Video-assisted thoracoscopy with two-lung ventilation and CO₂ insufflation in primary spontaneous pneumothorax:...

Primary spontaneous pneumothorax (PSP) is commonly treated with video-assisted thoracoscopic surgery (VATS), which traditionally requires one-lung ventilation (OLV) with double-lumen endotracheal intubation to optimize the surgical field. However, OLV may be associated with complications such as airway trauma and postoperative sore throat. In contrast, two-lung ventilation (TLV) with CO₂ insufflation has been proposed as an alternative that may reduce airway-related complications while maintaining adequate visualization. This study assessed the feasibility of VATS with TLV and CO₂ insufflation for PSP compared to the conventional OLV approach.

We retrospectively analyzed 181 patients with PSP treated at our center between July 2020 and December 2023; of these, 134 underwent thoracoscopic bullectomy. Fifty-six patients received VATS with TLV and CO₂ insufflation. Seventy-eight patients underwent OLV via double-lumen endotracheal intubation. Patient data were categorized into groups based on the minimization of bias between those receiving TLV and those receiving OLV, following analysis matched by propensity scores. A comparative analysis across these groups was also conducted, focusing on demographic data and intraoperative and postoperative outcomes.

The TLV group demonstrated several advantages, including shorter anesthesia induction time (13.45±5.25 min, P=0.01), shorter total anesthesia time (63.18±14.45 min, P=0.003), fewer days of chest tube drainage (1.41±1.22 days, P=0.04), shorter postoperative hospital stay (2.36±0.88 days, P=0.01), lower wedge resection specimen weight (3.21±2.5 g, P=0.03), fewer instances of postoperative ipsilateral and contralateral recurrence, and lower likelihood of short-term recurrence. No significant differences were found in surgical time (P=0.17), anesthesia recovery time (P=0.48), use of endostaplers (P=0.35), number of wedge resections (P=0.21), and pleurodesis (P=0.73).

In appropriately selected patients, TLV appears to be a viable option that does not increase recurrence risk compared to OLV while offering the benefit of a shorter anesthesia duration. Therefore, this method may be suitable for patients with PSP.