Subxiphoid approach for spontaneous bilateral pneumothorax: a case report

Abstract

An 18-year-old man presented to the Emergency Department (ED) with sudden onset chest pain and a nonproductive cough. He had no significant past medical history or underlying pulmonary disease and there was no history of trauma preceding the onset of symptoms. On admission the patient was dyspnoeic and had decreased breath sounds over the right hemithorax. He was haemodynamically stable with oxygen saturation of 94% on room air. Complete blood count and biochemistry results were within normal Abstract: The development of video-assisted thoracoscopic surgery (VATS) has contributed to reduced pain and improved recovery following thoracic surgery. However, pain remains a major issue. Patients with bilateral pulmonary pathology requiring operative intervention may have even more pain due to bilateral transthoracic incisions. The recently described uniportal subxiphoid VATS approach provides an opportunity to undertake bilateral thoracic surgery through a single incision that avoids the bilateral intercostal nerve damage caused by transthoracic incision and drainage. Here we report a case of a patient requiring bilateral bullectomy and pleurectomy for the management of pneumothorax that was performed successfully by the subxiphoid VATS approach. limits. A chest radiograph demonstrated a large right sided pneumothorax which was treated with insertion of a 14 Fr Seldinger chest drain and resolved spontaneously during a 2-day admission and he was discharged home. One month later he presented to the ED with similar symptoms and at this time chest radiography demonstrated a left sided pneumothorax which was treated with insertion of a 14 Fr Seldinger chest drain but had a persistent air leak. Chest computed-tomography (CT) revealed multiple subcentimeter blebs of variable size in the apical portion of both lungs. He was referred to our tertiary cardiothoracic centre for consideration of surgical treatment. Patient selection and workupIndications for thoracoscopic pleurectomy and bullectomy include patients following a second ipsilateral spontaneous pneumothorax or a first contralateral pneumothorax. Other patients who warrant consideration for surgical management include patients with spontaneous pneumothorax with: prolonged air leak, incomplete lung expansion, bilateral pneumothorax, tension pneumothorax or blebs on CT imaging (10). Contraindications to a subxiphoid approach include high BMI, patients with cardiomegaly and reoperative procedures. InstrumentsStandard VATS instruments with dedicated instruments specially designed for SVATS [Shanghai Medical Instruments (Group) Ltd., Shanghai, China] are used during the operations (Figure 1). Surgical procedureA single staged bilateral surgical intervention was planned. The operation was performed with the patient under general anaesthesia and double lumen endotracheal tube intubation to allow for selective lung ventilation. Patient was placed in a left lateral decubitus position slightly rotated posteriorly in order to optimize exposure of the subxiphoid region for the lef...

Comparison of post-operative pain and quality of life between uniportal subxiphoid and intercostal video-assisted thoracoscopic lobectomy

“…Since its first implementation in 2012, the uniportal subxiphoid approach has been used for thymomas, metastasectomy, hyperhidrosis, spontaneous pneumothorax, and anatomical lung resections-including pneumonectomies (9,12,20,26,27). SVATS can be challenging to learn and challenges early in the learning curve include difficulty controlling a bleeding incidence, due to the distance between the subxiphoid incision and the site of the vascular injury and difficulty conducting a complete mediastinal lymphadenectomy.…”

Subxiphoid pneumonectomy: the new frontier?

“…In the case of standard VATS, there are reports of requiring rib spreading and the lung being retrieved in pieces. Furthermore, retrieval may result in compression of the intercostal nerves which can result in chest wall pain which may be chronic in some patients More recently, the subxiphoid uniportal VATS technique has been described, avoiding any intercostal incision or instrumentation (14)(15)(16)(17)(18)(19)(20)(21)28,29). Additionally, since the chest drains are not entering the thoracic cavity through intercostal spaces postoperatively, they do not impinge on the intercostal neurovascular bundle during mobilization of the patient.…”

“…More recently, the subxiphoid-VATS approach has been described and is increasingly utilised for a range of thoracic operations including thymectomy, lobectomy, segmentectomies and resection of giant solitary fibrous tumours of the pleura (14)(15)(16)(17)(18)(19)(20)(21). In this technique, a single vertical muscle-sparing incision is made in the subxiphoid space permitting thoracic surgery to be performed without requiring intercostal incisions.…”

Anesthesia and enhanced recovery in subxiphoid video-assisted thoracoscopic surgery

“…They observed a significant reduction on postoperative pain in the SVATs group which was associated with earlier mobilisation and reduced risk of complication (5). The SVATS approach has become increasingly popular, and there are reports of a wide range of operations being performed from anatomical segmentectomies to pneumonectomies (6)(7)(8)(9)(10)(11)(12)(13)(14)(15).…”