Fast-track video-assisted bullectomy and pleurectomy for pneumothorax: initial experience and description of technique.

OBJECTIVE: Pleurectomy+/-bullectomy by video-assisted thoracoscopic surgery (VATS) is an established surgical procedure for pneumothorax. Early ambulation and discharge should be a reasonable goal. This study explores the feasibility of day-case surgery and identifies the obstacles requiring further work to facilitate day-case pneumothorax surgery. METHODS: Between June 2007 and May 2008, 16 consecutive patients underwent video-assisted thoracoscopic surgery bullectomy+/-pleurectomy (under the care of a single surgeon) with immediate connection to an ambulatory drainage system in the theatre following surgery. Analgesia comprised temporary paravertebral with early conversion to oral opiate+/-paracetamol. There were 13 males (81%), average age 23 (range: 17-29) years, and three females (19%), average age 35 (range: 22-46) years. Twelve patients (75%) had left-sided disease, of which nine (56%) underwent elective surgery. All patients had previously suffered at least one primary spontaneous pneumothorax. Patients with probable secondary pneumothorax were excluded from the study. Length of stay (LOS) was compared with a control group of patients conventionally treated prior to the study. RESULTS: In 13 patients (81%), early discharge was achieved 1 (range: 1-2 days) day post-op, whilst connected to an ambulatory drainage system. In three patients, early discharge was not achieved. One of these patients had the chest drain removed prematurely and remained an inpatient for 3 days with aspiration and observation for a small pneumothorax. The two remaining patients required extended inpatient admissions due to postoperative non-surgical complications. In the 13 patients discharged immediately, the time to drain removal (in clinic) was electively 7 days (range: 2-11 days). Two patients required re-admission: one for contralateral spontaneous pneumothorax and another for an ipsilateral basal pneumothorax treated with a drain. CONCLUSION: We have shown early discharge with ongoing ambulatory drainage following VATS pleurectomy+/-bullectomy in patients with primary pneumothorax to be feasible with paravertebral in the theatre and rapid conversion to oral analgesia. Patients managed intercostal drains at home. Limiting factors such as postoperative nausea and pain control usually can be sufficiently managed in the outpatient. Shorter stays may have a beneficial financial result. Long-term follow-up and a quantification of the patients experience is warranted.

Off-pump coronary artery bypass surgery.

Off-pump coronary artery bypass surgery has been adopted enthusiastically worldwide. However, despite more than 6 years' experience and refinement, many surgeons use it only sporadically and some hardly at all. This reluctance persists despite support for the procedure because of the lack of properly designed risk models and/or randomized studies. Although it has not been overwhelmingly shown that off-pump surgery is superior to the conventional on-pump procedure, the technique has its place in our specialty. It has been shown to be better for noncritical end points in selected patients in the hands of selected surgeons. That there are differences in surgical skill among surgeons is something we all know but rarely discuss in public. Until now, disparities in skill have been most salient with uncommon and extraordinarily challenging operations. Perhaps the off-pump procedure should be regarded as the "challenging" aspect of coronary artery bypass surgery, and self-restraint may need to remain in force if we are to continue to achieve the highest level of clinical excellence.

Minimally invasive vein harvesting significantly reduces pain and wound morbidity.

OBJECTIVES: Minimally invasive saphenous vein harvesting is advocated to reduce wound morbidity. Our early experience with minimally invasive techniques, however, suggested that increased tissue traction and trauma might follow. We aimed to test the hypothesis that minimally invasive harvesting reduces post-operative pain and inflammation. A secondary objective was to determine if minimally invasive harvesting could be performed efficiently. METHODS: Forty patients were prospectively randomised into minimally invasive harvesting (Minimal, n=22) and traditional open harvesting (Open, n=18). A modified bridging technique was used for minimally invasive harvesting (SaphLITE, Genzyme Surgical Products, Cambridge, MA, USA). One surgeon performed all operations. Primary end points were signs of impaired healing (a composite score) and pain (visual analogue score). Secondary end-points (operation variables) were also collected. Continuous variables were analysed by Student's t-test and categorical variables were analysed by Mann-Whitney U-test. RESULTS: There were no significant demographic differences between the two groups (height, weight, albumin, diabetes, and peripheral vascular disease). In the early post-operative period, Minimal group had significantly less leg wound pain (P=0.04) and wound sepsis scores (P=0.01). Sternal pain was the same in both groups. After 6 weeks, wound scores and leg pain scores were not significantly different. There were no significant differences in rate of harvest (1.1 cm/min in each group). In Minimal group, 4 cm veins were harvested for each 1 cm skin incision compared with 1 cm in Open group (P<0.01). CONCLUSIONS: Minimally invasive saphenous vein harvesting significantly reduces early post-operative leg pain and wound sepsis. Our study demonstrates that minimally invasive harvesting can be performed at a satisfactory speed and should be considered to help reduce early post-operative morbidity.