Joined: 05 Feb 2006
|Posted: Sun Feb 05, 2006 8:41 pm Post subject: Surgical strategies
|There are two objectives in the surgical management of a pneumothorax. The first widely accepted objective is resection of blebs or the suture of apical perforations to treat the underlying defect. The second objective is to create a pleural symphysis to prevent recurrences.
Method of entry :
- Open thoracotomy
Traditional surgical approaches have utilized a single large incision (cut) that is placed between the patient's ribs. The incision can be of varying lengths which allows the surgeon to have a wider field in which to operate for certain procedures. Often the thoracotomy approach is further described as posterolateral, which is an incision on the chest side and slightly more towards the back. It is usually in the area of the 5th or 6th rib. The anterolateral approach indicates the chest wall incision is more towards the front and side of the chest. The ribs are then spread apart, allowing the surgeon to look directly into the patient's chest. The surgery is then performed via this single large opening. These incisions are known as thoracotomies, and while very safe, are uncomfortable.
Click to of thoracotomy scar.
- Video assisted thoracoscopic surgery (VATS) / Thoracoscopy
Operative techniques have tended towards minimally invasive procedures over the last few years. Video Assisted Thoracoscopic Surgery, often referred to as VATS, is performed using a small video camera that is introduced into the patient's chest via a scope. With the video camera, the surgeon is able to view the anatomy along with other surgical instruments that are introduced into the chest via small incisions or "ports".
By utilizing VATS, a large incision is avoided, thereby sparing the patient some of the post-operative pain and assisting them with a potentially quicker recovery.
the impression that VATS is superior to open procedures in terms of morbidity and time in hospital may not be wholly correct. Minimally invasive surgery may have a complication rate similar to open procedures at about 8–10%.
Click to of a VATS procedure.
- Transaxillary minithoracotomy
Becker and Munro pioneered this technique in the 1970s. The procedure is considered a minimally invasive procedure. The incision in the axillary margin measures 5–6 cm. Apical pleurectomy or abrasion may be performed and the apex carefully inspected for pleural blebs or bullae which may be stapled. The largest series examining this technique reported a mean hospital stay of 6 days.
Removal of bullae (blebs):
After entry using one of the above mentioned procedures, the whole lung surface, particularly at the apex and the lung edges, are carefully searched for blebs/bullae. Apical Wedge resection/segmentectomy may be necessary to remove the diseased/damaged lung tissue. This is then followed by stapling or suturing to seal the affected area's (fibrin sealant or a staple line buttress such as "Peri-Strips" may be used to reduce chance of post op leak).
Means of adhesion :
In 1941 Tyson and Crandall described pleural abrasion as a treatment for pneumothorax and in 1956 Gaensler introduced parietal pleurectomy for recurrent pneumothorax. This procedure produces uniform adhesions between the pleura and the chest wall. Both of these techniques are designed to obliterate the pleural space by creating symphysis between the two pleural layers or between the visceral pleura and subpleural plane, in the case of parietal pleurectomy. In order to prevent recurrence, however, an appropriate closure at the site of the pleural air leak is essential either by cauterisation, ligation, or suture of accompanying blebs.
pleurodesis induces intrathoracic inflammation that causes the lung to fuse to the thoracic wall (chest wall), which obliterates the pleural space. Without a space to become lodged, the problem of air in the pleural space is eliminated. Pleurodesis can be done mechanically or chemically. Many prefer mechanical pleurodesis because it is less painful and more effective. It also has a decreased rate of complications. Chemical pleurodesis involves the insertion of a foreign substance into the pleural cavity which causes the desired irritation. Talc and silver nitrate are the most commonly used substances, but their use may cause appreciable disability and may fail to prevent recurrence.
- Pleurectomy - (removal of the pleura)
Parietal pleurectomy creates a uniform inflammatory surface with secondary adhesions of the lung to the endothoracic fascia (sheet of fibrous tissue) along the chest wall. The procedure may be completed via a large thoracotomy or median sternotomy or by a small lateral incision in the fifth or sixth intercostal space. The procedure involves the complete removal or oversewing of the pulmonary blebs and as complete as possible stripping of the parietal pleura.