Surgical strategies for spontaneous pneumothorax: a narrative review

Spontaneous pneumothorax is commonly classified into primary spontaneous pneumothorax (PSP), which primarily occurs in young, thin individuals without evident underlying lung disease, and secondary spontaneous pneumothorax (SSP), which develops in patients of varying ages with preexisting pulmonary conditions such as chronic obstructive pulmonary disease (COPD), interstitial lung diseases (ILDs), thoracic endometriosis-related pneumothorax (TERP), Birt-Hogg-Dubé syndrome (BHDS), or lymphangioleiomyomatosis (LAM). Mild or clinically stable cases may be managed conservatively with observation and rest. The randomized controlled trial conducted by Brown et al. demonstrated that even patients with moderate-to-large PSP could be safely treated conservatively, with outcomes noninferior to interventional management in terms of lung re-expansion and recurrence rates ( 1 ). For patients presenting with more extensive pneumothorax or with significant symptoms, simple aspiration or chest tube insertion is generally indicated, whereas cases with persistent air leak after drainage or repeated recurrence typically require surgical intervention ( 2 - 4 ). PSP usually occurs in otherwise healthy individuals, and surgical intervention is mainly indicated for recurrent pneumothorax or persistent air leak, aiming to seal the air leak and prevent further recurrence, as recommended by major international guidelines ( 2 - 4 ). In contrast, SSP requires a more individualized management strategy, as the underlying disease determines both the indication for surgery and the most appropriate surgical approach. Since the 1990s, the majority of pneumothorax surgeries have been performed using multiportal video-assisted thoracoscopic surgery (mVATS) under general anesthesia ( 5 , 6 ). More recently, minimally invasive techniques such as uniportal VATS (uVATS) and awake VATS performed under local anesthesia have been increasingly reported as feasible and safe in selected patients ( 7 , 8 ). Several narrative and systematic reviews have previously addressed the surgical management of spontaneous pneumothorax, often focusing on epidemiology, guideline recommendations, or broad outcome comparisons ( 1 - 4 ). Rather than attempting to replicate these comprehensive overviews, the present narrative review is intentionally positioned as a surgeon-oriented, technique-focused synthesis. In particular, we emphasize practical operative strategies and recurrence-preventive adjuncts that are directly applicable in daily clinical practice, including staple-line coverage, pleural covering, and chemical pleurodesis. Furthermore, for SSP, we deliberately focus on rare but high-recurrence and decision-intensive entities—LAM, BHDS, and TERP—in which disease-specific surgical strategies are especially critical. The objective of this narrative review is to summarize contemporary surgical strategies for spontaneous pneumothorax from a practical, surgeon-centered perspective, with particular attention to minimally invasive techniques, recurrence-prevention methods, and disease-specific considerations for LAM, BHDS, and TERP. We present this article in accordance with the Narrative Review reporting checklist (available at https://jovs.amegroups.com/article/view/10.21037/jovs-2025-1-50/rc ).

The standard surgical procedure for PSP is bullectomy performed with endoscopic staplers, typically via mVATS, and it is often combined with pleural reinforcement or pleurodesis. Compared with conventional open thoracotomy, VATS has been associated with a shorter hospital stay in comparative analyses ( 9 ). In a large propensity score-matched study by Pagès et al. , hospital stay was reduced by approximately one day in the VATS group. Recurrence occurred more frequently after VATS (3.8%) than after thoracotomy (1.8%) in the unmatched cohort, and this difference persisted after propensity score adjustment. Postoperative recurrence—particularly after VATS—remains a significant concern. Therefore, various adjunctive methods—such as staple-line coverage, pleural abrasion, and chemical pleurodesis—have been developed to address this persistent risk of postoperative recurrence, as discussed in detail in the following section. Surgical management of SSP is more complex and heterogeneous. Depending on the underlying pulmonary pathology, procedures may range from limited bullectomy to pleurectomy. Open thoracotomy is now rarely required and is reserved for refractory cases complicated by pleural infection or for those necessitating muscle-flap filling or thoracoplasty ( 10 ). Similar to lung cancer surgery, the trend toward increasingly less invasive procedures—especially the uniportal VATS approach, including intercostal and subxiphoid variants—has also advanced in pneumothorax surgery ( 8 ). Comparative analyses have demonstrated similar recurrence rates between uniportal and multiportal VATS approaches. For example, Janssen et al. ( 11 ) reported identical recurrence rates of 6% in both groups, with shorter chest drain duration (median, 4 vs. 5 days) and hospital stay (median, 5 vs. 6 days) in the uniportal group. In addition, Chuang et al. ( 12 ) observed significantly lower postoperative pain scores on the day of surgery in patients undergoing uniportal VATS (1.74±1.35 vs. 2.65±1.59), while recurrence rates were 3.3% and 5.0%, respectively. In recurrent or refractory cases, surgical strategies should be carefully individualized according to each patient’s clinical circumstances. Patients in high-risk occupations, such as pilots or divers, may be considered for surgical treatment even after the first episode to minimize the risk of life-threatening recurrence ( 2 - 4 ). In contrast to PSP, surgical management of SSP requires disease-specific planning, as the underlying pathology strongly influences both operative feasibility and recurrence risk. Rare disorders such as TERP, BHDS, and LAM each require distinct operative strategies. In TERP, endometriotic lesions have been identified not only in the diaphragm but also on the visceral and parietal pleura ( 13 ). Therefore, thorough resection or ablation of all intrathoracic lesions followed by pleural covering has proven effective ( 13 - 15 ). The surgical technique for TERP is demonstrated in Video 1 . In patients with BHDS or LAM, numerous cystic lesions are present, rendering complete resection impossible. Total pleural covering using oxidized regenerated cellulose (ORC) sheets has been associated with favorable postoperative outcomes ( 16 - 18 ). The surgical procedure for total pleural covering is demonstrated in Video 2 . Separately, chemical intrathoracic pleurodesis has been associated with a lower postoperative recurrence rate as an adjunctive technique ( 19 ). Intraoperative findings in a 43-year-old woman with right-sided TERP. TERP, thoracic endometriosis-related pneumothorax. Total pleural covering technique in a 40-year-old man with spontaneous pneumothorax secondary to BHDS. BHDS, Birt-Hogg-Dubé syndrome. In very elderly patients and those with severe COPD or ILDs, the perioperative risk—even for general anesthesia—is high, and a minimally invasive technique such as awake VATS under local anesthesia is preferred when feasible ( 7 ). Although this approach has certain limitations, including a restricted operative field and a shorter permissible operative duration, it allows direct visualization of the air leak site and enables reliable closure through covering, ligation, or suturing when compared with conservative management. The awake VATS procedure is demonstrated in Video 3 . Intraoperative findings during awake VATS under local anesthesia in a 70-year-old man with markedly reduced activities of daily living following cerebral infarction. VATS, video-assisted thoracoscopic surgery.

Recurrence prevention is a cornerstone of surgical management for spontaneous pneumothorax. Staple-line coverage using absorbable materials such as polyglycolic acid (PGA) sheets, ORC sheets, or Vicryl mesh has been widely adopted to reinforce the resection margin and reduce postoperative recurrence. Several studies have demonstrated that these techniques effectively decrease recurrence rates following thoracoscopic bullectomy ( 20 - 22 ). More recently, a dual covering method combining PGA and ORC sheets has been reported to further reduce recurrence ( 23 ). The dual covering method and intraoperative pleural coating with 50% glucose solution are demonstrated in Video 4 . Dual covering with absorbable sheets and pleural coating using high-concentration glucose solution during uVATS in an 18-year-old man with PSP. PSP, primary spontaneous pneumothorax; uVATS, uniportal video-assisted thoracoscopic surgery. Chemical pleurodesis using agents such as talc, OK-432, minocycline, or high-concentration glucose solution is an established adjunctive method for preventing postoperative recurrence and can be performed either intraoperatively or postoperatively. Talc poudrage produces a strong pleurodesis effect; however, adverse events such as fever and, historically, acute respiratory distress syndrome (ARDS) have been reported—the latter occurring more frequently before standardization of talc particle size ( 24 , 25 ). OK-432 and minocycline have also been widely employed, demonstrating efficacy in reducing recurrence, although post-instillation chest pain and fever remain concerns ( 26 , 27 ). High-concentration glucose solution has long been recognized as an adhesion-inducing agent; however, intraoperative administration may additionally promote pleural thickening. This feasibility was first described by Tsuboshima et al. ( 28 ), who observed pleural thickening after intraoperative application of 50% glucose solution following VATS bullectomy, suggesting a possible mechanism for recurrence prevention. Subsequently, Kiriyama et al. ( 29 ) demonstrated the clinical efficacy and safety of intraoperative spraying of 50% glucose (50 mL), reporting no recurrences in the glucose group compared with two in the control group, with minimal and transient hyperglycemia and increased drainage volume. Collectively, these findings indicate that intraoperative application of high-concentration glucose solution represents a safe and promising adjunctive approach for preventing postoperative recurrence. Pleural abrasion and pleurectomy are well-established mechanical techniques for achieving pleurodesis. Pleural abrasion is less invasive and has demonstrated recurrence-preventive efficacy comparable to pleurectomy in several studies ( 30 , 31 ). However, pleurectomy is associated with higher morbidity, including intraoperative bleeding and prolonged postoperative pain, although it yields very low recurrence rates. In selected patients with multiple recurrences or high-risk occupations, pleurectomy remains a valid option. In PSP, Lee et al. ( 20 ) demonstrated in a large prospective randomized trial that mechanical pleurodesis and staple-line coverage using ORC sheets resulted in comparable postoperative recurrence rates, with the coverage group experiencing less postoperative pain. Alternative or simplified procedures, such as bulla ligation or soft-coagulation ablation, have also been described—particularly in younger patients—as adjunctive methods that avoid stapling and reduce procedural costs. Although early outcomes appear favorable, current evidence remains limited ( 32 ).

Chest tube management remains a critical component of postoperative care. Recent evidence indicates that early chest tube removal is associated with shorter hospitalization durations and no increase in recurrence among selected patients ( 33 ). The optimal level of suction pressure remains controversial; several studies have suggested that water-seal drainage without active suction may shorten the duration of air leakage ( 34 ). Although recurrence rates after PSP surgery vary according to factors such as patient age (particularly in younger individuals) and surgical technique, bullectomy combined with pleural reinforcement or pleurectomy has been reported to reduce recurrence to approximately 3.9–12.1% ( 20 , 35 ). Even after surgical intervention, postoperative recurrence rates of TERP remain high—around 30%—reflecting its refractory nature. Recent studies have shown that the addition of hormonal therapies significantly decreases postoperative recurrence; therefore, postoperative hormonal therapy may be considered as an adjunctive strategy to reduce recurrence ( 14 ). Although both BHDS and LAM are characterized by diffuse cystic lung lesions, postoperative recurrence rates differ substantially—typically less than 10% for BHDS following total pleural covering, but approximately 10–20% for LAM, even with similar procedures ( 16 - 18 ). In patients with LAM, the mechanistic target of rapamycin inhibitor sirolimus, an immunosuppressive agent, has been shown to preserve pulmonary function ( 36 ) and significantly reduce postoperative pneumothorax recurrence ( 37 ).

Future directions in the surgical management of spontaneous pneumothorax include continued refinement of minimally invasive techniques such as uniportal VATS and robotic-assisted thoracoscopic surgery (RATS). RATS has demonstrated advantages in precision and ergonomics in lung cancer surgery; however, its role in the treatment of spontaneous pneumothorax has yet to be established, and clinical applications of artificial intelligence (AI) remain investigational ( 38 ). AI-based imaging analysis has also been explored in the context of spontaneous pneumothorax ( 39 ), although no clinical applications in pneumothorax surgery have yet been reported. Future studies focusing on pneumothorax-specific applications of RATS, as well as the integration of AI-based risk stratification and intraoperative decision support, may further refine patient selection and procedural planning.

❖ Strengths: surgeon-oriented synthesis; explicit focus on PSP and on LAM, BHDS, and TERP as high-recurrence, decision-intensive SSP; integration of recent guidelines and pivotal studies; procedural detail regarding minimally invasive strategies and recurrence-prevention adjuncts. ❖ Limitations: non-systematic selection without formal bias assessment; English-language restriction; absence of meta-analysis; heterogeneity of study designs and outcomes; few head-to-head trials; limited and early-stage evidence for RATS and AI. The deliberate focus on rare SSP entities limits generalizability to the broader SSP population dominated by COPD and ILD.

This review was conducted as a narrative synthesis. PubMed and leading thoracic surgery journals, including the Journal of Thoracic and Cardiovascular Surgery , Annals of Thoracic Surgery , European Journal of Cardio - Thoracic Surgery , Journal of Thoracic Disease , and General Thoracic and Cardiovascular Surgery , were searched for English-language studies published between January 1991 and January 2026. PSP was included as the most commonly encountered form and a practical reference point for surgical planning. For SSP, the review scope was restricted to LAM, BHDS, and TERP, as these represent prototypical rare disorders characterized by frequent recurrences and complex decision-making. This focused approach was chosen because COPD- and ILD-related SSP have been extensively reviewed elsewhere, whereas these rare entities require disease-specific surgical strategies due to their high recurrence risk. Key guidelines and pivotal clinical studies were prioritized, and the reference lists of relevant publications were hand-searched to identify additional reports. Study selection was based on clinical relevance and the author’s expertise; therefore, a formal systematic search or risk-of-bias assessment was not performed. The search strategy is summarized in Table 1 . BHD, Birt-Hogg-Dubé; LAM, lymphangioleiomyomatosis; PSP, primary spontaneous pneumothorax; SSP, secondary spontaneous pneumothorax; TERP, thoracic endometriosis-related pneumothorax.

Surgical management of spontaneous pneumothorax requires a multifactorial strategy that considers the distinction between PSP and SSP, patient background, and recurrence risk. Minimally invasive surgery has become the standard approach; however, recurrence prevention remains an ongoing challenge. Optimizing the choice of surgical technique and adjunctive methods while considering patient-specific factors will continue to be crucial. Future integration of robotics, AI, and personalized medicine may further advance the surgical management of pneumothorax.

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