Many patients with a primary spontaneous pneumothorax can be treated by observation or by simple aspiration. However, a subset of patients may require surgical therapy if there is failure to resolve, a high risk for recurrence or zero tolerance for a recurrence.


Indications after a first episode:

(1) prolonged air leak

(2) incomplete re-expansion of the lung

(3) associated single large bulla

(4) occupational risk (flight personnel, diver)

(5) absence of medical facility in a remote location


Relative indications after the first episode:

(1) tension pneumothorax

(2) hemopneumothorax

(3) bilateral pneumothorax


Indications after a second episode:

(1) ipsilateral recurrence

(2) contralateral recurrence


The nature of the surgical intervention depends on the underlying pathology:

(1) A large bulla can be resected.

(2) A persistent air leak can be stapled or sutured close.

(3) A bronchopleural fistula can be closed.

(4) Pleurodesis (adhesions between visceral and parietal pleura) can be performed either chemically or manually.


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