[Thoracoscopic Surgery of Thoracic Surgery] 4K Ultra HD Spontaneous Pneumothorax Surgery

What is pneumothorax

The pleural cavity is a gas-free, airtight space surrounded by the visceral pleura and the parietal pleura. The visceral pleura is close to the lungs, and the parietal pleura is close to the chest wall. There are two pleural cavities on the left and right, which are airtight to each other. There is only a small amount of serous fluid in them, which reduces friction during breathing and plays a role in lubrication. The negative pressure in the pleural cavity is lower than atmospheric pressure. Pneumothorax means that the pleura ruptures and air enters the pleural cavity, causing pneumothorax. The direct consequence of pneumatosis in the pleural cavity is compression of the lungs, causing the lungs to be unable to "work" normally.

Normally there is no air in the pleural cavity. They are divided into two categories according to their causes:

1. Primary spontaneous pneumothorax: It is caused by the sudden spontaneous rupture of lung tissue and visceral pleura, causing pneumothorax. It prefers thin and tall male young adults. The main reason is that boys with tall and thin bodies grow faster during development, the elastic fibers of the alveoli are underdeveloped, and the elasticity of the alveoli is relatively poor and easy to rupture. Tall and thin boys should pay attention to their intensity when performing physical exercise and strenuous activities. If they develop chest pain and difficulty breathing after severe coughing or excessive exertion, they should be alert to the possibility of spontaneous pneumothorax, especially if a spontaneous pneumothorax has already occurred. Yes, the possibility of recurrence is still relatively high, so you should go to the hospital for medical treatment in time.

2. Secondary spontaneous pneumothorax: pneumothorax caused by bronchial and pulmonary diseases, such as tuberculosis, chronic obstructive pulmonary disease, emphysema, pneumoconiosis, etc.; without appropriate protective measures in aviation and diving operations, sudden Pneumothorax can occur when a high-pressure environment enters a low-pressure environment, or when the ventilation pressure of a ventilator is too high.

Clinical manifestations

Pneumothorax can be divided into:

1. Small pneumothorax (lung collapse within 30%): The patient has no obvious symptoms of respiratory and circulatory dysfunction.

2. Moderate pneumothorax (30% to 50% lung collapse): Symptoms of chest tightness, chest pain, and tightness of breath after activity may occur, but most young people only have chest tightness symptoms.

3. Massive pneumothorax (more than 50% lung collapse): the thorax on the affected side is full; respiratory movement weakens or disappears, tympanic sound is heard on percussion, and the patient has obvious symptoms of dyspnea and irritability. In severe cases, cyanosis and even shock may occur.

We must diagnose it quickly and treat it correctly, otherwise it will cause lung atrophy and mediastinal compression shift, acute progressive respiratory disease, circulatory failure and even death.

What are the treatments for spontaneous pneumothorax?

1. Symptomatic treatment: Strict bed rest, sedation, analgesia and other drugs as appropriate, pay attention to monitoring the condition, high-concentration oxygen inhalation can speed up the absorption of air in the chest, and pay attention to the treatment of basic lung diseases.

2. Patients with moderate or large pneumothorax can be cured by non-surgical treatments such as thoracentesis and closed chest drainage.

3. Surgical treatment: Surgical treatment should be given to patients with recurrent spontaneous pneumothorax, persistent pneumothorax air leakage, and obvious lung bullae. At present, 4k ultra-high-definition thoracoscopy surgery is the main method, and the commonly used surgical method is lung surgery. Bullectomy + pleurodesis. This type of surgery has high safety and success rate, accurate curative effect, and low postoperative recurrence rate.

4. Diagnosis:

1. Chest X-ray

Chest X-ray is the fastest and most reliable diagnostic tool. Bullae may resemble pneumothorax. However, the separation between lung tissue and air is usually convex in the atmosphere and concave in a pneumothorax.

2. CT scan

Bullae

CT scan should not be considered a routine diagnostic step but an optional tool to differentiate airway from pneumothorax. Detection of contralateral bullae is particularly useful.

General Purpose has 3 goals:

1. Lung re-expansion: This can only be done through chest tube drainage, followed by suction therapy within a few days, with a negative pressure of about -20 cm H2O.

2. Leak repair: Surgery is usually required, including suturing, stitching or adhesion of parenchymal leaks.

3. Prevention of recurrence: involves different techniques whose aim is to eliminate the pleural space by creating adhesions between the splanchnic pleura and the chest wall. This pleurodesis can be performed surgically (abrasion, pleurectomy), thermally (cautery, laser) or pharmaceutically (instillation of antibiotics, talc, blood into the pleural space).

VATS conditions

Primary spontaneous pneumothorax: Whether primary spontaneous pneumothorax occurs for the first time after video-assisted thoracoscopic surgery (VATS) is still debated. The observed reduction in recurrence after VATS favors surgery. The cost (anesthesia, surgery, hospital stay) and the fact that simple drainage treats 50% of patients are harmful to VATS.

After 10 years of experience with VATS, we believe that the technique is safe for a skilled thoracoscopic group (Hurtgen et al., 1996). Thoracoscopy allows for extensive surgery and is often faster than open surgery. Adhesions, such as along the phrenic nerve or along the subclavian vessels, may require conversion to thoracotomy.

Secondary pneumothorax: requires the same prerequisites as thoracoscopic surgery. VATS can be performed by a skilled surgeon. Those with less experience in VATS prefer thoracoscopic surgery for secondary pneumothorax, especially when emphysema is present and the lung tissue is fragile. In these patients, the underlying obstructive pulmonary disease must first be treated. In all cases, conversion to thoracotomy cannot be excluded.

Clinical manifestations

Indications

All cases of first recurrence of primary pneumothorax;

In all cases of secondary pneumothorax recurrence, the patient can receive split-valve ventilation as long as the surgeon has sufficient experience in VATS.

Relatively taboo

Recurrence of primary pneumothorax after surgery,

Past history of ipsilateral pleural disease.

Anesthesia and ventilation

All elective thoracoscopic surgeries were performed under general anesthesia with a double-lumen tube for individual ventilation of the lung lobes.

By correct positioning of the endotracheal tube at the beginning of the procedure, a pre-existing pneumothorax is accomplished through passive pressure compensation between the external air and the pleural space, thus freeing the surgical site. If the lungs are not completely deflated, endobronchial suction or bronchodilator drugs may be given. Intrapleural air insufflation is not necessary. As an alternative to dual-lumen intubation, bronchoscopically positioned individual bronchial blockers can be used for one-lung ventilation.

It is important to partially inflate the lung during the intervention to detect any bullous disease on the surface of the collapsed lung.

Operating room settings

Patient

General anesthesia;

Double-lumen endobronchial intubation;

Lateral view (for standard posterolateral thoracotomy);

The ipsilateral arm is placed horizontally to maintain the extrathoracic working space for the instrument.

Team

1. The surgeon stands in front of the patient.

2. The assistant is next to the surgeon.

3. Place the scrub nurse next to the surgeon.

4. The anesthetist places the patient's head.

Equipment

thoracoscopic equipment

2. Anesthesia unit

3. Operating table

4. Instrument table

Trocar puncture

Optical needle: paravertebral, maximum distance from the anterior cannula;

Instrument cannula: third and ninth intercostal spaces in the anterior axillary line.

The trocar size should be appropriate for the diameter of the thoracoscope (10 mm or 7 mm) and the instrument used. We recommend using a 7-mm thoracoscope because the 7-mm cannula is less invasive to the paravertebral space.

Some surgeons prefer only 2 incisions to insert 2 instruments through a larger trocar. This technique may be adequate for simple intrathoracic maneuvers such as wedge resections. It is not suitable for difficult intrathoracic maneuvers due to the disadvantage of having two instruments on the same trocar that may interfere with each other.

Surgical Instruments

The solid chest wall greatly limits the maneuverability of instruments in the thoracic space. Therefore, greater requirements are placed on thoracic instrumentation than the tools used in standard laparoscopic surgery. At angles greater than 45°, strong friction within the casing hinders instrument movement. More freedom of movement within the chest can be achieved with angled or curved instruments and expanding the intrathoracic working space to the chest dome and diaphragm.

Flexible casing without valves is necessary.

Other instruments

Electric Surgical Unit

Monopolar and bipolar cutting and coagulating tips or endoscopic scissors are ideal for thoracoscopic pneumothorax surgery. Water irrigation during bullous cautery prevents carbonization and thus avoids iatrogenic gas leakage.

Nd:YAG laser

In thoracoscopic surgery, the thermal Nd:YAG laser has the advantage of being versatile in applications including cyst coagulation hemostasis or bullectomy compared with Nd lasers.

Argon ion beam

High frequency electrode

2. Argon gas flow

3. Organization

The argon arc beam is particularly useful for hemostasis in extensive areas of effusion after pleurectomy. The occurrence of pleurodesis is not easy due to the application of the beam to the parietal pleura. However, a large coagulated area on the pleura does not appear to be advantageous if HF-argon pleurodesis is performed (disruption of blood vessels may reduce fibrin supply). Therefore, it is recommended to coagulate only the stripes of the pleura, as this ensures the expression of fibrin in the pleural space.

Intrathoracic application of an argon beam is safe if pressure compensation between the thoracic cavity and the external air is ensured through an open trocar.

Endoscopic cutter

The endoscopic stapler used was specifically designed for thoracoscopic resection of lung parenchyma. They ensure safe closure of the tissue along the resection. There are four sizes of inner barrel utensils (30/35/45/60 mm). The 60mm stapler, due to its larger size, does not always provide free movement within the chest cavity, especially in a bra. New flexible staplers cannot compensate for this shortcoming.

Examine

The first indispensable surgical step is the complete release of adhesions. Only in this way can the examination be complete, ensuring that the dorsal part of the lungs, mediastinum and diaphragm are included. During the examination, gentle air insufflation helps to make the collapse of the lung surface grossly visible. For example, invisible bullae on an adherent parenchymal base are often clearly identified as the cause of pneumothorax and must be excised. Often found to be the result of previous pleurodesis or chest drainage. They are less vascular and less marked in recurrence than the above-mentioned adhesions. It must be dissected to allow for a thorough examination and to avoid some accumulation of fluid.

Excision

Small blisters

A single bulla with a small parenchymal base was excised using 2 inner rings combined with additional sutures to prevent them from sliding during lung inflation. Ligation can be controlled visually while the lungs are being re-inflated at the end of the procedure.

Large blisters

Endoscopic staplers with a broad parenchymal base or a large resection area for bullous bullae.

Lung tissue can be easily guided into an intraparenchymal clip, which must be inserted opposite the stapler. Guide the stapler both medially and laterally, and the position where the needle receives the stapler must be as low as possible as far back as possible. When using only 2 trocars, the stapler and clamp work parallel to each other, making insertion of the substance between the jaws of the stapler more difficult.

wedge resection

If there is no bleb or air leak, the approach of choice is apical wedge resection combined with partial pleurectomy.

Alternative technology

As an alternative to bullectomy, laser or bipolar electrocautery has proven to be particularly effective, particularly in patients with multiple subpleural bullae. Cauterization of the walls of bullae during water lavage helps prevent postoperative air leakage, which can be charred.

Pleurodesis

Repair of the actual air leak after additional pleurodesis may reduce the risk of recurrence by immobilizing the lung and chest wall. If weakness of the lung parenchyma subsequently occurs, this prevents the penetration of air from the lungs into the pleural space.

The pathophysiological principle of lung wall and chest wall adhesions is the secretion of autologous fibrin from the chest wall into the pleural space. Different technical solutions have been designed for this purpose (Hurtgen et al., 1996; Van den Brande and Staelens, 1989; Wakabayashi, 1989; Inderbitzi et al., 1993).

Partial or total pleurectomy is considered the safest technique for pleurodesis. The parietal pleura can be separated very delicately from the thoracic fascia within the avascular layer of reduced visual field. To initiate pleurectomy, digital detachment of the pleura can be performed before inserting the instrument cannula into the extrapleural space. VATS can control blunt dissection with different instruments. The pleurectomy is performed between the first and fifth ribs, assisting along the internal thoracic artery and following the sympathetic nerve down the paravertebral column.

With mechanical pleurodesis (pleural abrasion), we roughen the pleura with a dissecting swab until petechiae appear.

For thermal pleurodesis, electrocautery can be used along with argon beam technology or laser. The aim is to induce thermal damage to the parietal pleura, which then causes fibrin secretion.

Talc has been used in chemical pleurodesis for decades with high efficacy. It causes tight adhesions between the parietal wall and visceral pleura, making surgery difficult. Therefore, its use in younger patients is controversial. When administering talc (approximately 5 g), use a nebulizer to distribute it as a thin layer over the lung or parietal pleura.

Program ends

Reexpansion under visual control;

Chest tubes: There are usually 2 chest tubes (Ch 28) passed through the underarm incision and placed under visual control. At least one chest tube should terminate in the chest dome to achieve complete re-expansion with suction of -20 cm H2O;

The trocar wound is closed.

Thoracotomy conversion

Conversion to thoracotomy is not a complication in itself. Intraoperative complications may be necessary when endoscopic techniques are unable to achieve the same results as open surgery, such as when wide resection or extensive suturing is required, or when there is concern that some injury may be overlooked or required by palpation.

Postoperative period

chest tube

When there is no more air leakage, the suctioning is stopped and there are no postoperative complications. The chest tube can be removed 2 to 4 days after the operation. The chest X-ray shows complete lung re-expansion and no pleural effusion. Methods of handling chest drainage vary from hospital to hospital, based on the surgeon's experience.

The mid-term postoperative drainage time for idiopathic pneumothorax is 4 days after VATS surgery and 6.5 days after thoracotomy. However, for secondary pneumothorax, the difference between thoracotomy and thoracoscopic surgery was not significant. In these cases, longer drainage periods are associated with lack of access but with prolonged air leaks from the emphysema lung parenchyma.

Painkiller

Reducing postoperative pain and shortening the voiding period are the main quality criteria for minimally invasive procedures. In our protocol, patients receive analgesics regularly during drainage. Initial postoperative oral analgesics may be sufficient. However, IV treatments or epidural catheters can be more painful. It is important to eliminate pain so that the patient can be mobilized immediately after surgery. In some patients, pain relievers may be needed for several weeks after surgery.

Postoperative course

In more than 80% of patients, lung function returns to normal values, including forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) 6 weeks after surgery. In the remaining patients, moderately restrictive lung function with an FEV1 value of approximately 75% of normal can be found.

Based on our own experience, the overall recurrence rate after VATS pneumothorax treatment ranges from 3% to 8%, which is similar to data in the literature (Mouroux et al., 1996).

Complications

die

The mortality rate of VATS pneumothorax treatment in patients with primary spontaneous pneumothorax should be zero. Patients with secondary pneumothorax are typically older patients with severe emphysema and chronic obstructive pulmonary disease. Therefore, depending on the severity of the underlying disease, postoperative death may occur.

Bleeding

Severe bleeding from the intrathoracic intercostal arteries is rare but possible. It can be controlled, by VATS or by conversion, depending on the surgeon's experience. Diffuse postoperative bleeding should occur more frequently in patients undergoing surgery than in patients who did not undergo pleurodesis (Naunheim et al., 1995).

Casing damage

Trocar injury can be avoided by dissecting the trocar channel with digitally controlled scissors and using only blunt-tipped trocars.

The overall complication rate can be estimated at 5% to 8%, which is no higher than thoracotomy.

In conclusion

Recurrence rates after VATS are comparable to those after conventional thoracic surgery. Important advantages of VATS include accelerated recovery and reduced surgical trauma.

Experience shows that 4K ultra-high definition thoracoscopy provides a better understanding of the chest cavity, especially in the upper and lower parts of the chest, than open surgery. The magnifying effect of thoracoscopy allows more precise separation of the pleura from the intrathoracic fascia (Naunheim et al., 1995).

However, extensive experience is necessary to reduce the complication rate below that of thoracotomy. For example, postoperative bleeding is often caused by video miscalculation of chest wall hemostasis after pleurectomy. Compared with thoracotomy, video thoracoscopy is more difficult to inspect the total lung surface, especially intraoperative ventilation when detecting air leaks or bullae.