Robotic Repair of Catamenial Pneumothorax

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Catamenial pneumothorax (CP) can be defined as a recurrent spontaneous pneumothorax occurring within 24-72 hours of menses. CP is a common manifestation of thoracic endometriosis and is most commonly seen in women between the ages of 30-40. Video-assisted thoracoscopy may be used to identify common features, including diaphragmatic defects or fenestrations usually located at the central tendon and associated endometrial implants. Surgical management has shown to be superior to medical therapy alone, but most patients will require postoperative hormonal therapy for 6-12 months with a gonadotropin-releasing hormone (GnRH) analogue. (1) 
 
This video outlines a classic case of catamenial pneumothorax treated with a unique robotic surgical technique involving rotation of the robot to allow for optimal visualization during separate portions of the procedure. 
 
Patient Presentation 

The patient was a 39-year-old woman with a past medical history of dysmenorrhea and menorrhagia who presented to the emergency department with acute onset back pain. She was never a smoker and had no family history of pulmonary disease. Initial workup with a chest x-ray demonstrated a large right-sided pneumothorax. A chest tube was placed, the pneumothorax subsequently resolved, and she was discharged home on hospital day two with follow-up. 

She presented to her pulmonologist three weeks later with five days of progressive shortness of breath and imaging findings consistent with recurrent pneumothorax. The patient noted that she had begun menstruating shortly before the onset of both episodes. Catamenial pneumothorax was suspected, so she was brought to the operating room for surgical exploration. 
 
Operative Steps 

A port was placed in the eighth intercostal space in the posterior axillary line, and a thoracoscope was inserted. Upon initial inspection of the pleural cavity, multiple chocolate cysts were identified on the diaphragm and parietal pleura, as well as several subcentimeter defects in the central tendon of the diaphragm. 

Three additional port sites were created in the sixth intercostal space, but the middle port site was temporarily closed to prevent collision between the robotic arms. A thorough lysis of adhesions was performed from lateral to medial to allow for a full examination of the thorax. Multiple chocolate cyst-appearing lesions on the parietal pleura were excised using cautery. 

Next, a small apical bleb and a chocolate-appearing cyst on the visceral pleura were identified. A wedge resection was performed with serial fires of the 45 Blue SureForm stapler load. Two additional dark deposits were identified on the lateral aspect of the right middle lobe, and these were also removed with a wedge resection. 

The robot was then undocked, rotated 180 degrees, and redocked to the three robotic ports in the sixth intercostal space for an improved view of the diaphragm. An additional 1 cm chocolate cyst identified on the central tendon of the diaphragm was fulgurated. The surrounding tissue was extremely thin, with several defects and visible liver below. Diaphragm plication was performed using 0-Ethibond pledgeted sutures, cut to 20 cm. Multiple bites were taken traversing the central tendon, taking care not to damage the liver parenchyma below. This brought the healthy diaphragmatic muscle together and closed the visible defects. This stitch was repeated three times to close all central tendon defects, while avoiding damage to the phrenic nerve medially. 

A thorough mechanical pleurodesis was then performed using a Bovie scratch pad to abrade the entire parietal pleura from the apex to the base and from the anterior hilum to the posterior hilum. Care was taken near the subclavian vessels, internal mammary vessels, and sympathetic chain. 

An intercostal nerve block was performed, hemostasis was achieved, and the lung was re-expanded over a 24 French chest tube and a 24 French Blake drain. 

Postoperative Course 

A postoperative chest x-ray demonstrated full reexpansion of the right lung. The final pathology of the pleural deposit and right upper lobe wedge showed hyaline fibrosis and features suggestive of endometriosis. The OBGYN recommended hormonal therapy, and the patient was discharged home on postoperative day nine with follow-up in two weeks. 

References

1. Visouli AN, Zarogoulidis K, Kougioumtzi I, Huang H, Li Q, Dryllis G, Kioumis I, Pitsiou G, Machairiotis N, Katsikogiannis N, Papaiwannou A, Lampaki S, Zaric B, Branislav P, Porpodis K, Zarogoulidis P. Catamenial pneumothorax. J Thorac Dis. 2014 Oct;6(Suppl 4):S448-60. doi: 10.3978/j.issn.2072-1439.2014.08.49. PMID: 25337402; PMCID: PMC4203986.

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