Thoracoscopic Treatment of Spontaneous Pneumothorax

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

The patient had undergone thoracoscopic treatment of a left spontaneous pneumothorax approximately 2 years earlier after failed non-operative management

A decision was made to proceed directly to surgical treatment of the right side without an attempt at catheter thoracostomy due to prior contralateral recurrence

The patient is placed in the lateral decubitus position with an axillary roll on a beanbag for thoracoscopic pneumothorax treatment

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

A Lukens trap works well for thoracoscopic talc application: talc is placed in the trap, tubing is cut and attached to the spout, with one side attached to installation tubing and the other to a 5mm trocar

Several blebs were identified in the lung apex during full examination

The initial stapler firing did not capture an adequate margin under the blebs on the posterior surface

The stapler should be applied across a more generous margin of grossly normal lung tissue when initial margin is inadequate

Three firings of the stapler were necessary to completely remove the apical wedge in this case

The specimen can be removed directly through the largest chest wall incision

A pressure of 15 millimeters of mercury and a flow of 4 L per minute is used to insufflate the talc

It is important to keep the second trocar open in order to maintain a pressure differential and promote flow during talc insufflation

The tip of the trocar can be manipulated to distribute the talc widely

Adequate talc 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 talc

A 16 French chest tube is placed at the conclusion of the procedure