Reply to Rychlik and McManus.

We read with interest the paper by Ikeda et al. [1] regarding the treatment of catamenial pneumothoraces. We agree with the authors that the pathology of true catamenial pneumothorax is not clear. However, in most cases, diaphragmatic fenestrations play a role. On the left, the fenestrations are frequently plugged by the omentum. On the right, however, the liver prevents such plugging, which accounts for the right-sided prevalence of the catamenial pneumothorax. We too have used an absorbable mesh in the treatment of catamenial pneumothoraces for a number of years with good results; however, our practice differs from the one described by the authors. We have satisfactory results fixing the patch to the diaphragm without applying a patch to the lung tissue [2]. Our ability to inspect the diaphragm has improved, and our technique has evolved with the introduction of thoracoscopy. Whereas previously, via a muscle-sparing thoracotomy, we would have sutured a polygalactin mesh over the defects in the diaphragmatic surface, we now use an endoscopic tacker (The ProTackTM 5-mm Fixation Device, Covidien, UK) to fix the patch at thoracoscopy. This can be added to the standard pleurectomy and abrasion technique using three thoracoscopic ports. We would recommend that any surgeon operating on a female patient for pneumothorax should examine the diaphragm and treat any defects appropriately.