Single-staged uniportal VATS in the supine position for simultaneous bilateral primary spontaneous pneumothorax

A 17-year-old boy presented with chest discomfort for 1 week. A chest X-ray and preoperative high-resolution computed tomography (HRCT) revealed images of SBPSP with multiple apical bullae on both lung apices (Fig. 1a-b). Under general anesthesia with double-lumen endotracheal intubation for sequential, selective lung ventilation, the patient was positioned supine with arms hanging to the overhead strut of the ether screen using the arm slings. Then, cushion pads were packed below the midline of the back for chest elevation to avoid collision of thoracoscopic instruments and the operating table (Fig. 2a). After transverse single draping to expose the bilateral chest wall simultaneously, the operative side was slightly elevated by table tilting to the opposite side. Two discrete high definition monitors were set up for sequential operation without changing of monitor position (Fig. 2b). Then, a minimal skin incision (less than 2.5 cm in length) was made in the fourth intercostal space at the anterior axillary line. First, full thoracoscopic inspection was conducted from the apex to the base using a 5-mm, 30° thoracoscope and thoracoscopic assistant stands on the operator’s sides of the same view-point. Exploration of entire lung was possible by lung retractions using endo-grasper under rotated thoracoscopic view (Fig. 2c). An identified apical bullae lesion of the upper lobe was held with grasping forceps and resected with endostaplers (Echelon 60 Endopath stapler; Ethicon Endosurgery Corp., Cincinnati, OH, USA) through the uniport (Fig. 1c). Pleural abrasion was not performed, and a saline merging test by temporary lung expansion after infusion of warm physiological saline in the Trendelenburg position confirmed no air leakage. An absorbable polyglycolic acid sheet (Neoveil; Gunze, Kyoto, Japan) was covered with fibrin glue (Beriplast-P combiset; CSL Behring GmbH, Marbug, Germany). Then, a 16 Fr. chest tube was placed at the anterior part of the uniport. After confirmation of no wound bleeding into direct thoracoscopic view, intercostal nerve block was conducted. Then, the wound was closed layer by layer using an absorbable suture in a running fashion with 2-0 and 3-0 Braided synthetic absorbable suture (Polysorb^TM, Covidien, Mansfield, MA) under both lung ventilation, and the skin was approximated with 4-0 barbed absorbable suture material (V-Loc™ Absorbable Wound Closure Device product line, Covidien, Mansfield, MA). The same procedures were conducted on the contralateral side via a 2.5 cm single incision in the fourth intercostal space at the anterior axillary line (Fig. 2d). Under the selective one lung ventilation by experienced anesthesiologists, the table was slightly tilted to the opposite direction without changing position into lateral decubitus. During the single-staged operation on the contralateral side, function of the chest tube on opposite side is well detectable, confirming neither air leakage nor tube compression of the chest wall. The total operation time took 65 min without any intra-operative events. Intravenous patient controlled analgesia was applied for relief from postoperative pain. Bilateral chest tubes were removed on postoperative days 1 and 2, serially. The patient recovered uneventfully and discharged 3 days after the operation. The patient was followed at the out-patient clinic for 24 months without a recurrence of pneumothorax on both sides.

An 18-year-old boy was conservatively managed for a bilateral minimal amount of pneumothorax during following up of 6 months at the out-patient clinic. He visited the hospital again complaining of chest discomfort. A chest X-ray revealed bilateral spontaneous pneumothorax, and an HRCT revealed multiple, variable-sized apical bullae on both lung apices (Fig. 1d-e). An operation was performed to control recurrent pneumothorax with identified bilateral definite bullae. The operative procedures were similar to the Case 1 except division procedure of the adhesion band on the apex of the right upper lobe (Fig. 1f, Additional file 1: Video S1). The total operation time was 79 min without any intra-operative events. Bilateral chest tubes were removed on postoperative days 1 and 3. The patient discharged on postoperative day 4 without complications. He was followed for 19 months without recurrence of both sides.