primary spontaneous pneumothorax ( psp ) is a benign disease , usually occurring in young patients without known underlying lung disorder .
the occurrence rate is reported to be about 9 individuals per 100 000 each year .
depending on the individual severity , the therapeutic options include simple observation , needle aspiration , tube thoracostomy and definite operation . if surgery is indicated , video - assisted thoracoscopic surgery ( vats ) using an endoscopic linear cutter to resect the involved blebs is currently the most popular treatment .
nevertheless , we try to avoid using the endoscopic staple device at our hospital because payment for the device is excluded by the national health insurance system in taiwan .
thanks to the increased experience with therapeutic thoracoscopy that we have gained in recent years , we used the technique of thoracoscopic suturing to imbricate the blebs , without resection , to treat the air leakage in psp patients , and report here our early results .
from january 2001 to april 2002 , we had 50 episodes of primary spontaneous pneumothorax in 49 patients referred for the operation . among them , 26 patients with 26 episodes received transaxillary thoracotomy with or without assisted - thoracoscopy inspection .
twenty - one patients with 22 episodes of psp received vats wedge closure by suturing . in this study , we dealt solely with the vats group .
study patients included 2 female and 19 male patients , with a mean age of 25 years , ranging from 16 to 52 years .
these 2 female patients were much older than the other patients , being 52 and 45 years of age , respectively . because of no abnormal pulmonary disease except for the attack of pneumothorax
the surgical indications included recurrences in 11 episodes ( 10 patients ) , prolonged air leakage for more than 5 days in 4 episodes ( 4 patients ) , and apical blebs seen on radiography in 2 episodes ( 2 patients ) .
five patients in 5 episodes underwent the operation owing to fear of recurrence , thus not fitting the above indications .
the patients were kept in the lateral decubitus position after anesthesia was administered with single - lung ventilation .
the first 10-mm port was created in the 7th intercostal space ( ics ) , mid - axillary line .
the second 5-mm and third 10-mm ports were created in the 5th ics , anterior - axillary , and posterior - axillary line , respectively .
after the full exploration of the lung surface , the involved blebs were sutured with an absorbable ( 3 - 0 ) vicryl polyglactin suture ( ethicon endo - surgery , inc , cincinatti , oh ) .
the curved needle had to be straightened before it could be put into the trocar port .
if no bleb was found , the apical scar area was sutured in the same way .
coagulation of parietal pleura by the endo - instrument was routinely performed in all patients to achieve pleurodesis .
the mean disease duration from attack to operation was 5 days , ranging from 1 to 30 days .
the mean operation time was 133 minutes , ranging from 80 minutes to 270 minutes .
the mean hospital stay after the operation was 4 days , ranging from 3 to 8 days .
three patients complained of prolonged intermittent intercostal neuralgia during the follow - up period , and 1 patient suffered dehiscence at the chest tube port . during the mean 6-month follow - up , ranging from 1 to 16 months , most patients recovered well , except 2 patients who experienced recurrences .
vats endo - suturing of the leaking area was performed again , with apical pleurectomy for this patient .
the suture - puncture of the leaking blebs , instead of the normal tissue , in the prior operation was condemned .
no bleb was found in her prior vats . a relationship between the attack and her menstruation
no matter what surgical approach is executed , the goal of treatment is to find the offending bleb , remove it , and perform some manipulations to encourage adhesion formation .
recently , video - assisted thoracoscopic surgery ( vats ) has been shown to produce results comparable to those obtained following open thoracotomy , yet with a reduction of postoperative pain , respiratory dysfunction and catabolic response to trauma , and decrease in wound - related complications .
we believe that for psp vats is the best treatment , as abdala et al recommend , because it allows us to treat the ruptured bleb radically avoiding any recurrence .
however , it is not the treatment of choice for all physicians due to the high cost of the equipment and the stapling devices needed for the wedge resection of the involved blebs . in taiwan due to the financial policy of the national health system , the charge of the high price of the endo - stapling instruments to the patient always concerns us , which is just the same as that in yim 's report . finding a way to replace the endo - stapling method
endo - suturing is not a new skill , and it is widely applied in laparoscopic surgery .
nevertheless , using the endosuturing method to treat spontaneous pneumothorax was only reported by yim in 1995 in the english literature .
because the incurred blebs are always idiopathic in patients with primary spontaneous pneumothorax , we think that it is not necessary to remove them .
furthermore , the preserved bleb tissues are of help in wound healing and prevent air leakage from the wound , which can shorten the duration of the chest tube insertion .
therefore , the length of suturing is not a problem , and in 1 case a 10-cm suturing - line was performed without prolonged air - leakage . without adequate treatment ,
the recurrence rate after the first pneumothorax on the same side is about 25% , and after the second episode , more than 50% .
although no general agreement exists about the best time for surgical intervention ( ie , after the first or second episode ) , vats therapy is now accepted as a definite treatment even in the first episode . in this study
they were all well informed about the conventional indication of the surgery before being included in this study .
ventilation of 1 lung is mandatory in this procedure because complete lung collapse promotes the effect of suturing .
the suture tension becomes tight enough to stop any air leaks after the lung fully expands .
in addition , the tissue of the bleb itself can be used as a buttress to enforce the suturing area .
the recurrence rate after the vats operation is reported to be high , between 13.7% and 20% , due to newly formed blebs or bullae unidentified during operation .
recently , a favorable 2.1% recurrence rate by vats has been reported by maier et al who use a rotating brush as a supplement .
, the cause of recurrence is thought to be improper suturing with direct puncture of the blebs during the operation and thus the leakage area is not repaired well . during reoperation by vats ,
the air leak was found near the previous sutured area , which adhered intensively to the parietal pleura .
step - by - step dissection has to be carefully executed to prevent tissue damage during the second - look operation .
therefore , we have an 9.1% ( 2/22 ) recurrence rate , which is acceptable compared with that of the other vats reports .
the coagulation pleurodesis seems ineffective if the definite treatment of the ruptured blebs is not accurately executed .
it is thought that the limited pleura being applied via the 3 small ports during vats renders coagulation pleurodesis ineffective .
the incidence of chronic postoperative complaints after minimally invasive procedures for spontaneous pneumothorax is relatively high . in the majority of the patients ,
two of our patients complained of intermittent anterior chest pain in the ipsilateral side , which may have been due to concurrent injury to the intercostal nerve at the trocar site .
the vats wedge closure of the blebs by suturing , without resection of the involved blebs , is a feasible and effective alternative treatment for primary spontaneous pneumothorax if cost of the endo - stapler is regarded as a major problem .
 background and objectives : if surgery is indicated for primary spontaneous pneumothorax ( psp ) , video - assisted thoracoscopic surgery ( vats ) using an endoscopic linear cutter to resect the involved blebs is the most popular treatment . 
 we tried to determine whether closure of the blebs with sutures without resection is also efficacious enough to treat psp.methods:we prospectively analyzed 22 episodes of psp in 21 patients from january 2001 to april 2002 . 
 we endosutured the blebs , without removing them , no matter what the size and the number of the blebs were . 
 coagulation pleurodesis was added in every case . 
 only 3 ports were needed during the procedure.results:morbidity and cost efficiency were acceptable . 
 two recurrences were experienced . 
 the reasons for the recurrences were poor performance of the endo - suture in 1 patient , and no obvious blebs found in the other.conclusions:we believe that vats wedge closure of blebs by imbricating and buttressing them , without resection , is a feasible and effective alternative treatment for primary spontaneous pneumothorax . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSION