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Minimally invasive thoracic approaches are usually not recommended in redo procedures when severe adhesions are expected. However, in cases involving complex adhesions of the apex of the chest, particularly with vascular structures, the authors believe that the robotic approach may offer a better surgical view and a provide a safer dissection strategy (1).
This video demonstrates the case of a young patient suffering from recurrent pneumothorax after three previous thoracoscopic bullectomies and pleural brossage (4, 6, and 8 years earlier). Before offering the fourth surgical procedure, the surgeons ruled out any dystrophic disease through qualitative and quantitative assessment of alpha-1 antitrypsin and careful pneumological consultation.
The patient was placed in the right lateral decubitus position, and a two-port, one-utility incision robotic approach was utilized (Da Vinci Xi). The anterior utility incision was used for fenestrated bipolar forceps, the middle lower port for a 30-degree endoscope, and the posterior port for the Maryland robotic dissector and fenestrated bipolar forceps as needed. Single-lung ventilation was adopted without CO2 insufflation.
Careful dissection separated the lung from the subclavian and carotid arteries, and a wide bullectomy was then performed. Prolonged air leaks were observed for two weeks post-surgery, and the chest drainage was then safely removed. At the six-month follow-up, a chest X-ray showed a fully re-expanded lung, and no pneumothorax recurrence was observed.
References
- Shehata DG, Digesu CS, Lopez E, Vigna C, Moffatt-Bruce S, Stock CT, Servais EL, Watkins AA. Robotic-Assisted Pleurectomy Is a Safe and Effective Surgical Treatment for Spontaneous Pneumothorax. J Surg Res. 2024 Oct; 302:944-948.
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2 Comments
Great that you could safely dissect the small area of complex adhesions at the apex but could the need for multiple redo procedures have been avoided if the patient had had a thorough VATS pleurectomy at the first operation? There is a lot of untouched parietal pleura in the video and I fear that they will be back again in time.
Dear Nigel,
thank you for commenting our procedure.
VATS pleurectomy is for sure a valuable option, although in this case I guess pneumothorax recurrence was mainly due to bullae recurrence rather than to the lack of strong adhesions.
Nowadays the patient is 24 and she was 16yo at the first episode; we will follow up and will keep you updated on long-term outcome.
Kind regards,
FP