Thoracoscopic Treatment of Spontaneous Pneumothorax

This video will demonstrate the therchoscopic treatment of spontaneous pneumothorax, namely bleb resection and chemical pleurodesis using talc powder. The patient is an 18 year old male who had sudden onset of right chest pain and dyspnea, leading to a diagnosis of right spontaneous pneumothorax on chest X-ray. He had undergone thochoscopic treatment of a left spontaneous pneumothorax approximately 2 years earlier after failed non-operative management. A decision was therefore made to proceed directly to surgical treatment of the right side without an attempt at catheter thoracostomy. This picture shows the positioning and incision sites used for the procedure in a different patient undergoing thoracoscopic treatment of left spontaneous pneumothorax. The patient is placed in the lateral decubitus position with an axillary roll on a beanbag. Three triangulating incisions are used, 2 for 5 millimeter ports, and a third, more anterior one for direct insertion of a 12 millimeter endo GIA stapler. Talc instufflation is used for the pleurodesis while commercial preparations for throchoscopic application of talc are available, the use of a Lucans strap works quite well. The talc is placed in the trap. A portion of the tubing is cut and attached to the spout on the trap. One side is then attached to the installation tubing, and the other to one of the 5 millimeter trocars. After full examination of the lung, several blebs are identified in the lung apex. The endo GIA is applied across the apex. However, one can see that the stapler did not capture an adequate margin under the blebs on the posterior surface. The apex is therefore retracted upwards, and the stapler is applied across a more generous margin of grossly normal lung tissue. The first firing of the stapler is insufficient for completing the wedge resection. Two more firings are therefore necessary to completely remove the apical wedge. The specimen is then removed directly through the largest chest wall incision. The talc installation is then started using the setup described earlier. A pressure of 15 millimeters of mercury, and a flow of 4 L per minute is used to insufflate the tal. It is important to keep the 2nd trocar open in order to maintain a pressure differential and promote flow. The tip of the trocar can be manipulated to distribute the talc widely. Adequate distribution results when a snowstorm effect is witnessed in the thoracic cavity. It is particularly important to confirm adequate coverage of the apical, visceral, and parietal pleura with tut. A 16 French chest tube is then placed and the procedure terminated. The patient made an uneventful recovery.