Video-assisted thoracoscopic surgery (VATS) is the direction of minimally invasive surgery.
Video-assisted thoracoscopic surgery (VATS) is the direction of minimally invasive surgery. It is widely used in clinical practice due to its advantages of small trauma, quick recovery and aesthetic appearance. However, it also increases the financial burden of patients due to its high cost. From January 2005 to March 2010, we performed ligation of pulmonary herpes and/or spontaneous pneumothorax using TV thoracoscopy in 67 patients with pulmonary herpes and/or spontaneous pneumothorax, with no surgical death, no serious complications, and low cost and no recurrence at 2 months to 5 years of follow-up. Surgical method
Intravenous complex anesthesia with tracheal intubation and double-lumen tube tracheal intubation was used. During the operation, the healthy side was lying, the upper limb of the affected side was elevated, the forearm was fixed horizontally, and the towel was routinely disinfected and spread. In three cases of this group, simultaneous surgery of bilateral pulmonary herpes was performed, and the patient was turned to the standard position on the other side after completing the surgery on the more severe side, and then the surgery on the less severe side was completed. Intraoperatively, the contralateral side was ventilated with one lung to ensure good lung atrophy on the operated side. The thoracoscopic incision is usually chosen at the 7th intercostal space in the mid-axillary line, and the 2nd and 3rd incisions, usually the 4th intercostal space in the anterior axillary line and the 5th intercostal space in the posterior axillary line, are chosen under thoracoscopic surveillance, and instruments are inserted for exploration and surgery of the intrathoracic lesion. Clamping at the base of the pulmonary herpes, ligated with No. 7 silk and knotted with a knot tying device, for huge pulmonary herpes, electrocoagulation can be used first to burn enough to break the wall of the herpes to reduce the volume and then clamp at the base, the key to surgery is to find the base of the ruptured pulmonary herpes. If the location of the pulmonary herpes cannot be determined, the anesthesiologist can be asked to re-drum the lung and much can be found. Diffuse pulmonary bullae should be ligated with as many bullae as possible, usually without excision and suture ligation. After flushing the chest cavity and checking for air leaks, the wall pleura is rubbed with a dry gauze ball in the direction of the ribs until the pleural surface is gross with small bleeding spots. A chest drainage tube was placed from the placement port, with 2 to 3 lateral holes cut and the front end of the drainage tube placed at the apex of the chest. Results In this group of 67 VATS cases, intraoperative banded pleural adhesions were mostly seen at the thoracic placement, and pulmonary herpes were found in all 67 cases, including only 59 cases of pulmonary herpes in the apical part of the lung and 8 other cases in the apical part of the lung and dorsal segment of the lower lobe, 43 cases of single pulmonary herpes, 19 cases of 2~3 pulmonary herpes, and 5 cases of more than 3 pulmonary herpes. There were no complications such as postoperative death and air leak, infection, etc. The operation time alone was 30-60 min, and the bilateral operation time was 95 min, 125 min and 175 min in 3 cases, respectively. The average postoperative hospitalization was 4 days (3d~6d), 25 cases were followed up by letter, 38 cases by telephone, 4 cases were followed up by outpatient review, 27 cases were followed up for 2 months~1 year, 23 cases for 1 year~3 years, and 17 cases for 3 years-5 years, and there was no recurrence of pneumothorax, and all of them worked and lived normally except for 2 cases of elderly patients. In this group, there were 2 cases of elderly patients over 80 years old who could not tolerate open-heart surgery due to emphysema and poor lung function, and had good pulmonary resuscitation by thoracoscopic ligation of pulmonary herpes, lung reduction, and wall pleural friction method without persistent air leakage, etc. Discussion Pulmonary blisters are various types of abnormal air-containing cavities on the lung surface or within the lung parenchyma. It is most commonly seen in lean male smokers [1] and can be clearly diagnosed by X-ray and CT. Closed chest drainage is feasible in cases of complicated pneumothorax, but the recurrence rate is high, about 30-50% [2]. Currently, aggressive surgical treatment is mostly advocated [3]. The indications for surgery are: 1) tension pneumothorax or hemothorax; 2) recurrent pneumothorax; 3) large pulmonary blisters affecting respiratory function; 4) aerial work such as pilots or diving operations with occupational risk. Bilateral pulmonary blisters can be operated in one phase or in stages. In the past, traditional open thoracotomy was used, which is traumatic, bleeding, long operation time, long hospitalization time, many complications, high cost and large postoperative scar. In recent years, thoracic surgeons mostly perform pulmonary herpetomy with cutting sutures under thoracoscopy, which often requires more than two cutting sutures, which is expensive and increases the financial burden of patients. Through this group’s minimally invasive pulmonary herpes ligation method, we appreciate that thoracoscopic pulmonary herpes ligation has more advantages: 1. Small damage to the lung and incisional tissue, light damage to lung function, providing a new treatment method for those patients who need open-chest treatment and cannot tolerate open-chest surgery, old and weak with poor cardiopulmonary function; 2., with aesthetic effect, especially young people are easy to accept; 3. Short operation time, postoperative Patients recover quickly, less complications, high surgical safety; 4. low cost, according to China’s national conditions, under the specific conditions that medical costs still need to be controlled at a certain level, thoracoscopic pulmonary herpes ligation not only achieves the requirements of minimally invasive, but also controls medical costs, has the practicality and universal promotion of significance. In 65 cases in this group, all of them were narrow-necked pulmonary herpes, and preoperative CT and other related examinations were performed to clarify the situation in the thoracic cavity and the location and number of pulmonary herpes, and if there were extensive pleural adhesions, diffuse or subpleural pulmonary herpes, the VATS pulmonary herpes ligation method was not suitable, and the common open-chest or lumpectomy suture technique should be chosen [4] or used to excision of pulmonary blisters with a cutting suture [5]. For pneumothorax, closed chest drainage needs to be placed to reopen the lung before surgery, and CT examination is performed after reopening to clarify the condition of pulmonary bullae. 2 elderly patients with emphysema and poor lung function who could not tolerate open chest surgery and continued air leakage after closed chest drainage, in addition, for diffuse subpleural pulmonary bullae, ligation of pulmonary bullae for volume reduction can be considered, but the long-term results are not satisfactory, and the key is to choose a good indication. For those with bilateral pneumothorax and/or pulmonary bullae, and for patients of advanced age, the procedure is safe as long as the indications are well chosen. According to recent reports, the recurrence rate after VATS for spontaneous pneumothorax is slightly higher than that of conventional open-heart surgery, but there is no statistical significance between the two groups; therefore, VATS is still commonly used as the standard treatment for spontaneous pneumothorax and pulmonary herpes, considering the advantages of less trauma, aesthetic incision and faster recovery [6].
Ryu et al [7] followed 91 patients with spontaneous pneumothorax treated by VATS for 40.7 ± 17.1 months and found a recurrence rate of 8.8% after incomplete pneumothorax and 6.0% after complete pneumothorax, again with no statistical difference between the two groups. No recurrence cases occurred in the 67 patients we treated, which may be related to our small number of cases.