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.
In this study, the first 26 patients were treated with conventional three-port thoracoscopic surgery. The port wounds enable the use of a grasping endoscopic instrument by means of an endoscope (usually 10.5 mm, zero degree) and also a linear stapler.(Figure2A and B) Instruments introduced from different angles are very helpful in the creation of a three-dimensional working environment. Subsequently, we shifted this procedure to single-port approach. Initially we found the procedure difficult to be pferformed with a 15-mm wound. We used a 5-mm endoscope with 30 degrees. As a result, we were able to obtain a better field-of-view from slightly different angles (Figure1B). However, after confirming the location of the abnormal lung(Figure3A, green arrow), it was very difficult to keep the endoscopic view stable when a third instrument, usually a linear stapler, placed into the pleural space through the same wound, as in Figure1B. With repeated adjustments of the endoscopic view and proper arrangement of the instruments, the lesion site (could be) was eventually seen clearly and then a wedge resection could be performed with a stapler (Figure3B). The instruments have the potential to become crossed due to restriction imposed by a tiny wound (Figure3C). Thus, sometimes an endoscopic scissors was used to cut the specimen (Figure3D). After wedge resection, abrasion pleurodesis was performed using a linear, long endoscopic grasping device and a long, curved clamp together with a small cleansing pad (Figure4A and B). The abnormal lung was completely resected and removed from the tiny wound (Figure4C and D). During the procedure, we did not utilize any instruments that were not used in the conventional three-port approach. With simple modifications of the technique, thoracoscopic surgery was thus shifted to single-port surgery. In the following consecutive cases, there was no conversion from single-port to multiple port wounds required. Even in those patients with complex or heavy neovascularization (Figure5A), as well as active bleeding (Figure5B, the green arrow), the procedures of clipping and hemostasis were performed safely, even with such a tiny wound (Figure6A and B).
The operative time required for the single-port approach did not substantially differ from that required for the three-port approach. However, based on our experience, the time period was fairly long when we first began this approach. Later, the speed of the procedure accelerated quickly as it was learned how to position the endoscope and the arrangement of the instruments, in addition to the assistant becoming adequately skilled. In recent uncomplicated cases, the operative time has typically been less than 35 minutes (from skin incision to closure of skin wound). It is clear that the time required for this approach decreased significantly with time (Figure7).
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[2].
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.