Thoracoscopic surgery via a single-incision subxiphoid approach is associated with less postoperative pain than single-incision transthoracic or three-incision transthoracic approaches for spontaneous pneumothorax

Introduction

An increasing number of studies have demonstrated that thoracoscopic surgery is associated with decreased postoperative pain, reduced length of hospital stay, and fewer postoperative complications compared to open thoracotomy (1-5). Conventional thoracoscopic surgery is performed via three or four ports. In 2004, Rocco et al. reported on the use of single-incision thoracoscopic wedge resection for the treatment of diagnosis of interstitial lung diseases or treatment of primary spontaneous pneumothorax and found that uniportal thoracoscopic surgery for wege resection can be safe and effective (6). They also described 644 patients who underwent single-port thoracoscopic surgery for different indications (7) and the indications of single-incision thoracoscopic surgery were expanded. The potential advantage of reducing incisions is to decrease post-operative chest wall neuralgia and fasten recovery course.

Several studies have compared the intensity of self-reported postoperative pain and chest wall neuralgia between patients who received single-incision thoracoscopic surgery and those who underwent multiple-incision thoracoscopic surgery for pneumothorax (8-13). In some of those studies, acute postoperative pain was reported to be markedly lower in patients who received thoracoscopic surgery via a single incision than in patients who underwent surgery via three incisions. Nonetheless, even small chest wall incisions cause intercostal neuralgia and can result in chronic thoracotomy pain (6,14,15). A number of alternative methods have been developed to minimize trauma to the chest during surgery, including transvesical lung biopsy, transesophageal mediastinal lymph node dissection, transtracheal pericardial window creation, transoral dorsal sympathectomy, transumbilical lung resection and subxiphoid incision (16-23).

The subxiphoid approach to the thoracic cavity has been adopted in numerous procedures, such as subxiphoid pericardial window creation, coronary operations, thymectomy, ablative sympathectomy pulmonary wedge resection and lobectomy (16-25). Few studies have compared the perioperative and postoperative outcomes associated with single-incision subxiphoid transthoracic surgery, single-incision transthoracic surgery and three-incision thoracoscopic surgery. The aim of this study was to compare the intensity of acute chest pain associated with three thoracoscopic techniques, namely single-incision subxiphoid thoracoscopic surgery, single-incision transthoracic surgery and three-incision transthoracic thoracoscopic surgery for spontaneous pneumothorax.

Materials and methods

We retrospectively reviewed the surgical records of 57 consecutive patients who underwent thoracoscopic surgery for primary spontaneous pneumothorax at the Taipei Municipal Wanfang Hospital during the period August 2013 to September 2015. Data gathered from the records for analysis included demographic data, medical history, operative time, operative blood loss, length of hospital stay, duration of chest tube drainage, postoperative complications, and numeric pain rating scale scores. Surgical mortality was defined as death occurring during the same hospitalization or within 30 days after the operation. Indications for thoracoscopic surgery included recurrent pneumothorax or prolonged air leakage (>5 days). Thoracoscopic surgery was performed exclusively via the three-port approach in our hospital from 2009 to July 2013. Beginning in August 2013, we began to perform single-port incisions for patients with pneumothorax requiring thoracoscopic surgery and by the beginning of 2014 we began to perform thoracoscopic surgery via a single-incision subxyphoid approach. The indications for spontaneous pneumothorax were similar for all three approaches. Epidural analgesia is not used at our institution. The intensity of pain was estimated using an 11-point numeric rating scale. The numbers 0 to 10 are set out in a line at equal intervals, with the anchors ‘‘no pain [0]’’ and ‘‘pain as bad as you can imagine [10]’’ (26). The intensity of pain was evaluated immediately after surgery and then every 8 hours until discharge. The postoperative pain control protocol for all patients was as follows: diclofenac (25 mg) was administered every 6 hours during the postoperative course unless the numeric pain scale score was greater than 4, at which time intravenous injection of morphine (0.1 mg/kg) was administered. The pig tail was removed when postoperative chest plain films showed full expansion in both lungs without evidence of air leakage.

Surgical techniques

Patients were intubated with a double-lumen endotracheal tube under general anesthesia. The lateral decubitus positioning of the patients was based on the location of lesions. The blebs were identified using a thoracoscope. The pulmonary lesion was resected using a combination of endoscopic instruments (Scanlan International, Inc., USA) and an endo-stapler (Either Covidian or Ethicon End surgery, USA). Mechanical pleurodesis was also performed in the upper half of the pleural cavity by pleural abrasion with a cautery tip cleaner.

For three-port thoracoscopic surgery, a 30-degree 10-mm thoracoscope was placed through the 7^th intercostal space in the mid-axillary line and a utility incision (2 cm) was made at the 5^th intercostal space through which a wound protector (Alexis Wound Retractor, Applied Medical, USA) was introduced. Another 5-mm accessory port was placed at the 5^th intercostal space in the posterior axillary line (Figure 1A). After the operation, a pig-tail drainage tube was inserted at the 7^th intercostal space. For the single transthoracic approach, a 2-cm incision was created at the 5^th intercostal space in the anterior axillary line through which a wound protector (Alexis Wound Retractor, Applied Medical, USA) was introduced (Figure 1B). After the operation, the 14-Fr pig-tail drainage tube was placed at the edge of incision wound. For the single subxiphoid incision, a 2-cm incision was made over the subxiphoid area (Figure 1C). A substernal tunnel extending from the wound to the pleural cavity was made by finger blunt dissection. The sternum was lifted with a retractor to provide an adequate working space. A 30-degree thoracoscope was introduced into the pleural cavity via the subxiphoid wound. A pig-tail drainage tube was placed in the pleural cavity and the subxiphoid wound was closed with 3-0 vicryl suture.

Figure 1 Different incisions for thoracoscopic surgery. (A) A utility incision (2 cm) was made over the anterior axillary line at the 5^th intercostal space. Two accessory ports were placed at the 5^th and 8^th intercostal spaces in the posterior mid-axillary line, and mid-axillary line, respectively; (B) a 2-cm incision was created at the 5^th intercostal space in the anterior axillary line followed by wound protector placement; (C) a 2-cm incision was made over the subxiphoid area. The wound margin below the sternum was lifted with a retractor.

Statistical analysis

Continuous data are expressed as mean ± standard deviation (SD). Comparisons of continuous data between the three groups were made using the Krus-Wallis test. Categorical data were compared using the Chi-square or Fisher test. A P value <0.05 was considered to indicate statistical significance. All statistical analyses were performed using the statistical package SPSS for Windows (Version 12.0, SPSS, Chicago, IL, USA).

Results

During the period August 2013 to September 2015, fifty-seven patients with primary spontaneous pneumothorax underwent thoracoscopic pulmonary resection at the Wan Fang hospital. The 57 patients comprised 6 women and 51 men (Table 1). Of those patients, 14 received single-incision subxiphoid thoracoscopic surgery, 26 underwent single-incision transthoracic thoracoscopic surgery, and 17 received three-incision transthoracic thoracoscopic surgery. There were no significant differences in age, sex, side, surgical indication, operative blood loss, length of stay, duration of chest tube drainage or complications among the three groups. All surgeries were completed without the need for conversion to open surgery. There were no deaths in any of the groups and only one case of post-operative complication (prolonged air leakage) was observed in the single-incision thoracoscopic group. The patient was treated conservatively and was discharged on the 8th postoperative day. Operative time was significantly longer in the single-incision subxiphoid thoracoscopic surgery group than in the other two surgical groups (P=0.0064).

Table 1 Clinical characteristics and peri-operative outcomes of patients who received thoracoscopic surgery for spontaneous pneumothorax
Full table

In all groups, pain intensity was highest during the first hour after surgery and then decreased with time (Figure 2). However, patients who underwent the single-incision subxiphoid procedure had significantly lower 1-, 8-, 24- and 32-hour postoperative pain scale scores than patients who underwent the other two procedures (Table 2). The average and maximum pain scale scores in the first 24 hours were lowest in the single-incision subxiphoid group (P<0.0001). However, there was no significant difference in pain scale scores among the groups after removal of the chest drainage tubes.

Figure 2 The intensity of pain after surgery. Patients who underwent to single-incision subxiphoid procedure had significantly lower postoperative pain scale scores at the 1^st, 8^th, 24^th and 32^nd hour after surgery than patients who underwent the other two procedures (P<0.05).

Table 2 Numeric pain rating scale [0–10] after surgery
Full table

Discussion

In this study, we found that thoracoscopic surgery performed via a single subxiphoid port for spontaneous pneumothorax was associated with markedly less acute postoperative pain during the first 24 hours after surgery than single-incision thoracoscopic or three-incision thoracoscopic surgery.

Transthoracic thoracoscopic surgery is the most commonly employed approach to the thoracic cavity. Improvements in surgical instruments and surgical skill have resulted in a reduction in the number of incisions needed to perform thoracoscoic surgery. Single-incision thoracoscopic lobectomy and segmentectomy have been shown to result in perioperative outcomes similar to those of multiple-incision approaches (27). However, chest wall incisions are necessary even when performing thoracoscopic surgery via a single incision. The major shortcoming of the transthoracic thoracoscopic approach is chronic post-thoracotomy pain (6,14,15). Sihoe et al. (14) reported that more than half of their patients who received thoracoscopic surgery for spontaneous pneumothorax complained of chest wall paresthesia. Passlick et al. (28) found that 31.7% of patients who underwent three-port thoracoscopic surgery for spontaneous pneumothorax experienced chronic postoperative pain.

A subxiphoid incision is a simple and feasible route through which to enter the thoracic cavity (16-25). Liberman et al. reported on subxyphoid approaches for drainage of pericardial effusions (17). Yilmaz et al. reported on the removal of lung specimens via a subxiphoidal port after transthoracic thoracoscopic lobectomy in order to avoid mini-thoracotomy and found that subxiphoid route was an alternative method (29). Suda et al. (21) reported on the use of a single subxiphoid incision for bilateral thoracoscopic wedge resection and found that this technique enables exposure to both lungs through a single incision. Liu et al. (24) described the use of a subxiphoid single-incision thoracoscopic procedure for left upper lobectomy. The subxiphoid approach does not cause intercostal nerve injury and theoretically may result in reduced chest pain intensity. When we compared the perioperative and postoperative outcomes of the three procedures, we found that single-incision subxiphoid thoracoscopic surgery was associated with a longer operative duration than the other two techniques; however, duration of chest tube drainage, length of hospital stay, and rate of postoperative complications were similar among the three groups, indicating that the single subxiphoid approach is a safe and feasible surgical method for pneumothorax.

Surgical techniques that require fewer chest wall incisions reduce the chances of chest wall damage and intercostal nerve compression. In a review article that compared postoperative pain between patients who underwent single-port thoracoscopic surgery and those who received multiport thoracoscopic surgery, Young et al. found inconsistent results on pain intensity after single-port thoracoscopic surgery. The authors concluded that uniport thoracosccopic surgery may have a small clinical effect on reducing postoperative pain during the first 72 h following surgery (30). Jutley et al. compared pain outcomes associated with three-incision and single-incision thoracoscopic surgery for spontaneous pneumothorax and found that the intensity of acute postoperative pain was lower in patients who received the single-incision technique (8). Others studies have provided similar results (9-11). In contrast, Yang et al. found no significant differences in acute operative pain scale scores between patients who underwent a uniport technique and those who received thoracoscopic surgery via a three-port technique for primary spontaneous pneumothorax (13). In the present study, we compared the intensity of acute postoperative pain in patients who received thoracoscopic surgery via a single subxiphoid incision with the intensity of pain in those who underwent thoracoscopic surgery via a single transthoracic incision or three transthoracic incisions and found that patients who received surgery via a single subxiphoid incision had markedly lower pain scale scores during the first 24 hours after surgery than patients who received either of the other two techniques. The reason for the marked difference in postoperative pain intensity can be explained, at least in part, by the fact that the subxiphoid approach avoids injury to the intercostal nerve.

During the subxiphoid approach, we used a sternal retractor to increase the working space, thereby reducing interference caused by the heartbeat. No arrhythmic events occurred in any of the patients during or after surgery. Theoretically, it is possible that lifting of the sternum will induce sternal pain. However, pain was limited to the wound area in all 14 of the patients who received surgery via the single-incision subxiphoid approach. None of the patients reported significant sternal pain. The average and maximum VAS scores in first 24 hours were 0.94±0.32 and 1.64±0.50, respectively. Pain scale scores were significantly lower in patients who received surgery via the subxiphoid approach than in those who received surgery via either of the other two approaches in the first 24 hours after surgery (P<0.0001).

The main limitations of this study are the limited number of patients and its retrospective nature. In addition, exact doses of analgesic agents given to patients were not available for analysis. Furthermore, the intensity of pain was difficult to quantify and could have been influenced by emotion as well as by educational and socioeconomic backgrounds. These confounding factors were not investigated.

In conclusion, single-incision subxiphoid thoracoscopic surgery is associated with significantly lower postoperative pain than transthoracic thoracoscopic approaches and therefore may provide an alternative surgical technique for patients with spontaneous pneumothorax.

Acknowledgements

None.

Footnote

Conflicts of Interest: The authors have no conflicts of interest to declare.

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