and Michael Singh2
(1)
Department of Paediatric Surgery, Royal Hospital for Sick Children, Edinburgh, UK
(2)
Department of Paediatric Surgery, Birmingham Children’s Hospital, Birmingham, UK
Abstract
True spontaneous pneumothorax results almost exclusively from apical subpleural blebs (or less often, from bullae) in tall, thin adolescent males, sometimes with a smoking history. Secondary pneumothorax may occur in patients with underlying lung disease (e.g., cystic fibrosis, Marfan’s disease, asthma). Surgery is indicated in those who do not respond to conservative measures and in those with recurrence. The minimally invasive approach to spontaneous pneumothorax allows possible surgical cure while minimising the invasiveness, postoperative pain, and chest wall deformity from open surgery. It is relatively simple and may be performed with low-cost instrumentation.
Keywords
Spontaneous pneumothoraxApical bullectomyPleurectomy4.1 General Information
True spontaneous pneumothorax results almost exclusively from apical subpleural blebs (or less often, from bullae) in tall, thin adolescent males, sometimes with a smoking history. Secondary pneumothorax may occur in patients with underlying lung disease (e.g., cystic fibrosis, Marfan’s disease, asthma). Surgery is indicated in those who do not respond to conservative measures and in those with recurrence. The minimally invasive approach to spontaneous pneumothorax allows possible surgical cure while minimising the invasiveness, postoperative pain, and chest wall deformity from open surgery. It is relatively simple and may be performed with low-cost instrumentation.
Anatomically, blebs are found most commonly on the apical segment of the upper lobe but also may be located elsewhere. The second most frequent location is the superior segment of the lower lobe.
4.2 Working Instruments
5-mm port
Two 3- or 5-mm accessory ports
30° telescope
Two Endoloops (Ethicon; Somerville, NJ, USA)
Hook diathermy
Scissors
Maryland forceps
(Other instruments described in “Alternatives”)
4.3 Relevant Anatomy
Blebs causing spontaneous pneumothorax almost exclusively involve the apex of the upper lobe (Fig. 4.1). The next commonest site is the superior segment of the lower lobe (Fig. 4.2). Other relevant anatomy is shown in Figs. 4.3 and 4.4.
Fig. 4.1
Shown is the apex of the left lung in a patient with an apical bleb
Fig. 4.2
A ruptured bleb is seen in the lingular segment of the left lung in a patient with recurrent pneumothorax
Fig. 4.3
Anatomy of the left mediastinum at the apex of the lung. The aortic arch is seen here giving rise to the left subclavian artery, which subsequently gives rise to the internal mammary (thoracic) artery with its accompanying vein. All are covered by parietal pleura
Fig. 4.4
Anatomy of the stripped right chest wall. The structures deep to the parietal pleura can be seen in this figure. The intercostal bundles (vein, artery, and nerve) are seen more clearly now beneath each rib. Shiny fibres of the innermost intercostal muscles are also seen overlying the inner intercostals
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