电视胸腔镜手术治疗自发性气胸（图文演示）

中文版：电视胸腔镜手术治疗自发性气胸（中文图文演示）

VIDEO-ASSISTED   THORACOSCOPIC   SURGERY   FOR   THE   TREATMENT   OF   PNEUMOTHORAX
Authors
A Linder
Abstract
The description of the video-assisted thoracoscopic surgery for the treatment of pneumothorax covers all aspects of the surgical procedure used for the management of pneumothorax.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: examination, resection, pleurodesis, end of procedure, thoracotomy conversion.
Consequently, this operating technique is well standardized for the management of this condition.

1. Introduction
Etiology
Pneumothorax is caused by the entry of air into the pleural space, either via the airways and lungs or via the chest wall following an iatrogenic or traumatic injury. The negative intrapleural pressure changes to positive pressure, and the lung collapses.

Epidemiology
Idiopathic spontaneous pneumothorax is most often observed in teenagers or young adults up to 30 years of age. Secondary pneumothorax occurs mainly in the elderly and is often combined with bullous emphysema and/or chronic obstructive pulmonary disease (COPD).

Pathophysiology
A tension pneumothorax results from any lung parenchymal or bronchial injury that acts as a one-way valve, allowing air to move into but not out of an intact pleural space. The positive pressure used with mechanical ventilation therapy can also trap air. As pressure within the intrapleural space increases, the heart and the mediastinal structures are pushed to the contralateral side. The mediastinum impinges on and compresses the contralateral lung.

Pathogenesis
Ruptured bullae in the apices of the upper lobes are the most frequent cause of spontaneous pneumothorax. An adhesion from the parenchymal base of a ruptured bulla to the parietal pleura is often found during examination of the lung. In addition, smaller bullae may be lined up along the edges of the lobes. However, in at least half the cases of spontaneous pneumothorax occurring for the first time, thoracoscopic inspection finds no cause for the condition.

2. Diagnosis

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Most patients complain of chest pain, at rest or during exercise. The symptoms are usually the same for the second occurrence. In rare cases, a tension pneumothorax with life-threatening dyspnea makes emergency puncture necessary. In case of a spontaneous hemopneumothorax and pneumothorax caused by the rupture of a vessel inside an adhesion, circulatory symptoms may add to respiratory symptoms.

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A chest X-ray is the fastest and most reliable diagnostic tool. Large bullae may resemble a pneumothorax. However, the separation between lung tissue and air is usually convex in a bulla, and concave in a pneumothorax.

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1. Bullae
CT scan should not be seen as a routine diagnostic step but as an optional tool to differentiate a bulla from a pneumothorax. It is especially useful to detect contralateral bullae.

3. Therapy
General aims
There are 3 aims:
1. Re-expansion of the lung: can be achieved by chest tube drainage only, followed by suction therapy over several days with a negative pressure of about -20 cm H2O.
2. Leakage repair: usually requires surgery that includes suturing, stapling or gluing of the parenchymal leak.
3. Prevention of recurrence: involves different techniques whose goal is to obliterate the pleural space by creating adhesions between the visceral pleura and the chest wall. This pleurodesis may be performed surgically (abrasion, pleurectomy), thermally (cautery, laser) or pharmaceutically (instillation of antibiotics, talc, blood into the pleural space).

Conditions for VATS
Primary spontaneous pneumothorax: whether or not video-assisted thoracoscopic surgery (VATS) is indicated for a first occurrence of primary spontaneous pneumothorax is still under debate. The observed reduction of recurrences following VATS is in favor of the procedure. The cost (anesthesia, procedure, hospital stay) and the fact that a simple drainage cures 50% of the patients are detrimental to VATS.
After 10 years of experience with VATS, we believe that the technique is safe with a skilled thoracoscopic team (Hurtgen et al., 1996). Intrathoracic procedures can be performed as extensively and usually faster than via thoracotomy. Adhesions, eg along the phrenic nerve or along the subclavian vessels, may require conversion to thoracotomy.

Secondary pneumothorax: The same preconditions as for open thoracic surgery are required. VATS may be carried out by surgeons skilled in the technique. Those with less experience in VATS prefer thoracotomy for the treatment of secondary pneumothorax especially when emphysema is present and the lung tissue is fragile. In these patients, it is essential to treat the underlying obstructive pulmonary disease first. In all cases, conversion to thoracotomy can never be excluded.

4. Indications
Indications
- all cases of the first recurrence of primary pneumothorax;
- all cases of the first recurrence of secondary pneumothorax provided that the surgeon has enough experience in VATS and that the patient can tolerate split ventilation.

Relative contraindications
- recurrent primary pneumothorax after surgical treatment,
- previous history of ipsilateral pleural disease.

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All elective thoracoscopic operations are performed under general anesthesia with a double-lumen tube for separate ventilation of the lung lobes.
With correct positioning of the tracheal tube, the preexisting pneumothorax is completed through passive pressure compensation between the external air and the pleural cavity at the beginning of the operation, thereby leaving the operative site free. If the lung is not completely deflated, endobronchial suction or bronchodilator drugs may be administered. Intrapleural gas insufflation is not necessary. Alternatively to double lumen intubation, a separate bronchus blocker positioned bronchoscopically may be used for single lung ventilation.
It is important to partially inflate the lung during the intervention for the detection of all bullous disorders on the surface of the collapsed lung.

6. Operating room set-up

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- general anesthesia;
- double-lumen endobronchial intubation;
- lateral position (as for a standard posterior lateral thoracotomy);
- the ipsilateral arm is positioned horizontally to keep the extrathoracic working space free for the instruments.

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1. The surgeon stands in front of the patient.
2. The assistant is placed next to the surgeon.
3. The scrub nurse is placed next to the surgeon.
4. The anesthesiologist is placed at the patient’s head.

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1. Videoscopic unit
2. Anesthetic unit
3. Operating table
4. Instrument table

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Three trocars are usually required:
- optical trocar: paravertebral, at a maximum distance from the anterior trocars;
- instrument trocars: third and ninth intercostal spaces on the anterior axillary line.
Trocar sizes should be adapted to the diameters of the thoracoscope (10 mm or 7 mm) and of the instruments used. We recommend that a 7 mm thoracoscope be used if available, as a 7 mm trocar is less traumatic for the paravertebral space.
Some surgeons prefer only 2 incisions, whereby 2 instruments are inserted through a single, larger trocar. This technique may be sufficient for simple intrathoracic maneuvers such as wedge resections. It is not suitable for difficult intrathoracic maneuvers, because of the disadvantage of having 2 instruments that may hinder one another in the same trocar.

8. Instruments

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The rigid thoracic wall considerably limits the maneuverability of instruments in the pleural space. As a result, greater demands are made on thoracic instruments than on instruments used for standard laparoscopic operations. At angles greater than 45°, the strong friction within the trocar impedes the movement of the instruments. More freedom of movement inside the thorax can be achieved with angled or curved instruments and by extending the intrathoracic working space into the thoracic dome and to the diaphragm.
Flexible trocars without valves are necessary.

• Other instruments

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Monopolar and bipolar cutting and coagulation tips or endoscopic scissors are well suited to thoracoscopic pneumothorax surgery. Water irrigation during cauterization of bullae can prevent their carbonization, thus avoiding iatrogenic air leaks.

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In thoracoscopic surgery, a thermal Nd:YAG laser, as opposed to a CO2 laser, offers the advantage of multi-purpose applications including the coagulation of cysts, hemostasis or bulla resection.

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1. High frequency electrode
2. Argon flow
3. Tissue
The argon beam is especially suitable for hemostasis of wide areas of effusion following pleurectomy. It is uneasy to tell whether a pleurodesis effect occurs as a result of the application of the beam on the parietal pleura. However, if HF-argon pleurodesis is carried out, a large coagulation area on the pleura does not seem to be advantageous (the interruption of vessels may reduce the fibrin supply). It is therefore recommended only to coagulate stripes of parietal pleura, as this ensures expression of the fibrin into the pleural space.
Application of the argon beam inside the pleural cavity is only safe if the pressure compensation between the pleural space and the external air is guaranteed via open trocars.

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The endoscopic staplers used are especially designed for thoracoscopic resection of lung parenchyma. They ensure safe closure of the tissue along the resection. Four sizes of endostaplers are available (30/35/45/60 mm). The 60 mm stapler, because of its large size, does not always offer free movement inside the thoracic cavity, especially in the thoracic dome. The new flexible staplers do not compensate for this disadvantage.

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The first indispensable operative step is a thorough adhesiolysis. Only then is a complete inspection, including the dorsal, mediastinal and phrenic parts of the lung, guaranteed. During inspection, gentle insufflation of air helps make collapsed bullae at the lung surface visible. A concealed bulla on the parenchymal base of an adhesion, for example, can often be clearly identified as the cause of a pneumothorax and must be resected. Synechiae are often found as the consequence of previous pleurodesis or thoracic drainage. They are less vascular and, in terms of recurrence, less significant than the abovementioned adhesions. They must be dissected to allow for a thorough inspection and to avoid pockets of effusion.