Inferior pulmonary ligament dissection after thoracoscopic bullectomy for primary pneumothorax prevents recurrence.

Background: The recurrence of primary spontaneous pneumothorax (PSP) after video-assisted thoracoscopic surgery (VATS) is correlated with larger postoperative residual apical pleural space (RAPS). We hypothesized that inferior pulmonary ligament dissection (IPLD) would facilitate postoperative lung expansion and lower the recurrence. Methods: We retrospectively reviewed PSP patients who underwent VATS with or without IPLD from September 2009 to December 2016 at Ditmanson Medical Foundation Chia-Yi Christian Hospital. The primary endpoint was postoperative recurrence. Secondary endpoint was RAPS measured using the apex-to-cupola (ATC) distance, postoperative chest drainage duration and hospital stay. Results: Of the 153 patients enrolled, the overall recurrence rate was 4.6% with median follow-up of 49.4 months. The mean duration of postoperative chest drainage was 2.20+1.43 days. Younger age, larger RAPS and without IPLD were associated with significantly higher risk of recurrence (P=0.02, 0.001, 0.003). IPLD group had shorter ATC distance at postoperative day (POD) 4 to 14 (POD 4-14) (P=0.003). After propensity score matching for patient age, Light index, and chest tube suction, the IPLD group had a significantly shorter ATC distance at POD 0-3 (P=0.03) and POD 4-14 (P=0.007), shorter postoperative chest drainage duration (P=0.01), shorter hospital stay (P=0.006), and lower recurrence rate (P=0.03). Conclusions: IPLD could improve the postoperative lung expansion and lower the recurrence, and might be considered as an adjunct to thoracoscopic bullectomy with pleurodesis for pneumothorax prevention.