Thoracoscopic simultaneous bilateral bullectomy through apicoposterior transmediastinal access for bilateral spontaneous pneumothorax: a challenging approach.

BACKGROUND: Video-assisted thoracoscopic surgery (VATS) through transmediastinal access (TMA) for contralateral thoracic cavity is an operative alternative for bilateral pulmonary lesions. Recently, we introduced a novel method of apicoposterior TMA to perform simultaneous VATS bilateral bullectomy (BB) for bilateral spontaneous pneumothorax (BPTX). We retrospectively analyzed ten patients on whom this procedure was performed and evaluated the effectiveness of this approach. METHODS: From April 2006 to May 2010, ten patients underwent simultaneous BB through this approach. Mean postoperative follow-up was 33.2 months. All patients were young males (age range = 15-20 years) and eight patients had BPTX that developed simultaneously. Apical blebs or bullae were carefully identified using multidirectional high-resonance computed tomography (HRCT). VATS right bullectomy was done first. The left thorax was reached by going through the apicoposterior mediastinum between the esophagus and vertebral bodies, and then left procedure was performed through this access. RESULTS: All ten patients successfully underwent VATS BB through TMA without intraoperative complications. One patient developed prolonged air leakage for 6 days on the right side. During the follow-up period, two patients developed left PTX recurrence; one was treated with a chest tube at 13 months, and another underwent a left VATS reoperation at 20 months postoperatively because of new bulla formation around the previous stapling line. CONCLUSIONS: A VATS apicoposterior transmediastinal approach is relatively safe and technically reliable for highly selective BPTX patients who have localized blebs or bullae on the left apical lung. Pleural reinforcement procedures may also be required for the prevention of postoperative recurrence.