电视胸腔镜手术治疗自发性气胸（图文演示）

10. Resection

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A single bulla with a small parenchymal base is resected using 2 endoloops combined with an additional suture to prevent them from slipping during re-expansion of the lung. The ligation is visually controlled during re-inflation of the lung at the end of the operation.

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Larger bullae with wide parenchymal bases or bullous areas are resected with the endoscopic stapler.
The lung tissue can easily be guided into the stapler with an endoparenchymal clamp, which must be inserted opposite the stapler. To guide the stapler both medially and laterally, the trocar receiving the stapler must be located very low and as posteriorly as possible. When only 2 trocars are used, the stapler and clamp are working parallel to each other, making the insertion of the parenchyma between the jaws of the stapler more difficult.

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If no bulla or air leak can be found, the procedure of choice is apical wedge resection combined with a partial pleurectomy.

• Alternative technique
As alternatives to bulla resection, laser coagulation or bipolar cauterization have proven to be particularly effective, especially in cases of multiple subpleural bullae. Water irrigation during cauterization of the bulla wall helps prevent a postoperative air leak that could be concealed by charring.

11. Pleurodesis

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Additional pleurodesis following the repair of the actual air leak can reduce the risk of recurrence by fixing the lung to the chest wall. This prevents the penetration of air from the lung into the pleural space if weakness of the lung parenchyma occurs later.
The pathophysiological principle for creating an adhesion between the lung and chest wall is the secretion of autologous fibrin from the chest wall into the pleural space. Different technical solutions have been devised to this end (Hurtgen et al., 1996; Van den Brande and Staelens, 1989; Wakabayashi, 1989; Inderbitzi et al., 1993).

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Partial or total pleurectomy is considered the safest technique for pleurodesis. The parietal pleura can be detached very delicately from the endothoracic fascia in the avascular layer with the videoscopic approach. To begin the pleurectomy, digital detachment of the pleura can be performed before inserting the instrument trocars into the extrapleural space. Blunt dissection with different instruments can be continued extrapleurally under control of the intrapleural thoracoscope. Pleurectomy is performed between the first and fifth ribs, paramediastinally along the internal thoracic arteries and paravertebrally along the sympathetic nerve.

• Pleurodesis

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For mechanical pleurodesis (pleural abrasion), we use a dissecting swab to roughen the pleura until petechiae appear.

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For thermal pleurodesis, electrocautery as well as the argon beam technique or laser can be used. The aim is induce a thermal injury of the parietal pleura followed by fibrin secretion.

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Talc has been used for chemical pleurodesis for decades with high efficacy. It causes tight adhesions between the parietal and visceral pleura, making reoperations difficult. Therefore its application in young patients is controversial. When talc is applied (about 5 g), it should be distributed as a thin layer on the lung or parietal pleura with a sprayer.

12. End of procedure
- re-inflation under visual control;
- chest tubes: usually 2 chest tubes (Ch 28) are inserted through the axillary and inferior incisions and placed under visual control. At least one of the chest tubes should end in the thoracic dome to achieve complete re-expansion under suction of -20 cm H2O;
- closure of trocar wounds.

13. Thoracotomy conversion
Conversion to thoracotomy is not a complication in itself. It may be necessary for intraoperative complications and when the endoscopic technique cannot obtain the same results as open surgery, for instance when wide dissection or extensive suturing is necessary, or when it is feared that certain lesions may be overlooked or when palpation is required.

14. Postoperative period
Chest tubes
When there are no longer any air leaks, suction is stopped and in a postoperative course without complications, the chest tubes can be removed after 2 to 4 days, when the chest X-ray shows a complete re-expansion of the lung and no pleural effusion. The methods for handling chest tube drainage vary from one hospital to another and depending on the experience of the surgeon.
The medium postoperative drainage time for idiopathic pneumothorax is 4 days after a VATS procedure compared to 6.5 days after thoracotomy. For secondary pneumothorax, however, the difference between thoracotomy and the thoracoscopic approach is not significant. In these cases, longer drainage periods are related not to access but to prolonged air leaks caused by emphysematous lung parenchyma.

Analgesics
Reduction of postoperative pain and shorter drainage periods are the major quality criteria of the minimally invasive approach. In our protocol, patients receive analgesics regularly during the drainage period. Oral analgesics during the initial postoperative period may be sufficient. However, IV therapy or a peridural pain catheter may be better. It is important to eliminate pain in order to mobilize the patient immediately after surgery. In some patients, analgesics may be required for several weeks postoperatively.

Postoperative course
In more than 80% of patients, lung function returns to normal values 6 weeks postoperatively for forced vital capacity (FVC) and forced expiratory volume in one second (FEV1). In the remaining patients, a moderate restrictive lung function with values for FEV1 of about 75% of the normal value can be found.
In our own experience, the overall recurrence rate ranges from 3% to 8% following VATS pneumothorax treatment and is similar to the figures found in the literature (Mouroux et al.,1996).

15. Complications
Mortality
The mortality rate for VATS pneumothorax therapy should be zero for patients with primary spontaneous pneumothorax. Patients with secondary pneumothorax are usually elderly patients with severe emphysema and chronic obstructive pulmonary disease. Therefore, postoperative mortality may occur, depending on the severity of the underlying disease.

Bleeding
Severe bleeding from the internal thoracic and intercostal arteries is rare but possible. It can be controlled either by VATS or through conversion, depending on the experience of the surgeon. Diffuse postoperative bleeding should be expected more frequently following pleurectomy than in patients on whom pleurodesis was not performed (Naunheim et al., 1995).

Trocar injuries
Trocar injuries can be avoided by dissecting the trocar channels with scissors under digital control and by only using blunt trocars.
The overall rate of complications can be estimated at 5% to 8% and is no higher than that for thoracotomy.

16. Conclusion
Recurrence rates following VATS are comparable to those for conventional thoracic surgery. Important advantages of VATS include an accelerated recovery and decreased operative trauma.
Experience has shown that thoracoscopy provides a better view of the thoracic cavity, especially in the upper and lower parts of the thorax when compared with open surgery. The magnification effect of the thoracoscope allows for a much more precise separation of the pleura from the endothoracic fascia (Naunheim et al., 1995).

However, substantial experience is necessary to keep the rate of complications below that of thoracotomy. For example, postoperative bleeding is usually caused by a videoscopic miscalculation of the hemostasis of the chest wall after pleurectomy. The inspection of the total lung surface is more difficult by video-thoracoscopy as compared to open surgery, especially under intraoperative ventilation when checking for air leaks or bullae.

17. Reference
Hurtgen M, Linder A, Friedel G, Toomes H. Video-assisted thoracoscopic pleurodesis. A survey
conducted by the German Society for Thoracic Surgery. Thorac Cardiovasc Surg 1996;44:199-203.
Inderbitzi RG, Furrer M, Striffeler H, Althaus U. Thoracoscopic pleurectomy for treatment of
complicated spontaneous pneumothorax. J Thorac Cardiovasc Surg 1993;105:84-8.
Naunheim KS, Mack MJ, Hazelrigg SR, Ferguson MK, Ferson PF, Boley TM et al. Safety and efficacy
of video-assisted thoracic surgical techniques for the treatment of spontaneous pneumothorax. J
Thorac Cardiovasc Surg 1995;109:1198-203; discussion 1203-4.
van den Brande P, Staelens I. Chemical pleurodesis in primary spontaneous pneumothorax. Thorac
Cardiovasc Surg 1989;37:180-2.
Wakabayashi A. Thoracoscopic ablation of blebs in the treatment of recurrent or persistent
spontaneous pneumothorax. Ann Thorac Surg 1989;48:651-3.