Surgical strategies for spontaneous pneumothorax: a narrative review

Spontaneous pneumothorax encompasses both primary spontaneous pneumothorax (PSP) and secondary spontaneous pneumothorax (SSP), which differ in etiology and recurrence risk. Surgical management aims to control air leaks and prevent recurrence while minimizing invasiveness. This narrative review synthesizes current strategies, adjunctive methods, and special scenarios, and outlines future perspectives.

A narrative search of PubMed and major thoracic surgery journals was conducted for English-language publications published between January 1991 and January 2026, focusing on surgical indications; minimally invasive approaches [multiportal and uniportal video-assisted thoracoscopic surgery (VATS), and awake VATS]; adjuncts to reduce recurrence; and emerging technologies. For SSP, the scope was limited to lymphangioleiomyomatosis (LAM), Birt-Hogg-Dubé syndrome (BHDS), and thoracic endometriosis-related pneumothorax (TERP). Key clinical guidelines and pivotal studies were prioritized.

For PSP, stapled bullectomy remains the standard approach and is frequently combined with pleural reinforcement. Staple-line coverage with absorbable sheets has been associated with lower recurrence rates. Mechanical pleurodesis provides recurrence control comparable to pleurectomy in selected cases, whereas pleurectomy carries higher morbidity. Similarly, chemical pleurodesis has shown benefit as an adjunctive strategy. SSP requires individualized surgical planning based on the underlying disease; awake VATS may be considered for frail patients when feasible. In LAM and BHDS, total pleural covering has shown favorable outcomes, and sirolimus may reduce recurrence after surgery in LAM. Robotic-assisted thoracoscopic surgery (RATS) demonstrates ergonomic and precision advantages in thoracic surgery, but its role in spontaneous pneumothorax remains to be defined. Artificial intelligence (AI)-based imaging remains investigational without established surgical applications.

Contemporary surgery for spontaneous pneumothorax is defined by minimally invasive techniques supported by recurrence-preventive adjuncts tailored to patient characteristics. Evidence supports coverage techniques and selective chemical or mechanical pleurodesis, whereas disease-specific strategies remain essential for LAM, BHDS, and TERP.