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A New Procedure for the Treatment of Spontaneous Pneumothorax: The Cold Coagulation

Wednesday, March 18, 2009


Patients with recurrent or persistent spontaneous pneumothorax are treated thoracoscopically. Those with blebs or small bullae are generally managed by stapler resection of the lesions. We have recently experimented with a new device (Endo-Floating Ball) for the coagulation of blebs as an alternative to endostapler resection.


Patients with recurrent or persistent spontaneous pneumothorax are treated thoracoscopically. Those with blebs or small bullae are generally managed by stapler resection of the lesions [1-3]. We have recently experimented with a new device (Endo-Floating Ball) for the coagulation of blebs as an alternative to endostapler resection. In this way it is possible to reduce the already low invasiveness of the procedure. Most operations, in fact, were performed making only two incisions, in some cases under awake epidural anaesthesia. Results are comparable to those of series of standard thoracoscopic treatment already reported in the literature [4-6].


The Endo-Floating Ball 3.0 (Salient Surgical Technologies Inc., Dover, NH) is a 5-mm endoscopic instrument (Video 1 below) widely utilized for liver resections. This is a saline-cooled radiofrequency-powered device that plugs into a standard operating room electrosurgical generator. The coagulation power is typically set between 80-90 W. A sterile 0.9% saline solution bag is connected to the irrigation tubing and adjusted for a drip rate of 4–8 cc/minute (Video 2). The device conducts radiofrequency energy from the generator to the electrode tip, where continuous low-volume saline irrigation cools the contact interface with the lung tissue, keeping surface temperature at 100°C. This avoids the eschar and char formation that occurs with standard electrocautery devices. The thermal energy results in heat denaturation of protein in the wall of blebs and bullae, thereby shrinking the same blebs and bullae on their bases. Moreover, vessels and bronchioles afferent to the bulla may be sealed.

At this point, other concomitant cardiac procedures may be performed, in the usual fashion.


The procedure starts as a standard thoracoscopic procedure, which is performed under general anaesthesia and single lung ventilation. Two small incisions are made in the axillary triangle: one for the 7-mm thoracoscope and the other for the 5-mm endo–floating ball. After exploration, patients with blebs and/or bullae (stage III/IV according to Vanderschueren’s classification) undergo treatment with the new device. The procedure is very simple and generally lasts a few seconds, with the only recommendation to ensure that irrigation with the saline solution stays adequate and continuous. Both blebs or small bullae (Video 3) and larger emphysematous area (Video 4) may be coagulated with the saline-cooled device without desiccation, scaring and smoke. This technique preserves continuity of the visceral pleura, thus avoiding air leakage.

With the same device, stopping the saline solution perfusion, pleurodesis is then performed with standard hot coagulation over the first eight costal arches (Video 5), as we generally do in the standard technique. At the end of the procedure two pleural drains are inserted through the same operative incisions.


We performed such operation on 25 patients. There were 22 males and 3 females with a mean age of 27.7 years (range of 16 – 56). In the last 7 cases, because of its lesser invasiveness, we utilized thoracic epidural anaesthesia with the patients awake and spontaneously breathing. Mean operation time was 23 minutes (range of 11 – 50). The post-operative drainage period and hospital stay were on average 2.5 days (range 1-11) and 3.1 days (range 2-11), respectively. Prolonged air leakage occurred in 2 patients, one requiring re-operation after 8 days. At a mean follow-up period of 17 months (range 6 – 37) only one recurrence of pneumothorax was reported, which did not require re-operation.


Although our experience regards a small number of patients over two years, it seems that cold coagulation of small bullae and blebs is feasible and safe. It presents potential advantages: less invasiveness (just 2 very small surgical incisions), no retained foreign body, and a quicker and easier surgical procedure. The results in terms of prolonged air leaks and recurrences are comparable with those reported in the literature [4-6]; both the prolonged air leaks and the recurrence in our series occurred in the first ten patients, suggesting that even better results may be obtained with increased experience using the device. Moreover, this procedure seems particularly suitable to being performed under awake epidural anaesthesia, as has been recently suggested by other authors [7]. Using this technique, handling of the pulmonary parenchyma is significantly reduced, thus reducing coughing reflex, which represents one of the main limitations of this anaesthetic technique.


Video 1

Video 2

Video 3

Video 4

Video 5


  1. Inderbitzi RG, Leiser A, Furrer M, Althaus U. Three years’ experience in video-assisted thoracic surgery (VATS) for spontaneous pneumothorax. J Thorac Cardiovasc Surg 1994;107:1410-15.
  2. De Giacomo T, Rendina EA, Venuta F, Ciriaco P, Lena A, Ricci C. Video-assisted thoracoscopy in the management of recurrent spontaneous pneumothorax. Eur J Surg 1995;161:227-30. PMID: 7612762
  3. Baumann MH, Strange C, Heffer JE, Light R, Kirby TJ, Klein J, Luketich JD, Panacek EA, Sahn SA. Management of spontaneous pneumothorax. An American College of Chest Physicians Delphi Consensus Statement. Chest 2001;119:590-602. doi: 10.1378/chest.119.2.590
  4. Bernard PC, Regnard JF, Spaggiari L, Levi JF, Magdeleinat P, Guibert L, Levasseur P. Immediate and long-term results after surgical treatment of primary spontaneous pneumothorax by VATS. Ann Thorac Surg 1996;61:1641-45.
  5. Liu HP, Yim AP, Izzat MB, Lin PJ, Chang CH. Thoracic surgery for spontaneous pneumothorax. World J Surg 1999;23:1133-36. PMID: 10501875
  6. McKenna RJ, Brenner M, Gelb AF, Mullin M, Singh N, Peters H, Panzera J, Calmese J, Schein MJ. A randomized prospective trial of stapled lung reduction versus laser bullectomy for diffuse emphysema. J Thorac Cardiovasc Surg 1996;111:317-22.
  7. Pompeo E, Tacconi F, Mineo D, Mineo TC. The role of awake video-assisted thoracoscpic surgery in spontaneous pneumothorax. J Thorac Cardiovasc Surg 2007;133:786-90.


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