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Although video-assisted thoracoscopic surgery (VATS) is now accepted by many as the approach of choice in the management of primary spontaneous pneumothorax (PSP), the optimal procedure and timing of surgical intervention remain as areas of contention. The author reviewed his personal experience with 224 consecutive VATS procedures for PSP. Mechanical pleurodesis was performed in every case and was the only procedure in 20 patients. We had experienced with several means of eliminating subpleural bullae once identified: stapled bullectomy (151), endoloop (12), argon beam coagulation (6) and endoscopic suturing (35). There were no mortality or intraoperative complications. The median postoperative hospital stay was 3 days. So far, we have had 4 recurrences (1.8%) after a mean follow-up of 20 months (range 1 to 36 months). Complications consisted of 10 persistent air leaks, 1 wound complication, and 1 chest wall bleeding. We conclude that 1) VATS is a safe and effective approach in the treatment of PSP; 2) Stapled-bullectomy is quick and reliable but costly; 3) Endoloop and suturing are viable alternative techniques that may prove to be more cost effective; and 4) we do not recommend the use of argon beam coagulation as the primary treatment modality.

Video-assisted thoracoscopy (VAT) offers a new approach to the diagnosis and treatment of many thoracic conditions. From September 1992 to August 1993, a total of 163 VAT procedures were successfully performed on 108 patients (87 male, 21 female; age range from 12 to 77) which consisted of 42 bleb eliminations and 64 mechanical pleurodesis for spontaneous pneumothorax, 11 wedge resections for pulmonary nodules, three wedge biopsies for diffuse pulmonary infiltrate, four thoracic sympathectomies, resections of two mediastinal masses, three pericardial windows, 10 guided pleural biopsies for undiagnosed effusions, six guided drainage of empyema and haemothorax, 16 staging of intrathoracic tumours and two explorations for penetrating thoracic trauma. There was no procedure-related mortality. Complications included one recurrence for spontaneous pneumothorax, one re-exploration for bleeding (also by VAT approach), one wound infection, and six persistent air leaks for more than 10 days. The median duration of postoperative chest tube drainage was 2 days and the median hospital stay was 4 days. It was concluded that VAT is a safe and effective approach in thoracic surgery and with further refinement in instrumentation even more procedures will be technically feasible. The long-term results of VAT are being awaited in order to define its true merits in thoracic surgery.