The adequacy of single-incisional thoracoscopic surgery as a first-line endoscopic approach for the management of recurrent primary spontaneous pneumothorax: a retrospective study
© Chen et al.; licensee BioMed Central Ltd. 2012
Received: 10 March 2012
Accepted: 22 September 2012
Published: 29 September 2012
Thoracoscopic surgery is a commonly used endoscopic surgical treatment approach in patients with primary spontaneous pneumothorax. The conventional thoracoscopic approach utilizes three or more small wounds for surgery. Currently, a single port approach is a potential alternative procedure in general thoracoscopic surgery. We investigated whether a single-port approach is suitable as a first-line endoscopic approach for all patients with primary spontaneous pneumothorax requiring surgery.
From July 1st, 2008 to Dec 31, 2009, a total of 62 patients was included in this study. All the patients were admitted to our ward because they had surgical indications for surgery. Twenty-six patients underwent conventional three-port thoracoscopic surgery and thirty-six underwent single-port thoracoscopic surgery. All of the clinical data were analyzed retrospectively. Variables were compared and analyzed to determine the outcomes of the different surgical approaches.
The mean age of the 62 patients was 27.2 years. Forty-nine patients were men and thirteen patients were women. The mean time required for the operation was 61.6 minutes. There was one patient who had a recurrence in single-port group and 2 patients had a recurrence in three-port group during the period of follow-up. The average pain scores at 24 and 48 hrs after the operation were similar, but the pain scores at 72 hrs in the single-port group were better than the three-port group. There was no case that required conversion from a single-port to multiple wound approach in this study. There was no immediate postoperative recurrence. The follow-up duration was greater than 12 months.
This study showed that single-port thoracoscopic surgery is a feasible and reasonable first-line endoscopic approach in the surgical treatment of primary spontaneous pneumothorax.
Thoracoscopic surgery has long been employed as a treatment option for primary spontaneous pneumothorax. Conventional thoracoscopic surgery usually requires multiple small wounds for the purposes of dissection, resection, grasping and the scope itself. In the management of spontaneous pneumothorax, thoracic surgeons commonly utilize three port wounds to complete the procedure. One port wound is for the thorascope itself, another small wound is for any endoscopic grasping instrument that is needed to search for and hold the abnormal lung to be resected and a third small wound is for a stapling, clipping or electrical cauterization. Currently, thoracoscopic surgery can be accomplished through single incision in a variety of common and uncomplicated diseases in the chest[1–5]. However, this technique has not been routinely as a first-line endoscopic approach in most institutions. The purpose of this retrospective study is to evaluate the adequacy of single-incisional thoracoscopic surgery as a first-line endoscopic approach for the surgical treatment of primary spontaneous pneumothorax.
From July 1st, 2008 to Dec 31, 2009, a total of 62 patients was included in this study. All of them had the diagnosis of primary spontaneous pneumothorax. There were 49 men and 13 women, and the study period was 18 months. All of the operations were performed by a single thoracic surgeon. In the initial 8 months, conventional three-port thoracoscopic techniques were used in 26 patients. In the following 10 months, a single-port approach was used for the remaining 36 patients. The change at that time was due to modifications in the surgical techniques employed. Therefore, the study population was not assigned randomly. After the initial successful application of this procedure, it was used in consecutive 36 patients.
The visual analogue pain score was recorded 24 hours, 48 hours and 72 hours after the operation. All patients were followed in the outpatient department for at least one year. The indications, side of the pneumothorax, hospital stay, operative time, recurrence and clinical variables were recorded for comparison.
We used SPSS 13.0 for comparison of the clinical variables in the two groups. The Chi-square test and Student t-test were used to compare the means of the category and continuous variables. A p-value of less than 0.05 was considered significant.
The clinical variables and outcome after single-port and three-port thoracoscopic surgery
prolonged air leak
VAS for pain
Immediate postoperative recurrence did not occur in any patient. However, postoperative recurrence of pneumothorax occurred in three patients during the course of follow-up, including one patient in the single-port group and two patients in the three-port group. The patient with recurrence in the single-port group was treated with observation alone because the extent of pneumothorax was minimal in the apex and he remained asymptomatic. Among the two patients with postoperative recurrence in the three-port group, one patient was treated with surgery again because of a prolonged air leak and inadequate lung expansion after tube thoracostomy. One was treated with bedside tube thoracostomy with subsequent chemical pleurodesis. The agent for chemical pleurodesis was Minocycline, 400 mg, for 3 consecutive periods. There were no deaths during the time of follow-up. The average visual analogue pain scores were 4.2 at 24-hours, 3.4 at 48-hours and 2.7 at 72-hours.
In the single-port group, there were 27 men and 9 women, while the three-port group, there were 22 men and 4 women. There was no significant difference (p < 0.36). The mean age in the single-port group did not differ from that in the three-port (29.1 vs 24.5 years.; p value is 0.14) The operative time in the single-port group was slightly shorter than that in three-port group, but did not reach statistical significance (59.3 minutes vs 63.5 minutes, p value is 0.30). The ICU stays of the two groups were quite similar, although not significant. (0.56 days vs 0.44 days, p < 0.1) The hospital stay in the single-port group was 4.1 days, which is significantly shorter than the 6.2 days in the three-port group. (p <0.001) The complication rate in the three-port group was slightly greater than in the single-port group, but did not reach the level of statistical significance (p < 0.07). The visual analogue pain scores at 24 hours and 48 hours were similar. However, the pain score at 72 hours in the single-port group was 2.5, significantly lower than the score of 2.9 in the three-port group (p < 0.008).
Thoracoscopic surgery has been developed over a period of many years and became a surgical treatment for primary spontaneous pneumothorax. The most popular approaches include the making of three port wounds for wedge resection and pleurodesis. In recent years, thoracoscopic procedures have been carried out with a single small wound. Uni-port, single-port and single-incisional thoracoscopic surgery have all suggested that there are a number of procedures that can be performed using only a single small wound. Currently, from primary spontensous pneumothorax to lung cancer resection, thoracoscopic surgery using single-port approach has been shown to be feasible[2, 4–7]. Taking advantage of the various modifications endoscopic techniques, we can now perform nearly all such procedures without the need of either curved instruments or additional port wounds. However, there is no report on the adequacy of single-port thoracoscopic surgery as a first-line thoracoscopic approach. We thus evaluated the role of such technique as a first-line approach in our study.
The pain scores were similar in the first 48 hours after the operation. At 72 hours after the operation, the average pain scores in the single-port group were better than the three-port group (p < 0.008) The results may be attributed in part to the smaller number of wounds. No patient required an epidural or intravenous patient-controlled anesthetics. We injected Marcaine for intercostal block in all cases.
It has been anticipated that, in the case of failure, more port wounds would be introduced. In the study period, however, additional wounds were not required. Our confidence developed that the procedure can indeed serve as a first-line approach for thoracoscopic surgery in the management of primary spontaneous pneumothorax. Both experience and technical modifications are mandatory to safely perform these procedures.
One of the two patients with postoperative recurrence in the three-port group was treated by endoscopic surgery again 6 months after the first operation. The apparently greater likelihood of higher recurrence rate in the three-port group than the single-port group may reflect the difference of the follow-up period. The mean follow-up period was 30.5 months in the three-port group and 16.3 months in the single-port group. If the follow-up period similar, the difference between the two procedures may turn out to be smaller.
The minimum effective wound size was 1.5 cm in most of these patients. Due to the pliancy of the lung tissues, the wound can be very small[4, 5]. Currently, the wound size depends on the overall size of the three instruments, including a 10-mm stapler, a 5-mm endoscope and a 5-mm grasp, as shown in Figure1B. If the instruments and the endoscope were smaller, the effective wound size be further decreased[4, 8]. The use of multiple rigid trocars, as described by Chen would necessarily result in a larger wound.
To the best of our knowledge, this is a first study of single-port thoracoscopic surgery as a first line management of primary spontaneous pneumothorax. This study support the adequacy of the single-port procedure as a first-line endoscopic approach for surgical treatment of primary spontaneous pneumothorax.
Single-port thoracoscopic approach for primary spontaneous pneumothorax is effective. At the very least, this is a reasonable alternative approach to conventional three-port techniques. Long-term follow-up will be required to confirm the efficacy, safety, cosmetic results and the ultimate patient outcome.
Written informed consent was obtained from the patient for publication of this report and any accompanying images.
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