTX may not be widely advertised or adopted due to several controversies so far, it is technically feasible as one of the minimally invasive surgical options.
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References
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Abstract
1. Introduction