Ann Thorac Surg 2003;75:1080-1085
© 2003 The Society of Thoracic Surgeons
Original article: general thoracic
Needlescopic versus conventional video-assisted thoracic surgery for primary spontaneous pneumothorax: a comparative study
Jin-Shing Chen, MDa,b,
Hsao-Hsun Hsu, MDa,b,
Shuenn-Wen Kuo, MDa,b,
Pi-Ru Tsai, RNa,b,
Robert J. Chen, MD, MPHa,b,
Jang-Ming Lee, MD, PhDa,b,
Yung-Chie Lee, MD, PhDa,b*
a Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
b National Taiwan University College of Medicine, Taipei, Taiwan
Accepted for publication October 14, 2002.
* Address reprint requests to Dr Yung-Chie Lee, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, No. 7, Chung-Shan South Rd, Taipei, Taiwan.
e-mail: wuj{at}ha.mc.ntu.edu.tw
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Abstract
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BACKGROUND: Management of primary spontaneous pneumothorax by needlescopic video-assisted thoracic surgery (VATS) has rarely been attempted and no comparison study with conventional VATS is available. In this study, we compared the clinical outcomes of needlescopic VATS with conventional VATS in treating primary spontaneous pneumothorax. The technique and our experience with needlescopic VATS are reported.
METHODS: Between April 2001 and April 2002, a total of 63 patients with recurrent, persistent, or contralateral primary spontaneous pneumothorax were recruited for this study. Operative procedures included needlescopic VATS in 28 patients and conventional VATS in 35 patients. We used a modified operative technique to improve the poor and narrower vision of the needle-videothoracoscope.
RESULTS: There was no mortality or major complications in either of the two groups. Needlescopic and conventional VATS groups had comparable operation times, postoperative pain, requested doses of meperidine hydrochloride, durations of postoperative chest drainage, and length of hospital stay. After a mean follow-up of 8 months, the needlescopic VATS group had less residual neuralgia (p = 0.021) and better wound satisfaction (p = 0.043) than the conventional VATS group. Ipsilateral recurrence of pneumothorax occurred in 1 patient (3.6%) in the needlescopic VATS group but not in any patients in the conventional VATS group.
CONCLUSIONS: Our experience showed that needlescopic VATS is technically feasible and can be a satisfactory alternative to conventional VATS in treating primary spontaneous pneumothorax. Limited vision of needlescopic VATS can be improved by the modified technique we used. However, conversion to conventional VATS or minithoracotomy is suggested in selected patients to prevent early recurrence.
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Introduction
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Primary spontaneous pneumothorax most commonly occurs in young, tall, lean males [1, 2]. Optimal management of this benign disease has been a matter of debate. Although open thoracotomy provides the definite treatment in patients with recurrence [3, 4], physicians are reluctant to refer patients for this treatment because of long postoperative recovery, pain, and a high rate of complications. The advancement in video-assisted thoracic surgery (VATS) has enabled bullectomy and pleural abrasion through thoracoscopy a viable alternative in the treatment of primary spontaneous pneumothorax [5, 6]. However, postoperative chest pain has not been completely alleviated [7–9] and the surgical wounds of VATS have not shown cosmetic excellence.
Recently, the development of technology in the videoscopic field has produced 2-mm and 3-mm needlescopic equipment and instruments. Sympathectomy for hyperhidrosis and preoperative diagnostic workup in general thoracic surgical fields using the needlescopic VATS technique have shown clinically excellent results with less postoperative pain and scarring [10, 11]. A previous study also showed that needlescopic VATS is feasible in the treatment of primary spontaneous pneumothorax [12]. Although needlescopic operations may reduce the trauma inflicted on the chest wall, there are still some limitations to its use, because of the narrow field of vision, lower resolution, and difficulty in handling bulky tissue, when compared with conventional VATS. Furthermore, no comparative or prospective studies have been conducted to prove that needlescopic VATS is less painful, equally effective, or more cosmetic. In this study, we used a modified method and port strategy of needlescopic VATS technique to treat primary spontaneous pneumothorax. In addition, we compared the feasibility, complications, and short-term outcomes of this procedure with those of conventional VATS procedures.
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Patients and methods
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From April 2001 to April 2002, a total of 73 consecutive patients requiring VATS caused by recurrent, persistent, or contralateral spontaneous pneumothorax were enrolled in this study at the Thoracic Surgical Division, National Taiwan University Hospital. Ten patients were excluded because of their age (> 50 years of age) (4 patients), underlying pulmonary diseases (3 patients), bilateral pneumothorax (2 patients), and previous ipsilateral thoracic operation (1 patient). The remaining 63 patients chose to undergo conventional VATS or needlescopic VATS. Each patient made his or her own choice after the attending surgeon explained the differences between the two procedures. The cost of the operation, cosmetic results, and risk of ipsilateral recurrence were the main points considered by the patients as they made their choices. The cost of needlescopic VATS is higher than that of conventional VATS because our national health insurance will cover only a part of the disposable equipment. Informed consents were obtained from the participating patients after our thorough explanations.
Operative technique of conventional VATS
The operation was performed in a standard fashion under general anesthesia using intubation with a double-lumen endotracheal tube. The patients were placed in a lateral decubitus position, and the ipsilateral lung was deflated. One set of video-thoracoscopic equipment (Karl Storz, Tuttlingen, Germany) was placed near the patient’s head. A 10-mm, 30-degree telescope (Karl Storz, Tuttlingen, Germany) was first inserted through the previous chest tube wound to examine the pleural cavity. If the chest tube wound was not available, a 12-mm port was made at the sixth or seventh intercostal space. Two 15-mm skin incisions were made at the third or fourth intercostal space, anterior and posterior axillary line. Light pleural adhesions were freed using electrocautery. When blebs were identified, they were grasped with the ring forceps and excised with a 45-mm endoscopic stapler. Blind apical stapling was done if no bleb could be identified. The entire parietal surface was abraded by inserting the dissector with a gauze pledget or strip of a diathermy scratch pad through the port sites. After postoperative lung reinflation, normal saline solution was instilled to check for air leaks. A chest tube was placed in the apex through one of the insertion wounds. The surgical specimens were routinely sent for pathologic examination.
Operative technique of needlescopic VATS
The anesthesia, preparation, and operative procedures of the patients were almost the same as for conventional VATS. However, two sets of independent video-thoracoscopic equipment and monitors, one for needlescopic videothoracoscopy and the other for 10-mm videothoracoscopy, were used simultaneously and placed near the patient’s head (Fig 1).
Basically, we used the 10-mm videothoracoscopy for most of the surgical steps. A needlescope was indicated only when we needed the chest tube wound to insert the endoscopic stapler and ring forceps, or to extract the specimen.
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Fig 1. Two cameras with independent sets of videothoracoscopic equipment and monitors, one for 10-mm videothoracoscopy (Monitor 1) and the other for needlescopic videothoracoscopy (Monitor 2), were used concomitantly to improve the vision and shorten the time of operation.
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The port site strategy is illustrated in Figure 2.
A 10-mm, 30-degree telescope was inserted through the previous chest tube wound. Two small skin punctures were made and mini-ports were inserted for needlescopic instruments (2-mm instruments, US Surgical, Norwalk, CT; 3-mm instruments, Olympus, Tokyo, Japan). The inferior mini-port was located at the sixth intercostal space, posterior axillary line, at the same level of the chest tube wound to avoid mirror image during surgical procedure. The superior mini-port was located at the third intercostal space of the middle axillary line. Initially, the 10-mm telescope and two mini-endograspers were used to identify the bullae (Fig 2A). When a bulla was identified, it was fixed by using the mini-endograsper at the upper mini-port. The mini-endograsper at the lower mini-port was withdrawn and a 2-mm or 3-mm needlescope was introduced to visualize the bulla. The 10-mm telescope was then withdrawn and an endoscopic stapler was introduced to resect the bulla (Fig 2B). The surgical specimen was retrieved from the chest tube wound. The 10-mm telescope was inserted again to check the stapling line. Electrocautery was used when bleeding from the stapling line was noted.
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Fig 2. Operative technique of needlescopic video-assisted thoracic surgery. (A) A 10-mm, 30-degree telescope and two mini-endograspers were used to identify the bulla. (B) After the bulla was identified and fixed, a needlescope was inserted through the lower mini-port. The bulla was resected by an endoscopic stapler introduced through the chest tube wound. (12 mm = 12 mm disposable trocar [US Surgical, Norwalk, CT]).
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Pleural abrasion was performed under the vision of needlescope. Curved ring forceps with a diathermy scratch pad were inserted through the chest tube wound. We used the 10-mm videothoracoscope intermittently to ascertain that the entire pleural surface was thoroughly and evenly rubbed. After the operation, normal saline solution was instilled to check for air leaks. A chest tube was placed in the apex through the chest tube wound. The punctures sites of 2-mm ports required no suturing. These holes were closed with adhesive tape (Steri-Strips [3M Health Care, Borken, Germany]).
Postoperative care
The patients were extubated in the operating theater and observed for 1 to 2 hours in the recovery room. The tube was connected to a low-pressure suction system. Postoperative analgesics include routine oral nonsteroid analgesics and acetaminophen. Intramuscular meperidine hydrochloride (Demoral, 50 mg/ampule [Pharmaceutical Plant National Bureau of Controlled Drugs Department of Health, Taipei, Tawain, R.O.C.]) was administered every 4 to 6 hours according to the patient’s request if the pain became intolerable. Intensity of postoperative pain was evaluated by a visual analogue scale (zero represented no pain and 10 represented intractable pain) on the first, second, and third postoperative days. In both groups, the tube would be removed when the lung was fully expanded and no air leaks could be noted in a 24-hour period. Patients were discharged 1 day after the removal of the drainage tube if no complications were encountered.
Data collection and analyses
The clinical data, operative findings, operation time, durations of postoperative chest drainage, length of hospital stay, and complications were collected from the medical records. The requested doses of meperidine and data of visual analogue scale were collected from the nursing records. Follow-ups were conducted by a registered nurse who was blinded to the group allocation during clinical visits or by telephone conversation, according to a standard questionnaire that included when patients returned to work or school, and whether a recurrence occurred, when it happened, and how it was treated. Residual postoperative neuralgia was evaluated on a pain score from 0 to 5, in which 0 was pain free, 1 was occasional discomfort, 2 was occasional use of analgesics, 3 was using nonopiate analgesics, 4 was regular pain using opiates, and 5 was severe and intractable pain. Finally, to evaluate the cosmetic results of the operation, patients were asked to score their satisfaction with the scars on a scale from 1 to 5, in which 1 was very unsatisfied, 2 was unsatisfied, 3 was acceptable, 4 was satisfied, and 5 was very satisfied.
Continuous variables such as age or weight were expressed as the mean ± standard deviation and analyzed by the two sample t-test. Categorical variables such as gender or smoking status were presented by frequency (%) and analyzed by the Fischer’s exact test. Intensity of postoperative pain measured by visual analogue scale (from 0 to 10) were summarized by median (range) and compared by Wilcoxon rank-sum test. Scores of residual neuralgia and satisfaction with scars were analyzed by the Wilcoxon rank-sum test. A p value of less than 0.05 was considered statistically significant.
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Results
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Of the 63 patients, the median age was 22 years (range, 14 to 48 years; 51 males, 12 females), and 15 (23.8%) were smokers. The indications for operation were ipsilateral recurrence in 24 patients (38.1%), continuous air leaks in 33 (52.4%), and contralateral recurrence in 6 (9.5%). Blebs or bullae were identified in 57 patients (90.5%). Among these patients, multiple blebs (
3 blebs) were visualized in 20 patients (35.1%), and the most common site for blebs was the upper lobe (86%). Thirty-four patients chose conventional VATS and 29 chose needlescopic VATS. However, 1 patient in the needlescopic VATS group was converted to conventional VATS because air leaks could not be found. In the needlescopic VATS group, the initial 9 patients were managed with 2-mm instruments. The 3-mm instruments were used in the remaining 19 patients because 1 patient had early recurrence caused by a missed bleb. In addition, manipulation of the lung tissue with 2-mm instruments was inconvenient.
The demographic data and operative findings are summarized in Table 1.
The two groups did not differ in age, sex, weight, body surface area, smoking status, side involvement, surgical indications, and operative findings. Time of operation, postoperative pain, request of opioid analgesics, and results of treatment in each groups are summarized in Table 2.
Although there were no significant differences between the two groups, a trend toward less postoperative pain, a lower dose of meperidine request, and shorter periods of chest drainage and hospitalization were found in patients undergoing needlescopic VATS. No operative deaths and no major complications were reported in either of the two groups. Three patients (4.8%) had air leaks lasting longer than 5 days; these patients were managed conservatively. Pleural detachment was noted in 1 patient after removal of the chest drainage. Subcutaneous hematoma was noted in 1 patient in the conventional VATS group.
Patients were followed up between 2 and 14 months with a mean follow-up of 8 months. Only 1 patient in the conventional VATS group was lost to follow-up. Ipsilateral recurrence of pneumothorax occurred in 1 patient 3 weeks after the 2-mm needlescopic VATS. He underwent a subsequent conventional VATS and a missed bleb was noted at the lower edge of the right middle lobe of the lung.
After operation, patients returned to work or school very early in the course of this study, with a mean interval of 10.0 ± 2.7 days in the conventional VATS group and 9.9 ± 2.4 days in the needlescopic VATS group. When the groups were compared for residual neuralgia, occasional or persistent pain on the operated side presented in 53% of patients in the conventional VATS group and only in 25% of patients in the needlescopic VATS group (p = 0.021; Table 3).
In addition, more patients were very satisfied or satisfied with their scars in the needlescopic VATS group than in the conventional VATS group (86% vs 75%; p = 0.043; Table 3).
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Comment
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VATS has been performed widely in the diagnosis and treatment of intrathoracic diseases. Recently, interest has grown in reducing the size of scopes and instruments used in simple procedures [10, 11]. However, management of primary spontaneous pneumothorax by needlescopic VATS has rarely been attempted. Needlescopic surgery generally refers to procedures that use instruments with an external diameter of less than or equal to 3 mm [13, 14]. Smaller instruments would permit smaller incisions, which, in addition to improving cosmetic results, may reduce postoperative pain and incision-related morbidity. However, no prospective or comparative studies have been conducted to verify this assumption.
In this study, patients with primary spontaneous pneumothorax were managed with needlescopic or conventional VATS. In addition to nearly equal satisfactory clinical results obtained by both methods, we found that residual neuralgia was significantly less, and patients were more satisfied with their scars after having been treated with needlescopic VATS. Although selection bias existed because of the nonrandom design of this study, both groups were statistically homogeneous in terms of demographic characteristics and operative findings. Thus, the confounding effects from the nonrandomization may not be considerable. Another potential bias may come from the interviewer’s postoperative follow-ups, but this was carefully avoided by the blinding the nurses to the group allocation.
Although needlescopic operations represent the next logical step in the evolution of VATS, there are technical limitations associated with needlescopic instruments [11, 12]. Identification of blebs or air leaks through thoracoscopy requires good illumination and high resolution. These conditions correlate with the scope size. Previous publications and our experience show that scopes with a needle size (especially the 2-mm size) provide poor visibility. Furthermore, the mini-instruments are inconvenient in grasping the bulky lung parenchyma or holding the bullae tightly, because their jaws are very small. In this study, we used a modified port strategy and combined the needlescope with the 10-mm telescope to simplify the technique of the operation. Two cameras connecting the needlescope and the conventional telescope have been used in needlescopic abdominal operations [13]. This modified operative technique offered us an excellent alternative to solve difficulties previously described in the management of primary spontaneous pneumothorax. Patients with spontaneous pneumothorax had the advantage of an existing incision that was already at least 10 mm to 12 mm for a chest tube prior to the operation. This incision made it possible for us to use a 10-mm thoracoscope for most of the surgical steps. After operation, the wound was again used for chest drainage. These modifications made the needlescopic operation comparable with an operation performed with a 10-mm video-thoracoscope, whereas almost no additional wounds were necessary because 2-mm or 3-mm ports do not leave visible scars after 2 months.
The operative time in needlescopic VATS is also comparable with that for conventional VATS (77 vs 84 mins); possible explanations are that needlescopic VATS saves time on skin incisions and closures, and that concomitant use of the 10-mm telescope and needlescope can save time from switching scopes and provides an excellent viewing field. Not surprisingly, postoperative pain and request of analgesics were not significantly decreased in the needlescopic VATS group because of pleural abrasion.
Complications were minimal in both groups. However, in the needlescopic VATS group, 1 patient was converted to conventional VATS because air leaks could not be found. Another patient had ipsilateral recurrence because of a missed bleb at the uncommon site of the lung. In our experience, the 2-mm instruments are only suitable in patients with localized, obvious bullae because the viewing field of the needlescope is too narrow and the jaws of the mini-endograspers are too small to grasp the tissue tightly. The 3-mm instruments are more convenient in identifying the bullae, grasping the tissue and bullae, and providing a better viewing field during the operation. In addition, instruments of 3-mm or more are durable and less expensive, and the scars are almost comparable with those of the 2-mm needlescope. Nevertheless, for patients whose bullae or air leaks could not be found, conversion to conventional 10-mm ports or minithoracotomy should be considered to avoid missing blebs and early recurrence.
We acknowledge that the subjects were not randomized and potential biases may have existed during allocation of surgical procedures. In addition, the follow-up period was short for this study. Despite these limitations, our data suggest that needlescopic VATS can be performed safely with nearly equal clinical efficacy as with conventional VATS in selected patients by our modified operative techniques. Better results in residual neuralgia and wound satisfaction by needlescopic VATS were also noted after a mean follow-up of 8 months. Further research that includes randomized design and long-term follow-up are needed to analyze the true value of needlescopic VATS in the treatment of primary spontaneous pneumothorax.
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Acknowledgments
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We thank Chuan-Wen Tsui for her technical assistance in the preparation of the illustrations.
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References
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Abstract
Introduction
