Procedure of uniportal intercostal bullectomy for pneumothorax and its indications: a clinical practice review

Uniportal video-assisted thoracoscopic surgery (VATS), which is predominantly performed with an intercostal approach, has been gaining popularity as a less invasive surgical treatment for bullectomy. With the widespread use of this procedure, the number of reports on surgical outcomes has increased. With the advent of the transareolar or subxiphoid approach, there is an increasing need to discuss the indications for these approaches in order to establish evidence. Therefore, we aimed to summarize the intercostal procedures of uniportal VATS for pneumothorax and discuss the favorable indications for this approach. In terms of indications, the pneumothorax size of the patients treated by surgery has not been elucidated and needs to be clarified for the indication. Considering the indications and outcomes of uniportal intercostal VATS, the presence of bullae may be a favorable indication for the procedure. Additionally, initial surgery for pneumothorax is the preferable indication, since pleural adhesion was an exclusion criterion for performing uniportal VATS. To reduce invasiveness, postoperative prolonged air leakage should be minimized, and the causes should be investigated. Each approach has its own advantages owing to anatomical differences. The distribution of the responsible lesions can be an indication for these approaches. Both the transareolar and intercostal approaches allow for resection of the apex of the lung. The intercostal approach can be superior to the other two approaches for resecting posterior lesions. From the perspective of cosmesis and invasiveness, a transareolar approach may reduce the involvement of the intercostal nerve and it can be performed without any recognizable scarring. The subxiphoid approach eliminates the involvement of the intercostal nerve and offers favorable access to the bilateral thoracic cavity. An intercostal approach can cause intercostal nerve involvement, but the incision used for the placement of the preoperative drain tube in the lateral thorax can also be used as an operative incision with this approach. Moreover, this approach allows for the easy exploration of the whole lung in order to avoid overlooking any bullae, and its lateral decubitus position is favorable when an additional incision is needed in the case of unexpected situations, such as adhesion.